it is an acute or chronic purulent pleurisy. Acute purulent pleurisy begins in the same way as an ordinary acute serous pleurisy. In the latter the febrile exacerbation disappears in a few days. We have in the acute purulent pleurisy an initial chill or chilliness, with more or less pain in the affected side, dry cough, rapid pulse, elevation of temperature ranging from 101 to 105, increased respiration and later on the physical signs of effusion. The intercostal spaces on affected side are widened and in some rare instances may bulge outward. In inspiration the affected side fails to expand to the extent of the sound side. Vocal fremitus is diminished and most usually imperceptible. There may be lateral displacement of the heart apex and downward displacement of the abdominal viscera. Adhesions may take place between the pleuræ, causing circumscribed and encapsulated effusions.

The fever in these cases persists in spite of treatment. If thoracentesis is performed we obtain fluid containing a large quantity of pus. The skin is dry and hot, appetite impaired and occasionally the patient suffers from night sweats. Close examination will also reveal an edema of the chest wall of the affected side. Chronic purulent pleurisy begins in a similar manner to that of acute pleurisy. The febrile disturbances disappear in a few days, leaving only the physical signs of a collection of fluid in the pleural cavity. It is astonishing that patients suffering from chronic purulent pleurisy do not have more fever considering the amount of pus within the chest wall. I have observed in every case of pus in the pleural cavity an edema of the chest walls as well as the face and cervical region of the diseased side. In fact I believe with others this is one of the most characteristic and diagnostic signs we meet with where pus is present in the pleural cavity. We also observe a bulging or dilatation of the chest and frequently a pointing of the abscess, most usually at the third intercostal space near the sternum. Mensuration shows an increase of the chest wall on the affected side and percussion, flatness or dullness below the level of the fluid. Auscultation may reveal an absent, diminished, distant or bronchial respiratory

murmur.

In purulent pleurisy the absence of the whispered voice through the chest walls is a sign of considerable significance in deciding between the presence of pus or serous effusion. The presence of fibrous deposits and the consistency of the pus interferes with the passage of the voice. If, however, any doubt exists in the mind of the physician or surgeon, thoracentesis or aspiration will clear up the diagnosis. If pus is found the indications are just as urgent for prompt and thorough evacuation as it would be if the same condition existed in any other part of the body. Spontaneous cures are rarely ever produced by absorption. As has been truly said by Douglas Powell: "The spontaneous disappearance of such effusions is too uncommon to be expected, and the process of reabsorption is one too full of peril to be anticipated with anything but dread. It is indeed an attempt at such absorption that occasions the most characteristic hectic symptoms." Clifford Allbutt says, "If pus or septic material be present in the body we must not rest until it is removed. I therefore dislike and reprobate all tampering with an empyema."

The surgical treatment of empyema will depend upon the condition of the patient, the amount of pus present, and the pathological condition of the lung at the time of operation, and consists of thoracentesis, thoracotomy, and thoracoplasty. The objects to be obtained are the removal of the pus and the obliteration of the pus cavity by the safest and most perfect plan. As I have said above, it is unwise, unsurgical, and, I might add, even criminal to allow pus to remain in the pleural cavity with the hopes of it being absorbed. Prompt surgical interference is just as imperative in these diseases as in lumbar, pelvic and liver abscesses or pus in the peritoneal cavity. Thoracentesis is not in itself a surgical procedure that cures empyema, but a valuable and indispensable means of determining the presence of pus and improving temporarily the condition of the patient before thoracotomy is done. It is indicated when the fluid collected in the pleural cavity is sufficient to embarrass the patient's respiration, and if done early frequently prevents adhesion of the pleura. In children it sometimes effects a cure since the fluid in many of these cases is due to the presence of pneumococcus. In performing thoracentesis or aspiration, it is absolutely necessary that the strictest aseptic and antiseptic means should be observed. The skin over the chest wall should be thoroughly scrubbed with soap and water, washed with one to one thousand bichloride solution, and lastly with alcohol or ether. Sterile towels should be placed around the seat of operation and the patient given a stimulant before the needle is introduced so as to prevent cardiac syncope. The patient should be placed in a half-upright position, and the needle introduced through the eighth intercostal space in the post axillary line. A potain or ordinary aspirator may be employed, but before using this the needle should be thoroughly sterilized by boiling. The removal of the fluid should continue until cough or other serious symptoms connected with the circulation or respiration are observed. Too rapid and free removal of the fluid causes the lung which has heretofore been compressed to expand too rapidly, causing cough and frequently, serious heart-failure. This operation is very simple, and if the precautions above referred to are observed there is no special risk to life. No general anesthetic is required. Some local anesthetic, such as cocain, or chloride of ethyl spray may be used. After the needle is withdrawn the puncture is dressed with iodoform gauze and sealed with collodion.

