resolved upon the radical operation, he expected rather to have a branch from the carotid system to deal with than the vertebral artery.

The only means of determining whether an aneurism in this region is supplied by the carotid system or the vertebral artery is, as is well known, alternate, isolated compression of the vertebral and common carotid arteries. The vertebral artery may be compressed against the cervical vertebræ below the carotid tubercle, but in this place pressure is likely to occlude both the common carotid and the vertebral arteries. Above the carotid tubercle, that is, above the place where the vertebral artery enters the canal, it is possible, by pressure, to occlude the common carotid alone. In the majority of cases this will be conclusive, but it is not always reliable, as the vertebral artery may enter the canal at the fourth or fifth instead of the sixth cervical vertebra. Consequently it is not only always difficult, but it may, in certain cases, be impossible exactly to locate the vessel supplying the aneurism.

If, however, this difficulty has been overcome, that is, if the vertebral artery has been found to be the vessel supplying the aneurism, what is to be done?

A priori, we have the choice of three methods of procedure: First, external compression: second, ligation of the vertebral artery below the carotid tubercle; third, the radical operation, that is, the opening of the sac, removal of the clots, and stoppage of the hemorrhage by ligation or compression. It is almost needless to state that the two first methods are unreliable, but still direct pressure succeeded in stopping the pulsation, with recovery of the patient, in Mobe's case, reported by Kocher.* The majority of patients cannot endure a pressure sufficient to cure the aneurism on account of the excessive pain; but this procedure should, of course, be tried before resorting to more radical measures, as cases may be found in which either the wound in the artery is so small, or the local conditions otherwise so favorable, that absolute immobility of the parts may cure the aneurism. This has been seen in a case cited by Holmest in which spontaneous cure, "aided only by applications of cold,” took place.

The ligation of the central end of the vertebral artery below the carotid tubercle has not been resorted to in any of the successful cases on record, although the artery has been successfully tied at this place for other purposes.

The radical operation has, finally, to be resorted to when pressure fails to cure the aneurism. In the course of the artery through the canal in the transverse processes of the cervical vertebræ, it has hitherto been and will probably always be impossible to apply a ligature to the artery, and consequently the only means by which the hemorrhage in the exposed cavity of the traumatic aneurism can be checked is by plugging the cavity with tampons so as to occlude the opening in the artery. This treatment was successful in Kocher's case (op. cit.), in which pulsa

* Langenbeck's Arch. f. klin. Chir., vol. xii; Virchow-Hirsch Jahresbericht, 1871, vol. ii, p. 331.

†System of Surgery, vol. ii, p. 415.

tion and hemorrhage occurred after a punctured wound in the region of the fifth and sixth cervical vertebræ. When he had laid open the cavity, he could see both ends of the divided vertebral artery, but was unable to seize and ligate them. The cavity was plugged with tampons soaked in perchlorid of iron, and, notwithstanding an attack of erysipelas during the after-treatment, the patient recovered.

The same method was resorted to by Dr. J. Mason Warren,* to the courtesy of whose son, Dr. J. Collins Warren, of Boston, Mass., we are indebted for the report of the case. A boy eleven years of age received a gunshot wound of the vertebral artery, followed by violent hemorrhage. On the following morning Dr. Warren resected a portion of the transverse process of the second or third cervical vertebra. The hemorrhage now recurred. Systematic plugging with bits of sponge was now resorted to, and was followed by the recovery of the patient.

In the upper part of the artery, between the occiput and axis, the ligation can be done, as was shown in our case, and is, it is needless to state, preferable, as it is as safe a method as plugging is unsafe. That the ligation at this point is difficult will be seen by the remark of Vischer† that "the part of the artery between the occiput and the transverse processes of the first and second cervical vertebræ is not accessible for direct ligation, even when a part of the sternocleidomastoid muscle has been removed."

As will be seen from the history of the case, our patient came very near dying on the table, and lost so much blood that immediate transfusion was imperative. It is, however, possible that the ligation at this point in a similar case might be facilitated by, as a preliminary step to, the operation, cutting down upon and securing the central end of the vertebral artery below the carotid tubercle by a loop, to be used for compression during the operation. We shall not hesitate to recommend and employ this procedure in similar cases in the future.

