operation is performed, the more quickly will the fistula heal up in favorable cases, and it is evident that the thoracoplastic operation is liable to be more effectual when the layer of connective tissue covering the lung and the wall of the thorax is of moderate thickness, instead of being firm, hard, thick, and unyielding in any direction. Furthermore, one of Estlander's main arguments for delaying the operation until the pleura has been transformed into a thick connective-tissue membrane is this: That the pleura has lost its character of serous membrane, and thus the danger of opening into a pleural cavity is obviated. His reasoning here is not quite correct, because at no period of an empyema is there any danger from opening the pleural cavity under antiseptic precautions in adults, and, besides, if the empyema cavity be local, that is, only a part of the whole pleural cavity, there is no likelihood of opening or cutting into healthy parts of the pleural cavity during the operation, as the adhesions necessarily surrounding the empyema cavity will probably always be extensive enough to prevent such an accident, and in most cases no serous or healthy parts of the pleural cavity will be found at all. As contraindications, advanced tuberculosis of the lung, albuminuria, and extreme debilitation of the patient naturally present themselves. Of the first two named, the albuminuria from amyloid kidney is probably the most important, as such patients are liable to succumb to the shock of even a not very serious or prolonged operation. As to the third contraindication, the debilitation of the patient, Estlander has shown that in patients emaciated almost to a skeleton, and so weak that they could take only a few steps, and in one in which the patient was so weak that he could hardly turn himself in bed, the operation has caused very slight transitory derangements in the patient's condition, and that the slight fever and pain following the operation have disappeared in a few days, to be followed by a remarkable, almost constant, improvement. It is thereby shown that the operation is by no means an exhausting one, but may be resorted to in cases where the patients are extremely debilitated. Operation. In deciding upon the plan of operation in each special case, the first consideration is naturally the shape and size of the cavity, and the plan will be essentially different when the cavity has its greatest length from above downward in a perpendicular direction, and when its direction is transverse from before backward. A longitudinal cavity covered by five, six, or seven ribs, and not extending from the sternum to the vertebral column, but occupying only part of the thoracic cavity, will usually have the greatest depth in the axillary and infra-axillary regions, and will require the resection of small pieces, that is, from 2 to 6 cm., of a large number of ribs. In one of Estlander's cases, in two successive operations, 2 to 6 cm. were resected of not less than nine ribs -from the third to the eleventh inclusive. The first and second ribs are, as a matter of course, so inaccessible and, also, so near the large vessels, that they are out of the question for resection. The twelfth rib is too short and too movable ever to require the operation. A transverse cavity requires the resection of a larger piece of one or a few ribs. As to the length of these pieces, Homén, from a rather theoretic point of view, by mathematic deductions, gives the rule that there should be resected of each rib a piece the length of which is equivalent to the greatest distance between the inner surface of this rib and the pulmonary surface of the cavity. Consequently, of several ribs covering the cavity the largest piece will have to be resected from the rib extending over the middle of the cavity. In the main these theoretic deductions will be found practically applicable. The most important muscles interfered with are the pectoralis major and the serratus anticus major. When the resection is made strictly subperiosteally, there will be the same rehabitation of functions. of these muscles as in the subperiosteal excisions of joints, a more or less extensive formation of new bone always taking place in the periosteal sac of the excised ribs. The incision varies according to the number of ribs to be resected. For the excision of long pieces of two or three ribs one single incision parallel to and either between the two, or along the middle rib of the three, will give sufficient space for the removal of the pieces, especially when, by sinking in of the thorax, the ribs are in more or less close approximation to one another. For the excision of small pieces of a large number of ribs it is best to make several incisions parallel to and above each other in the intercostal spaces, each incision permitting the excision of two ribs. Estlander attempted in such cases to make one vertical incision for the resection of several ribs, but found it inconvenient, as he was obliged to make several secondary incisions at right angles to the first, and so made an irregular wound, requiring several drainage-tubes, and which was slow and somewhat difficult to heal. Through the incision in the skin the periosteum is divided along the external surface of the rib and stripped from the latter by a common gouge. This is usually accomplished without difficulty. Occasionally it is rendered more difficult when, by sinking in of the thorax, the ribs are pressed together, and sometimes even