In

Thoracentesis does not cure an empyema, but in a few hours, if not almost immediately after the operation, the patient's respiration and pulse improve, temperature is lowered, and general condition much benefited. twenty-four or forty-eight hours after aspiration, thoracotomy should be done. This consists in making a free incision in the chest wall through the intercostal space for the purpose of allowing pus to be discharged from the pleural cavity. It may be necessary in many instances to resect a portion of the rib in order to insure more perfect drainage, for as has been said, "cases without efficient drainage are entirely without drainage." In thoracotomy the field of operation should be made aseptic as in thoracentesis, and the instruments, as well as the surgeon's hands, should be thoroughly sterilized. Slight chloroform anesthesia is required in children, but local anesthesia of cocain or chloride of ethyl can be used in adults. I have resected as much as two inches of rib in this operation with very little pain to patient by hypodermic use of two per cent. cocain solution. The opening may be made through the sixth or eighth intercostal space in posterior or mid-axillary line. I prefer the eighth, since it is nearer the bottom of the abscess and affords better facilities fordrainage. Having determined upon thoracotomy an incision about two inches long is made down to the pleura. The hemorrhage is then stopped and the hypodermic needle is thrust into the pleural cavity to again ascertain the presence and location of the pus. If the pus be found, the costal-pleura is divided the entire length of the external incision. There will be at once a free flow of pus. A rubber tube or soft catheter is now introduced into the pleural cavity and the same is thoroughly irrigated by a one to ten thousand bichloride solution and then with a normal salt or two per cent. boric acid. During the irrigation the patient's position should be so changed as to allow the solution to enter every corner of the abscess cavity. Great care should be exercised in irrigating the pleural cavity. I have never failed to irrigate every case of thoracotomy and as yet have seen no alarming symptoms. I think it is indicated and the thoroughness with which the flushing is done hastens the expansion of the lung and therefore the filling of the abscess cavity. After irrigation the drainage is kept up by means of rubber tubing. I prefer the soft elastic rubber about threeeighthsof an inch in diameter, fenestrated beyond the point of the costal pleura. Two of these tubes are introduced and held in position by safety-pins passed through the projecting ends. Beneath the safety-pins and around the tubes is placed several layers of iodoform, or sterile gauze. The same material is laid loosely over the end of the tubes. and the whole enveloped in a heavy absorbent dressing of gauze and cotton. The length of the tubes will depend entirelyupon the size and depth of the abscesscavity. Usually it is only necessary to carry them about an inch beyond the costal pleura. The dressing should be changed daily or even twice a day if there is much discharge, and the cavity well irrigated once in twenty-four hours. The tubes should be kept in position as long as there is any purulent discharge. As this diminishes and the fluid becomes serous in character, the tubes are gradually shortened and removed. If the cavity does not close by the expansion of the lungs, contraction of the chest wall and by return to their normal position of the heart and diaphragm within four to six weeks, the chances are that thoracoplasty or the radical operation will have to be performed. For this intractable and dangerous condition, Estlander's operation is advised.