*Surgical Observations, with Cases and Operations, by J. Mason Warren, M.D., Boston, Mass., 1867.

† Billroth and Lücke's Deutsche Chirurgie.

THE THORACOPLASTIC OPERATION OF

ESTLANDER *

In the last twenty years the treatment of empyema has gradually drifted from the repeated aspirations through the stage of the use of the permanent cannula into the stage of free incision, with excision of a piece of a rib, if necessary, and with thorough drainage, with or without the washing-out of the cavity.

The repeated aspiration will possibly retain a permanent place in the treatment of empyemas in children: the permanent cannula will never attain its object, namely, to shut out air from the pleural cavity, except when evacuation and washing out are performed. It will, consequently, have to be abandoned in favor of the more effective method of free incision. But it was natural that the two first-named methods should have their trial before the advent of antiseptic surgery, which has enabled us so to disinfect the air entering the pleural cavity through the drainage-tube at each inspiration as to render this air free from noxious germs, and, consequently, harmless.

The antiseptic method, then, is a conditio sine qua non for the employment of the method of free incision; it also enables us to treat the cavity on rational modern surgical principles; that is, to have two openings, an anterior and a posterior, and sufficient drainage through these to effect not only the evacuation, but also the thorough washing out, and, if necessary, the disinfection, of the cavity.

Homén, in his interesting paper on Estlander's method,† has been able to gather statistics of 52 cases of empyema treated by free incision, with all antiseptic precautions. Of these, 50 per cent. recovered, 33 per cent. died, and in 17 per cent. permanent fistulas remained.

Homén's total statistics include 141 cases treated by free incision, but in all of which strict antiseptic precautions had not been observed. As may be expected, the results of the operation are less favorable than in the class of cases just mentioned. Of these, 46 per cent. recovered, 33 per cent. died, and a permanent fistula remained in 21 per cent.

As our attention is to be called only to the treatment of permanent pleural fistulas, we will now look a little closer into the condition of patients so affected, and then into the prospects for their future.

The fistulous opening leads, with the exception of a few cases, in which the sole remnant of the empyema is a carious rib, into a cavity

* Med. News, 1882, vol. xli, p. 337.

† Langenbeck's Arch. f. klin. (hir., 1881, vol. xxvi, p. 151.

between the thorax and the lung-a cavity with fibrous connectivetissue walls, covered with a layer of soft, pus-secreting granulating tissue, and usually without, but sometimes with, connection with one of the bronchi. It is needless to state that the size of such a cavity, and the amount of purulent matter secreted from its walls, may vary indefinitely; but even a small cavity, with a moderate secretion, is not only a constant inconvenience to the patient, but also a fruitful source of danger to his health and life in the course of time.

The patient usually is pale, weak, and unable to perform the ordinary duties of life. From time to time the fistula may close up, and retention of pus, with subsequent pain, exhaustion, and fever, result. In cases where primary tuberculosis or cheesy deposits in the lung tissue do not exist or are at a standstill, the constant suppuration of the cavity, together with the formation of a deposit of cheesy matter, may be the starting-point for tuberculosis, or, by breaking down the patient's general health, may arouse a latent tuberculosis.

But if tuberculosis be not the main danger in these cases, there is another, just as serious, and perhaps more certain sooner or later to ensue, namely, the amyloid degeneration of the kidney, spleen, and liver. In the majority of fistulas we are liable to find some day, sooner or later, the patient with edema around the malleoli, a slight amount of albumin in the urine-sure signs that he is approaching the inevitable fatal termination.

The objection might be made here that a number of cases are met with and on record in which, for a long series of years, a discharging thoracic cavity has been sustained without much impairment of the general health, without the development of tuberculosis or amyloid degeneration. But this being granted, we must confess that in such cases we never know when the fatal complications will commencewhether in a few months or in a few or many years. Consequently we must regard every permanent empyema cavity as a constant menace to the life of the patient.

In view of these considerations it is not only our prerogative, but also our duty, to try every reasonable means for the obliteration of the cavity.

