or when operation is not indicated. In very large effusions it is wise to aspirate and withdraw part of the effusion several days before doing a radical operation. After the aspiration the patient takes an anesthetic with more safety, and the danger is obviated of suddenly evacuating a large effusion. The trocar must not be used except in an emergency; the aspirator is greatly to be preferred. The aspirator evacuates the fluid, and, as bacteria do not enter, the lung expands and infection does not occur. The skin, the instruments, and the surgeon's hands must be asepticized. Give the patient a little whiskey, and, unless he is very weak, make him sit up in bed. The arm hangs by the side, and the surgeon introduces the needle in the fifth interspace, just in front of the angle of the scapula. The surgeon marks the upper border of the sixth rib with the index finger, and plunges in the needle just above the finger, thus avoiding the intercostal artery, which lies along the lower border of the rib above. Always guard the needle with a finger to prevent its going in too far. After withdrawing the needle, place iodoform collodion over the opening into the chest. In pleuritic effusion, if the lungs will not expand after tappings, perform thoracotomy.

Thoracotomy is an incision into the cavity of an empyema. It may be merely an intercostal incision, or may be an opening into the chest after resecting a portion of a rib. The instruments required are a scalpel, a grooved director, forceps (hemostatic and dissecting-), scissors, a dry dissector, retractors, bone-instruments (in case rib-excision is required), drainage-tubes, and needles. Chloroform is given the patient, who lies supine at the

edge of the table, with the arm elevated to a right angle with the body. Make an incision about three inches in length along the upper border of the lower rib bounding the space it is proposed to penetrate. This space is either the sixth or the seventh, and the desired site is in front of the posterior axillary fold. Incise the superficial structures, divide the intercostal muscles near the rib, push a grooved director through the pleura, and enlarge the opening by means of forceps and the finger. The finger removes all masses of tubercular material or aplastic lymph within reach. Some surgeons advocate immediate irrigation, but this procedure is unsafe, as it

FIG. 186.-Resection of rib (Esmarch and Kowalzig).

may produce dyspnea or pleuritic epilepsy, and has caused death. In some cases a counter-opening is made by cutting. down upon the long probe which is pushed against the chestwall after being introduced through the incision; in other cases it is necessary to resect a rib (page 609; Fig. 186). A short drainage-tube is introduced and stitched in place. If a counter-opening has been made introduce another short tube, but do not pull one tube through both openings. Arrest bleeding, suture the skin, dust with iodoform, dress with gauze, wood-wool, and a binder, and have the dressings changed as soon as they become soaked at one point. This operation is rarely curative, and in most cases the intercostal spaces are too narrow to permit of satisfactory drainage. It is far better to remove a piece of rib as directed on page 609 (see Fig. 186). Remove the periosteum and open the pleura. After opening the pleura insert a finger into the pleural cavity. Note if the lung can expand. If it is evident that it can expand, insert a short drainage-tube, close the soft parts, and dress. Several times a day change the patient's position. At each change have him on the diseased side for half an hour, and with the foot of the bed raised for half an hour. Favor expansion by causing the patient to blow into a washbottle filled with water. Remove the tube when the discharge becomes thin and scanty (about the eighth or tenth day, as a rule). If the lung is bound down with adhesions and cannot expand to fill the space vacated by the pus, perform the operation of Schede or Estlander.

Thoracoplasty (Estlander's operation) is employed in old cases of empyema in which drainage has failed, and in cases with retracted chest-walls, collapsed lungs, thickened pleura, and cavities whose rigid walls will not collapse. The procedure recognises the fact that after pus is evacuated, if the lung is adherent, it cannot expand to fill the space once occupied by fluid, and that the rigid chest cannot fall in as a substitute for the lung, and seeks to destroy the rigidity of the chest and permit it to collapse and thus obliterate the cavity of the empyema. When the surgeon resects a rib and finds a cavity with uncollapsable walls, or a lung bound down with firm adhesions, he should perform thoracoplasty. This operation causes the obliteration of the cavity by collapsing that portion of the chest-wall overlying it. The cavity is in the upper or central part of the pleural space (Treves). The instruments required are the same as those for resection of a rib. The position is the same as that for rib-resection. The length of the incision depends on the size of

the cavity. The surgeon usually removes portions of the second, third, fourth, fifth, sixth, and seventh ribs. Make a transverse incision along the center of an intercostal space, and through this incision remove the ribs above and below by the method set forth on page 609 (the removal of six ribs will require three incisions). Instead of this incision, we can make a vertical incision or a U shaped flap. Always take away the periosteum. Treves recommends that the cavity be at once washed out with corrosive sublimate (11000); that if small it be packed with iodoform gauze and allowed to granulate; that if large it be drained by a large tube, the skin being sutured by silkworm-gut. Irrigation is thought by many to be dangerous and to possess no special power for good.

