The following methods of evacuating the pus may be employed: simple puncture, siphon drainage, thoracotoniy with or without resec tion of ribs. The point of selection is determined by the exploratory puncture (see above). If open to choice the median or posterior axillary line about the seventh or eighth rib is preferred, in thoracotomy the scapulary line.
1. The simple puncture as it has been described above should only be attempted in a recent pneurnococcus empyema (metapneumonic empyema) of small area without large coagula, since in this instance recovery is exceptionally possible. The lumen of the trocar must meas ure at least 3 mm., and the pus is to be evacuated as completely as possible by aspiration. If recovery does not take place after two punc tures at most, one must proceed differently. In strepto-, staphylo and fetid enmyenia, puncture is to be abandoned from the outset. On the other hand, puncture (with siphon drainage) is the most appro priate procedure in tuberculous empyema, though even here resection of the ribs is frequently preferable even when a passably good pul monary and general condition exists. Puncture is also often employed with advantage in ordinary empyema as a preparatory operation, when ever the patient collies under treatment in an urgent and very debilitated condition from an extensive effusion, and when one wishes to give him a few days' time to recover his strength for the operation to be undertaken.
2. The siphon drainage often named after Billau, but already used previously by Playfair and others, has been frequently employed during the last t wenty years. After ancesthetizing the skin a trocar of at least the calibre of a lead pencil is introduced in the 6-7 intercostal space in the median axillarv line. After removal of the stillet a rubber drainage tube as thick as possible is immediately passed through the cannula into the pleural cay-ity. The eannula is then carefully drawn over thc tube, the end of which is immediately clamped so that no air can gain entrance. The tube is firmly fastened to the chest by- a silk thread and collodion dressing. After removal of the clamp an additional rubber tube filled with boric acid solution is connected with the drain by means of an interposed glass tube, and is led into a glass vessel standing on the floor Wiliell is partially filled with boric acid solu ti on (see Fig. 91). In this way the pus yvill be evacuated gradually' into this vessel. The puncture wound in the chest wall enlarges taneously' during the next few day's, and the drainage tube is changed several times for still larger tube,(.. After about 14
days, simple drainage without aspiration tubing and a cotton dressing are employed (Orloff). The advantages of the phon drainage consist in that no ancesthetic is required and that the slight operation generally causes but little weakness. The advocates of this method see its greatest value in the prevention of a pneumothorax. The tages are as follows: The flow of pus is often interrupted by large coagula which are frequently present in pneurnococcus empyema. (The siphon drainage, moreover, is especially recommended in streptococcic empyema which is comparatively rare in children.) The evacuation must then be accomplished by means of a piston syringe which is attached to the tube. Frequently, evacuation of the tough pus and shreds is very inadequate. The pus may re-accumulate, or the method may be a failure from the first, so that thoracotomy must after all be under taken subsequently.
The Bfilau method does not give good results in small effusions, old ernpyema, and sunken thorax (with slight internal pressure). The after-treatment requires constant medical supervision and makes great demands on the attendants, so that the siphon drainage is not well adapted to private practice.
3. Simple tboracotomy may- be undertaken in younger children un der a local anaLsthetie of ethyl chloride; in older children slight chloro form anTsthesia is required. A longitudinal incision is made in about the 6-7 intercostal space closer to the lower than the upper rib, and after division of the intercostal muscles the pleura is freed in this situ ation, which usually does not demand the ligation of vessels. The pleura is then incised, tile pus slowly CVIICU ated (the wound being frequently plugged with the fin ger), and the opening enlarged to the size of the external wound by means of a blunt instrument. The large coag ula are removed with the forceps. Irrigation of the pleural cavity is often harmful, and is attended by danger of collapse or convulsions, and is to be advocated only in fetid empyenia. A thick, short drainage tube is placed in the wound. Dressing as in resection of the ribs is etn ployed. Simple thoraeotomy amply suffices in recent empyema (Foltanek), and is preferred by some to resec tion of the ribs (Koplik, Cautley, Blaker), especially in children under IS months. KopLik recommends it in children over 18 months only when high fever, cardiac weakness, or pericarditis, are present. Should resection of the ribs become advisable later on, it can then be much better undertaken on the patient who has improved in strength.