overlap. To perform the operation in such cases it would be necessary to commence with the most superficial rib, of course. As a matter of course, the ribs should not be denuded of periosteum beyond the location of the piece to be excised, with the view, as Homén states, of avoiding necrosis of part of the resected rib. Fear of such a necrosis would be unnecessary if all excision wounds healed by first intention. But this will, as a rule, not take place, because the wound is in connection with an already suppurating cavity, from the walls of which, by the most careful scraping out, all the inflammation-producing germs cannot be removed. The hemorrhage is always insignificant; Estlander has never been obliged to make a single ligation. If the cavity is small and the walls sufficiently firm, it may be well to remove the soft suppurating layer of granulations with the sharp spoon, providing the cavity is so situated that no important organs are thereby endangered, for the following reason: If the thoracoplastic operation is sufficient to produce perfect approximation of the walls of the cavity, the scraping out might make closure by first intention possible. A counteropening from the cavity to the posterior wall of the thorax at the latissimus dorsi muscle is desirable, if not necessary, if the cavity is of considerable size. The external wound should, of course, be united, drained, and dressed antiseptically. The after-treatment lasted generally about ten weeks in the cases in which recovery took place. The fever following the operation was always moderate. The rather constant and more or less violent pain in the operation wound was remarkable. It usually lasted only for a few days, and was easily overcome by morphin. The wound should be dressed every two to four days, according to the amount of discharge, accompanied by washing out with antiseptic fluids through the drainage-tubes. How far the theoretic rational advice of Homén to assist the sinking in of the thoracic wall operated upon, by local pressure upon it, is practicable, cannot yet be stated. In my case it was impossible to resort to this measure because of the pain in the side, which did not permit me to apply the common dressings even as firmly as I wished, but obliged me to apply the roller-bandages as loosely as possible and still hold the dressings in place. An important question during the after-treatment is to determine the progress of the diminution of the cavity, by means of the quantity of fluid injected and the probe. When it is found that a cavity comes to a standstill, a second or even a third operation may have to be resorted to. The time between the two operations in the same case has varied from six weeks to five months. The thoracoplastic operation should undoubtedly be accepted as a valuable, if not a necessary, final step in the treatment of empyema, a general view of which would be nearly as follows: As soon as the diagnosis of an empyema is thoroughly established, aspiration should be first resorted to if the pus in the pleural cavity is not fetid. If, after repeated aspirations, the fever does not decrease nor the lung expand, and the cavity refills rapidly, the empyema operation by incision in loco selecto, and counteropening in the lowest part of the cavity, with resection of a piece of rib, if necessary, and thorough drainage and washing out, is in order. This operation should be performed as early in the disease as possible, as the statistics have shown that the earlier it is performed the better are the chances for recovery. Finally, if this operation does not procure complete recovery, that is, complete closure of the cavity within about six months, the thoracoplastic operation should be performed, and, if necessary, be repeated until perfect recovery is obtained. Estlander has established beyond doubt that some lives otherwise lost may be saved by this operation, and I am glad to do honor to the memory of a man with whom I have been in friendly relations in former years, and whose premature death is a deplorable loss to science, by bringing his operation before the notice of the profession of this country. REPORT OF A CASE OF PENETRATING WOUND OF THE ABDOMEN AND SMALL INTESTINE* THE case to which I desire to call your attention today has a certain practical importance, mainly because it belongs to the class of traumatic and consequently acute injuries, which any of you may occasionally meet with in your future practice, and in which prompt action will be required of you-action so prompt as not to admit of the delay which the obtaining of skilled assistance would cause, and an action on the promptness of which the patient's life depends. The history of the patient whom I now present to you is as follows: Pascale Copelli, an Italian who has been only a short time in this country, forty years of age, a shoemaker, was admitted to the Cook County Hospital at 4 P. M. November 14, 1881. An hour before admission, while engaged in a dispute over cards, he was stabbed with a stiletto in the left side of the abdomen, causing the protrusion of a mass of the small intestines from 8 to 10 feet in length. The weapon also passed obliquely through the intestine, inflicting an incised transverse wound about an inch in length. He became unconscious after receiving the injury, and was brought immediately to the hospital and placed under my care. When I was called to see the patient I had just finished an autopsy lecture in the dead-house, and consequently, as I did not