When fluid has ceased to be serous and has become purulent, as in empyema, it is often so thick that it will not flow through any hollow instrument. In such an event free incision should be made. When the thorax is involved incision is made between the ribs, and in order to maintain drainage a good-sized drainage tube should be inserted. This at times may be so compressed between the ribs that an inch or more of one rib should be exsected to provide against this possibility.
TRANSFUSION AND INFUSION.
Though much has been said concerning the indications for these procedures no explicit directions have been given. While they are often emergency measures they are, nevertheless, frequently practised. In well-regulated institutions the conveniences are always at hand for instant resort when needed; but it would be well for every general practitioner to have ready at all times the few things that are required, for at least hypodermoclysis. In country practice, however, a clean fountain syringe, a suitable aspirator needle (both carefully sterilized), some boiled water, table salt (when nothing else is at hand), and soap and water for sterilization of the operator’s hands and the patient’s skin are all that are necessary. In every outfit there should be a needle which may be used for this purpose. It may be carried in a glass tube, always sterilized, and ready for use. No fountain syringe should be used which has not been freshly boiled, except in an emergency. Tablets containing common salt in definite amount, so that a solution of given strength can be made by adding them to a definite amount of water, can be procured. With such a needle, a few tablets, and a fountain syringe the surgeon is prepared for any emergency.
For intravenous infusion for which no pressure is required, an ordinary funnel, with rubber tubing attached, will be sufficient without the use of a rubber bag.
The use of salt solution has supplanted the transfusion of blood. This requires a source of blood which is not always at hand and an amount of attention which can rarely be given in emergencies; moreover, it has been shown that the injection even of defibrinated blood is a dangerous procedure, because of liberation of hemoglobin and destruction of white corpuscles, with the liability to coagulation of the blood from increase of fibrin ferment, and the possible death of the patient. Direct transfusion from another person into the veins of the patient is also difficult, and has rarely been of service.
As already stated in the chapter on Shock, the best solution for infusion is composed of calcium chloride 2 parts, potassium chloride 3 parts, sodium chloride 9 parts, sterile water, 1000 parts. The addition of one part of sodium bicarbonate will sometimes prove of advantage, while in diabetic cases this may be increased to three parts to a thousand. It has also been suggested to add a small proportion of sugar, even up to thirty parts, to this solution, in order to increase osmotic action and better preserve the red corpuscles from injury. It is supposed also to give a certain nutritive value.
When the fluid is injected into the venous system all that is desired is that it barely enter; consequently the receptacle containing the fluid should be held but a few inches above the level of the opening. When hypodermoclysis is practised more pressure will be needed and a greater difference of level should be maintained. In the veins the amount injected should not exceed 100 Cc. each minute. From 500 to 1500 Cc. may be used altogether. There need be no hesitation in introducing it at a temperature considerably above the body normal, and in cases of shock it may be introduced even at 115° F. The character of the pulse will afford the indication as to the amount of fluid to be used as well as the wisdom of repeating the measure after an interval.
For intravenous infusion a vein in the arm is usually exposed and the needle point carefully inserted. It is an advantage to have for this purpose a special needle, made with a blunted extremity, enlarged a little, so that by the use of a temporary ligature the vein may be held tightly around the cannula, for such it really is, and the escape of fluid be prevented. After withdrawal of the needle a double ligature should be placed for purposes of security. The limb should also be kept at rest for a few days.
For hypodermoclysis from 500 to 1000 Cc. may be employed; the anterior abdominal wall, the flank, the thigh, and the retromammary tissues are the best regions in which to inject the solution. Absorption will be assisted by gentle massage. Local anesthesia by the freezing spray, or by cocaine, will rob the procedure of its discomfort. Adrenalin may be added to the solution, whose formula is given above, in emergency cases where it seems to be especially needed. In instances where infusion is practised for the purpose of washing out the blood, i. e., in the acute toxemia of uremia, alcoholism, etc., nothing of the kind will be required; but in conditions of lowered blood pressure, i. e., shock, it will prove of great value, as already indicated.