Schede's Operation.-Schede showed that when the pleura is much thickened even Estlander's operation will not permit the chest-wall to collapse and fill the cavity once occupied by the fluid. Instruments, same as for Estlander's operation, plus boneshears. A U-shaped flap is made from the level of the axilla in front to the level of the second rib and between the scapula and spine behind. The lowest level of this incision corresponds to the lowest limit of the pleura (Fig. 187). The flap is loosened and raised, and the scapula is lifted with it. The ribs from the second rib down and from the costal cartilages to the tubercles are removed, along with the chest-muscles and the pleura. This is accomplished by cutting with bone-shears and scissors. Hemorrhage is arrested. The pleura is curetted. A drainage-tube or a piece of iodoform gauze is introduced, and the raw flap is laid against the visceral layer of the pleura. The superficial incision is sutured.

FIG. 187.-Incision for Schede's operation of thoracoplasty (Esmarch and Kowalzig.)

Pneumotomy for Abscess of the Lung.-The instruments required are scalpels, hemostatic forceps, dissectingforceps, dry dissector, retractors, periosteum elevator, meta

carpal saw, scissors, needles, curved and straight, Paquelin's cautery.

Operation. Place the patient recumbent with the shoulders a little raised. Make a U-shaped flap over the suspected trouble. If the intercostal spaces are wide, cut down in a space to the pleura. If they are not wide, resect a rib. If it is found that adhesions do not exist between the pulmonary and costal layers of the pleura, stitch these layers together with catgut and postpone further operation for forty-eight hours. If adhesions exist, proceed at once. Incise the agglutinated layers of the pleura, and pass an aspirating-needle into the lung in various directions. When the abscess is located open it by the cautery. Carry the Paquelin cautery slowly into the lung in the direction of the abscess-cavity. The cautery-knife should be at a dull-red heat.

Fowler calls attention to the fact that lung-tissue is so insensitive that the administration of ether can be suspended as soon as the pleura has been opened. When the cautery opens the cavity withdraw the instrument and insert a drainage-tube or a bit of iodoform gauze, and suture the flap of superficial tissue. If the abscess is not found after one or two punctures with the aspirating-needle, abandon the attempt.

Tuffier explores for an abscess by what he calls décollement of the parietal pleura. He exposes the parietal layer, passes his hand between this layer and the chest-wall, strips the pleura off over a considerable area, and is able to feel the lung below, and thus determine its condition.

XXVI. DISEASES AND INJURIES OF THE UPPER DIGESTIVE TRACT.

Diseases of the Mouth, Tongue, and Esophagus. -Harelip and Cleft Palate.-Harclip is a congenital cleft in the upper lip due to defective development. Cleft palate is a congenital fissure in the soft palate or in both the hard and soft palates. In harelip the cleft is usually complete, through the entire lip into the nostril, but in rare cases it may only show as a furrow in the mucous edge or as a split from the nostril partly into the lip. It is most common on the left side. In double harelip the central portion of the lip is often adherent to the tip of the nose (Bowlby). Double harelip may be free from complication, but is often associated with a malformation of the alveolus and palate (Heath). Median harelip is exceedingly rare. In cleft palate the

septum of the nose is usually adherent to the palatine process opposite the side upon which the fissure exists. In those rare cases of cleft palate double in front the nasal septum is attached only to the premaxillary bone, and the premaxillary bone is not attached at all to the superior maxillæ. In harelip there is often a cleft in the alveolus, and almost always flattening of the corresponding side of the nose. Harelip is often associated with cleft palate, talipes, and other deformities. It is a great deformity, and interferes with sucking, swallowing, and articulation.

Operation for harelip should be performed between the third and sixth months of life in a child in good health, free from stomach trouble, cough, or coryza, but operation is not advisable in the early weeks of life. Always, if possible, operate before dentition begins (seventh month). If the child is in poor health, postpone the operation until restoration has so far advanced as to render operation safe. While waiting for operation be sure the child is getting enough food. If it cannot suck, feed it with a spoon. If a cleft exists in the palate, operate first upon the lip, because the pressure of the parts after the edges of the gap are approximated aids in the closure of the bony cleft. Cleft palate interferes with sucking, deglutition, mastication, and articulation. In severe cases the food passes into the nose and excites inflammation. Loss of control of the palate-muscles always exists, and liquids and solids are liable to pass into the windpipe. Clefts in the hard palate should not be operated on until the second year, but should be operated upon then, otherwise speech will be permanently affected. Some surgeons refuse to operate until the tenth or twelfth year, but operation done this late will not correct speech-defect. In many cases the passage of food and drink into the nose can largely be prevented by the use of

a diaphragm. The patient at the period of operation should be well and free from cough.

FIG. 188.-Malgaigne's operation for harelip.

Operation for Harelip.-The instruments required are a tenotome, harelipclamps, toothed forceps, hemostatic forceps, scissors curved on the flat and pointed, straight blunt-pointed scissors, needles (straight and curved), silver wire or silkworm-gut and silk sutures, a mouth-gag and tongueforceps, a needle-holder, and sequestrum-forceps, each blade protected by a rubber tube. Wrap the child in a