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weight for weight white bread is better than whole-meal bread. It has been found that on a mixed dietincluding white bread 8 per cent. of the energy valueof the food was lost in the faeces, while with wholemealbread the amount lost was 14 per cent. The vitaminB contained in wholemeal can be supplied in otherways and any laxative effect produced by theindigestible carbohydrate residue can be secured- equally well by the consumption of other vegetableproducts, so that the authors of this report see noreason at present for any universal advocacy ofwholemeal bread.

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WE are happy to be able to announce that theKing’s convalescence is making progress. The collec-tion of pus which formed under the site of the oldscar has now drained and the abscess is nearly healed.X rays show the existence of one or two minutesequestra, but there is good prospect of the conditiondearing up without further interference.

Sir William Thompson, whose death occurred lastSunday at Dublin in his sixty-ninth year, had notlong retired from the position of Registrar-Generalfor Ireland.

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I the annotation on the Birthday Honours inour last issue it should have been stated that Dr.H. K. Graham Hodgson, honorary radiologist toKing’s College Hospital, receives a C.V.O. in recog-nition of his services during the King’s illness.

Mr. T. Franklin Sibly, D.Sc., has accepted the

post of Vice-Chancellor of the University of Reading.The severance of his’ connexion with the Universityof London, where his short term of office as Principalhas entailed heavy responsibilities during a periodof reorganisation, will be widely regretted. The goodwishes of the many friends he has made in Londonwill follow him to his new work.

Mr. Arthur Greenwood, the Minister of Health inthe new Government, was a student of VictoriaUniversity who became head of the EconomicsDepartment of Huddersfield Technical College andlectured on Economics in the University of Leeds.He was Assistant Secretary of the Ministry of Recon-.-struction in 1917-19 and Parliamentary Secretaryto the Ministry of Health during the last LabourParliament. He has been a close student of theilealth and physique of school-children to which helias made some personal contribution. Miss SusanLawrence, M.P., has been appointed Parliamentary:Secretary to the Ministry of Health.

Dr. Christopher Addison has been appointedParliamentary Secretary to the Ministry of Agri-culture and Dr. Drummond Shiels ParliamentaryUnder Secretary to the India Office.

Mr. F. G. H. Holt has been appointed Secretary.and Manager of THE LANCET in succession to thelate Mr. R. E. Sare.

DONATIONS AND BEQUESTS.-Mr. Richard BerrimanChellew, of Tremorvah, Truro, Cornwall, shipowner, lefttIO00 each to the Royal Cornwall Infirmary, and St. Dun-stan’s Hostel for Blinded Sailors and Soldiers.-Mr. LawrenceMatthew, of Elmsholme, Grange-road, Ealing, left .S500each to King Edward’s Memorial Hospital, Ealing, and tothe Hostel of St. Luke’s, Fitzroy-square, W.-Miss MariaMargaretta, Horrocks, of Ribblesdale, Preston, left 2500 tothe Preston and the County of Lancashire Queen VictoriaRoyal Infirmary, and 2300 each to the Preston IndustrialInstitution for Blind Children, the Harris Orphanage,Fulwood, and the Royal Cross School for Deaf and DumbChildren.

Modern Technique in Treatment.A Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.

CCXCIV.-TREATMENT OF EMPYEMA.

THE principles which should guide the treatmentof empyema will be discussed under two headings :(1) Tuberculous, and (2) Non-tuberculous cases.

Tuberculous Empyema.This condition may arise as a late result of pleural

effusion but is more frequently found as a complicationof artificial or spontaneous pneumothorax, andstrictly should be called pyopneumothorax.When a clear effusion develops in the course of

artificial pneumothorax treatment the prognosis doesnot become more serious, but if that effusion ispurulent the outlook at once becomes very grave.Except in a few cases of ruptured lung the conditionis due to the tubercle bacillus alone and not to amixed infection, for not only is the pus characteristicin appearance, but no other organism except thetubercle bacillus is found. As soon as tuberculouspus has developed in the pleural cavity the followingprinciples of treatment should be adopted

1. Remove the pus by aspiration and not by opendrainage.

2. Encourage the lung to expand in order to obliteratethe pneumothorax or empyema cavity.

3. Should the lung fail to re-expand, some thoracoplasticoperation should be performed to obliterate the cavity.

4. Attend to the general condition of the patient.In order to cleanse the cavity and assist the lung

to re-expand it is best to wash it out with a 1 in 5000solution of methylene-blue or with Dakin’s solution.I use two needles for this purpose ; through the upperone oxygen is introduced in a steady stream whilethe pus flows evenly out of the lower needle. Bythis means the intrapleural pressure is kept eventhroughout the procedure. When as much pus aspossible has been removed, methylene-blue or Dakin’ssolution is introduced through the upper needle

and the pleural cavity gently washed out. The lowerneedle is then removed and the intrapleural pressureis taken by a manometer connected with the upperneedle. The pressure is left at about - 6 cm. water. Bythese means the lungwill re-expand in a certain numberof cases, although the aspiration may have to berepeated. If there is a perforation in the visceral pleurait may be difficult to wash out the cavity, and Dakin’ssolution should not be used. In such cases, afterremoving the pus, oil of gomenol has been introduced,but in my experience this has not proved helpful,although good results in a few cases have beendescribed by other writers.

If the lung fails to re-expand, the pleural spaceshould be closed by thoracoplasty, since the mortalityin those cases which are left alone is very high. Itis important to see that the patient’s condition is asgood as possible before operation, and therefore heshould be given a period of treatment in the freshair with a generous diet, including plenty of glucose.A preliminary operation for phrenic evulsion isadvisable and the subsequent thoracoplasty is usuallyperformed in two stages, although some surgeonsprefer to complete it at one operation.

