Death sometimes occurs through asphyxia. The disappearance of fluid from the pleura is followed by an afflux of blood to the capillaries not only of the lately compressed lung, but also of that on the sound side ; for the latter has been likewise relieved from pressure by the return of the heart and mediastinum to their normal position. If the afflux of blood becomes a distinct congestion, acute oedema may result, unless the vessels retain sufficient tonicity to enable them to resist the abnormal pressure. Again, cerebral embolism may occur, as in a case reported by M. Vallin, in which this observer attributed the catastrophe to the sudden disengagement of fibrinous clots which had formed in the pulmonary veins of the affected side. Such clots are liable to become detached as a consequence of ex pansion of the lung, of a sudden movement, or of washing out of the pleu ral cavity.
If after one or more applications of the aspirator we find that purulent fluid is always reproduced, or if the fluid withdrawn is fetid, it is better to make an opening in the chest and introduce a drainage-tube. Opinions are divided as to whether a single or double opening is to be preferred. If a single opening allows of perfect evacuation of the pleural cavity, it seems to be preferable to a double aperture, for the drainage-tube passing from one opening to the other may, as Dr. Allbutt has suggested, act as a seton and keep up a constant irritation. If a single opening be made, the spot selected should be at some point on a level with the lower angle of the scapula. One end of the drainage-tube should be passed through the opening, and the other may be allowed to dip into a large bottle half full of water. The operation should be performed with antiseptic precautions. If chloroform be given, great care must be exercised in its administration. It is better to do without and produce local insensibility by freezing the skin at the site of the operation.
After the tube has been inserted the chest should be bound round with an antiseptic binder, and the pleural cavity may be left to drain itself. It will not be necessary to wash it out with disinfecting solutions unless signs of decomposition have been noticed. If, however, the pus which flows after the operation is fetid, injections of a solution of iodine may be em ployed, diluting one drachm of the tincture with one ounce of water ; or carbolic acid may be used diluted with thirty times its bulk of water. This measure will not be required when the pus continues to be perfectly sweet.
In such cases the introduction of antiseptic solutions seems to keep up an irritation which it is desirable to avoid. Moreover, the operation is usually distressing to the patient, and is not without danger, for syncope and other alarming symptoms have sometimes been seen to follow the in troduction of the fluid. In cases where the empyoma is fetid, Mr. R. W. Parker recommends a double opening to be made in the chest-wall through which the drainage-tube can be threaded, and prefers, to injections of an antiseptic fluid, placing the child daily in a warm bath with sufficient depth of water to cover the upper opening. The water can be medicated, if desired, by a weak antiseptic solution. It is needless to say that all in struments used in operation upon such cases should be scrupulously clean and be carefully disinfected before use.
Complete drainage of the cavity is followed in most cases by great im provement in the condition of the child. His temperature, if it had been ele vated, falls ; his appetite improves ; and if diarrhcea had been present, the stools become fewer in number and much healthier in appearance. Any after elevation of the temperature or return of the signs of 'distress and irritation should lead us to suspect some retention of fluid in the pleural cavity, or the onset of some complication, such as a secondary tuberculosis. In the first case it will be well to wash out the chest thoroughly. In the second, special measures must be resorted to for the treatment of the complication. If secondary tuberculosis have come on, the prospects of the child are most gloomy, and little can be done to arrest the downward progress of the dis ease.
In cases where the above method of drainage fails to bring about closure of the cavity, owing to imperfect expansion of the lung or rigidity of the chest-walls, which are slow to adapt themselves to the diminished size of the organ, resection of a portion of the rib seems often to be of advan tage in helping the disease to a favourable termination.
In all cases of chronic empyema the strength of the child should be sup ported by a free supply of nourishing food. Meat (pounded if necessary) strong meat essence, milk, eggs, etc., should be given in quantities such as the patient can digest ; and port wine, St. Raphael tannin wine, or the brandy-and-egg mixture should be offered in sufficient doses. Cod-liver oil is also, especially in children of scrofulous constitution, an important addition to the treatment.