wish to operate upon or even to handle the prolapsed intestines, I requested the house surgeon, Dr. B. C. Meacher, to perform the operation. On examination, an incision through the abdominal wall was discovered, just in front of the left anterior-superior spine of the ilium. Eight to 10 feet of the small intestine which had prolapsed from the abdominal cavity were wrapped up in some old garments, after the removal of which, and some blood, partly fluid and partly clotted, a transverse incision, an inch in length, passing through the peritoneal and muscular coats of the intestine, was found on the convex side of one of the loops. In the central part of the incision the mucous membrane protruded like a hernia, and constant bleeding took place from severed vessels in the submucous tissue of the intestine. No fecal matter or air escaped through the incision, probably because the mucous membrane was not entirely perforated. Dr. Meacher now proceeded to unite the wound in the intestine in the following manner: A slightly curved needle, armed with medium-sized catgut, was introduced on one side, and 1⁄2 inch from the edge of the incision passed through the peritoneal and muscular coats in the submucous tissue, down toward the wound for about 4 inch, and then brought out 1/4 inch from the edge of the wound; reintroduced 1/4 inch from the opposite edge of the wound, passed through the wall of the intestine in the manner described above for 4 inch, and finally again brought through the surface. Six such sutures, distant about three lines from each other, were found to be sufficient for the perfect closure of the wound in the intestine. When these sutures were tied, the hemorrhage from the intestine ceased, *Clinical lecture delivered at Cook County Hospital. Chic. Med. Review, 1882, vol. v, p. 11. and a perfect juxtaposition of the peritoneal surface surrounding the wound was effected to the extent of about 1⁄2 inch. The mass of prolapsed intestines and the anterior wall of the abdomen were now carefully cleansed by irrigation with a 2.5 per cent. solution of carbolic acid. Numerous small adherent clots of blood were removed by disinfected sponges and a dressing forceps, and the prolapsed intestines replaced through the opening in the abdominal wall, not without difficulty, as there was considerable hemorrhage from the abdominal wound. As the opening in the skin was not large enough to allow of thorough examination of the deep parts of the wound, the wound through the integument was dilated about an inch upward and downward, after which it was seen that the opening through the muscles and peritoneum was larger than the original opening in the skin. Two bleeding vessels in the bottom of the wound were caught up and ligated, and thereafter the blood which had entered the abdominal cavity was removed. The latter procedure was effected by means of small disinfected sponges on sponge-holders, which were introduced upward and downward over the whole region of the abdomen, and which brought out a moderate quantity, perhaps two ounces, of blood, partly fluid and partly clotted. Having thus thoroughly cleansed the peritoneal cavity, the wound in the abdominal wall was united by deep and superficial sutures, a drainage-tube inserted in the wound of the abdominal wall only, not extending through the peritoneal wound. Antiseptic dressings were applied and retained in position by a cincture around the abdomen and a spica bandage. After the operation the patient's pulse was 102; temperature, 97° F. The patient showed no evidences of shock when he awoke from the narcosis. He was ordered on absolute diet-that is, he was not allowed to eat or drink anything. For thirst or dryness he was allowed to keep small pieces of ice in the mouth. November 15th, A. M.: Pulse, 126: temperature, 99° F. Tincture of opium, given with the ice, was vomited up twice and was subsequently given per rectum. He rested well during the night and complained of no pain. P. M.: Pulse, 108; temperature, 98° F. November 16th, A. M.: Pulse, 90; temperature, 99.2° F. The patient slept well and has had no recurrence of the vomiting. He has a little tympanites of the abdomen, but no diffused pain, and a feeling of soreness only around the wound. P. M.: Pulse, 90; temperature, 99.4° F. November 17th, A. M.: Pulse, 90; temperature, 99.2° F. Has slept well, and complains of slight pain in the region of the wound. Is getting hungry. P. M.: Pulse, 90; temperature, 99° F. November 18th, A. M.: Pulse, 84; temperature, 99.2° F. ture, 99.6° F. Milk and wine were administered per rectum. November 19th, A. M.: Pulse, 84; temperature, 98.4° F. subsided after the passage of flatus through a rectal tube. is hungry and constantly calling for something to eat. P. M.: Pulse, 90; tempera The pain in the abdomen The patient feels well, but November 20th, A. M.: Pulse, 88; temperature, 98.4° F. The patient was given some oyster soup last night, and complains of a little pain in the left side, but there is no tympanites. November 23d: Pulse, 76; temperature, 98.4° F. The wound was dressed, and the sutures and drainage-tube removed. Perfect union by first intention was obtained. The patient was still confined to liquid diet. November 26th: Pulse and temperature normal. The bowels moved for the first time since the operation, without the use of a laxative. November 27th: The patient is up, walking about the wards, and feels well. December 5th: The patient is walking about the whole day and feels perfectly well. |