It is not my intention here to discuss the whole local and general treatment of empyemas, the various fluids injected, and so on. This paper is intended to treat only of those empyema cavities where the rational operation has been performed in time, where antiseptic dressing, accompanied by thorough drainage and washing out with the various disinfectant and alterative fluids, has been used; in short, where all other possible means have been exhausted, but the lung will not expand any more, the thorax cannot sink in any more, and no injection of fluid causes any formation of connective tissue to fill up the cavity; it is in these cases that we are obliged to employ Estlander's operation.

The only way to close an empyema cavity in this condition is to effect, by an operation, a more or less complete contact of the walls of the cavity. As it is not in our power to act upon the internal or pul

monary wall of the cavity, or, in other words, as we are unable to bring the surfaces of the lung out in contact with the wall of the thorax, nothing is left but to obviate the rigidity of the wall of the thorax by taking away, from the ribs covering the cavity, pieces as large and as many as may be necessary to effect a further sinking in of the thoracic wall, and sufficiently extensive to bring the latter in contact with the surface of the lung.

Before discussing the details of the indications for the operation, the operation itself, and the after-treatment, I will report the following case as an illustration:

Right-sided pleurisy, resulting in empyema; repeated aspiration; inefficient fistulous opening discharging for a year and a half; dilatation of opening, drainage, and washing out; no counteropening; daily washing out for a year; removal of 7 cm. of the sixth, 6 cm. of the fifth, and 6 cm. of the fourth rib in the axillary region over a transverse cavity 2 inches long, 11⁄2 inches high, and about 1 inch deep; slight fever for six days; small subcutaneous abscess below the scar after eighteen days; drainage-tube of cavity removed in thirty-seven days; cavity and fistula closed in fifty-four days.

Rebecca S., sixteen years of age, was admitted to Cook County Hospital October 11, 1881. Her history was as follows: Her father died of acute consumption at about the age of thirty. Her mother is still living, thirty-four years of age, and enjoys good health. The patient's hygienic surroundings have been relatively good. She had rubeola and whooping-cough in her sixth year, but had no other sickness until two years and nine months before her admission to the hospital, when she had a severe attack of pleurisy on the right side, which kept her in bed for two weeks and terminated in an empyema. Aspiration was employed three or four times by her physician, Dr. Banga, at intervals of about a week, but difficulty was always experienced in drawing off the pus on account of its admixture with fibrinous matter, so that complete evacuation was impossible. One of the openings made by the aspirator needle remained open and discharged a considerable amount of pus daily for a year and a half. During this time, and until a year before her admission to the hospital, she had no medical treatment. At this time her general health began to be much impaired, she lost flesh and appetite, and became weak and anemic.

On account of this she consulted Dr. E. Andrews, of Chicago, who dilated the already existing opening into the pleural cavity, inserted through this a drainage-tube, and washed out the cavity with carbolic acid solution. The cavity was washed out daily until her admission to the hospital, and in consequence her health improved to some extent.

On admission the patient was found to be small for her age, spare, but not extremely emaciated; she was pale, her appetite poor, and she could not sleep without the use of hypnotics, rather because of her habituation to their use than on account of any especial pain in the side. The right half of the chest was sunken and flattened; the right shoulder was lower than the left; a slight curvature of the spine in the dorsal region, with concavity to the right, was noticeable, which had resulted, as is usual in such cases, from the sinking in of the right wall of the thorax. Two and one-half inches below and 1⁄2 inch to the right of the nipple, between the sixth and seventh ribs, was a fistulous opening leading upward and backward into the empyema cavity, and into which a probe could be passed 51⁄2 to 6 inches. The amount of discharge was from 11⁄2 to 2 tablespoonfuls daily.

Percussion resonance was clear over the clavicular and in the infraclavicular region, down to about the fourth rib, but dull from this point down to the liver. In the place of the clear percussion vesicular respiration was somewhat weak, but still could be distinctly heard. On the dorsal side there were clear percussion and vesicular respiration all over the scapula; in the infrascapular region, dull percussion and no respiration sound.