Non-tuberculous Empyema.In these cases treatment depends largely on whether

the pus is free in the pleural cavity, or whether it isin a local pocket cut off from the general pleuralcavity by adherent pleura. If it is free in the pleuralcavity, the condition is really one of pyothorax, andany operation for open drainage will convert it intoan open pyopneumothorax, and in this condition themortality is very high indeed.

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When an open wound is made into the pleuralcavity on one side the pressure is affected practicallyto the same degree on the other side, provided thereare no adhesions and the mediastinum is free. Conse-quently, during inspiration much of the air that shouldenter the lungs through the trachea enters the pleuralcavity through the open wound. In addition tothis many of these cases have a pneumonic condition,so that the lungs are already getting insufficientair and an open pneumothorax results in a fataldyspnoea.The great principle of treatment should therefore

be to avoid an open pneumothorax. This may bedone by inserting a drainage-tube with a valve sothat no air can enter the pleural cavity, but pus canleave-in other words, a negative drainage systemis established. The tube may slip out, however, andtreatment by repeated aspiration in this stage isperhaps better.

In some cases the condition may be cured byaspiration alone, but usually the liquid, which isat first cloudy, becomes more and more purulentand drainage later becomes necessary. As a

result of the aspiration, however, the lung. partiallyre-expands and adhesions form to the chest wall.Moreover, time is given for the acute pneumonicprocess to subside, so that the patient is in a bettercondition to stand an operation.

In practice it is found that in a case of pneumo-coccal lobar pneumonia the empyema forms after thepatient has recovered from the pneumonia, and thereare so many adhesions that the empyema is shut offfrom the main pleural cavity, and consequently opendrainage often gives excellent results. The pus isusually very thick and drainage is necessary.

In cases of streptococcal pneumonia, however,especially in those very acute forms which followinfluenza, a cloudy serous effusion forms early in thedisease whilst the patient is still thoroughly toxic and Ibefore adhesions have had time to form. It is inthese cases that early operation and open drainagegive such disastrous results.W. J. Stone 1 has published the results of three series of

cases:-

(a) Eighty-five cases treated by early operation anddrainage had a mortality of 61-2 per cent.

(b) Ninety-six cases treated by early aspiration and lateoperation had a mortality of 15-6 per cent.

(c) Ninety-four cases treated by early aspiration and lateoperation with a mortality of 9-6 per cent.

The importance of avoiding an open pneumothoraxis clear, and for practical purposes it may be assumedthat when the effusion has developed into frank pusadhesions will have formed, and operation is safe.

Re-expansion.Another important principle in treating empyema

is to encourage the lung to re-expand in order toobliterate the empyema cavity. If this is not donesubsequent thoracoplastic operations may be neces-sary in order to deal with a chronic empyema. There-expansion of the lung is prevented largely by thefibrinous exudate which forms and organises over thevisceral pleura, and by the air which enters throughthe operation wound. To remove the fibrinousmembrane from the lung-in other words, to decor-ticate the lung-the empyema cavity should frequentlybe irrigated with Dakin’s solution. Not only will thisremove the membrane, but it will also tend to sterilisethe empyema cavity and so prevent the pus fromre-forming. The practice of washing out the cavityafter operation is a very important one, and if carriedout carefully will prevent many of the late compli-cations of empyema.

It is also important to attend to the general con-dition of the patient. As a rule, the appetite returnswhen the acute toxic effects of the pneumonia havepassed off, so that it is possible to give a nourishingdiet before operating; this increased appetite is

1 Amer. Jour. Med. Sci., 1919, clviii., 1.

probably another factor in lowering the mortalitywhen preliminary aspiration, rather than earlyoperation, is adopted.

It is, of course, possible to operate too late as wellas too early. On general principles it may be con-sidered safe to operate when the effusion has developedinto frank thick pus and when the patient has gotover the initial toxaemia of the pneumonia. The badresults of early operation are due to the absence ofadhesions with a freely movable mediastinum and tothe toxic condition of the patient.

Conclusion. ’

To sum up, the following principles should beobserved in the treatment of empyema :-

1. Remove the pus, but always avoid an openpneumothorax.

2. Encourage the lung to re-expand and obliteratethe empyema cavity. In order to do this the cavityshould be irrigated with Dakin’s solution, and anydrainage of a large cavity should be arranged as faras possible so that air cannot enter from outside.

3. Sterilise the cavity by frequent irrigations withDakin’s solution.

4. Attend to the general condition and nourishmentof the natient.

L. S. T. BURRELL, M.D., F.R.C.P.,Physician, Royal Free Hospital and Hospital for

Diseases of the Chest, Brompton.

Public Health Services.REPORTS OF MEDICAL OFFICERS OF HEALTH.I THE following are 1928 statistics of three boroughs :!

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* The standardised rate was: for Hove 11’2 and forStafford 10"l.

t Infant deaths in the first week of life only.

Hove.Dr. Augustine Griffith says the chief event of the

year was the extension of the borough, increasingits area from 1594 to 4010 acres. The county councilhas delegated its powers under the Nursing HomesAct and 30 homes have been registered, 3 for maternitycases, 8 for maternity and other, 3 for invalids, and16 for medical and surgical cases. No applications.were refused. An epidemic of measles, with manysevere cases and 10 deaths, raised the question ofthe inadequacy of the hospital to provide for thisdisease. There were 97 admissions for scarlet fever,which caused no deaths in the borough, to 10 formeasles. The council completed 86 houses duringthe year, bringing the total of municipal housesup to 521. There are 46 more in course of erectionand tenders accepted for another 50. There arestill some families "living under bad conditions."The council contribute towards the cost of thePortslade child welfare centre which is used by themothers of their housing estate.