CASES OF LONG STANDING With &SWIM, deformity, and great rigidity of the tal walls, may require what is known as the Letievant-Estlander operation, an operation first suggested by Letiovant and practiced by Estlander. The tion has been variously applied to any resection of ribs for the purpose of the approximation of the walls of the chest. The most important distinction to be made, however, is that originally the eration included more than one rib and several inches of length in the resection. [Frederick S. Dennis has awarded the credit of the first suggestion of resection of the ribs to Dr. Warren Stone, of New Orleans, while Dollinger (Annual, .90) and others state that LetiGvant first suggested it.
The two suggestions were probably original so far as each of the above sur geons were concerned. Many operations have heeu done in this way, as seen in the case of W. W. Keen. J. _MCFADDEN GASTON, JR.] The operation of Schede consists in the complete removal of the muscles and tissues adherent or attached to the ribs, with the exception of the skin, the fascia, and the parietal pleune, aud these are stitched together and form the only pro tection to the chest at the point of the operation, and the only hope of restoring the tissue lies in the granulating process.
The incision is a IJ-shaped one, ex tending from the axilla in front down ward to the limit of the pleura and ward and upward to the second rib, lift ing the scapula in the removal of the bony flaps. This operation has been ad vised as a modification of Estlander's operation, in cases where the pleura is much thickened and where the walls fail to respond to ordinary means of reducing the cavity of the chest.
Estlander's operation—which consists in removing, not only a certain length or a certain number of ribs, but all the ribs lying in the wall of the empyeina —performed twelve times, the results being nine ciires and three deaths, one from tuberculosis, the second froni car diac disease, and the third from albu minutia. J. Boeckel (Revue Chin, Apr. 10, 'SS).
Extensive thoracoplasty by Schede's method performed in a ease of thoracic einpyema of twelve years' duration. Sec ond operation perfornied three months after first. Reeovery was without inci dent, though slow. Eight months after the second operation the wound broke open again and discharged a small quantity of pus. By a third operation some more of the chest-wall at the upper posterior angle was removed. A cavity three and one-half inches long and as.
thick as the thumb was found. This was nearly obliterated by granulation tissue. W. W. Keen (Annals of Surgery, June, '95).
One hundred and twenty--nine eases of empyema treated by resection of the ehest-wall, in which 56.3 per cent. were healed, 20 per cent. improved, 3 per cent.
age, and Estlander's operation have been fruitlessly employed. He reported a suc cessful case in which this operation was performed after other measures had been unsuccessfully resorted to during seven years.
Roswell Park, of Buffalo, states that the treatment of empyema should be based upon the same principles as are applicable to other abscesses. In acute cases presenting streptococcic and staphy lococcic suppuration it may be sufficient in a few instances to simply aspirate. A summary of the treatment to be em ployed in cases of empyema may include the following features:— (a) Prophylaxis.
1. Care should be taken to jugulate, if possible, all cases of incipient pneu monia, pleurisy, and bronchitis.
unchanged, and 20 per cent. died. There is little or no tendency to spinal curva ture or to impairment of function of the corresponding upper extremity follow ing these operations. Voswinkel (Dent. Zeit. f. Chin, B. 45, S. 77).
Deformity observed resulting from re moval of the fourth, fifth, sixth, and seventh ribs. This consisted of a large depression of the whole left side, begin ning about two inches below the clavicle and extending below the free border of the ribs. There was a marked degree of lateral curvature. L. Emmett IfoIt (Archives of Ped., Jan., '06).
In the treatment of empyona success obtained by removing the whole of the chest-wall covering the cavity (Schede) and breaking up and loosening of the contracted picture (Delorme). Jordan (Med. Record, May 14, '98).
Christian Fenger, of Chicago, holds that there are certain cases in which Schede's operation is required; viz., after milder measures, such as incision, drain 2. All penetrating wounds of the chest, whether from gunshot wounds or stab wounds, should be hermetically sealed.
3. Collections of blood-serum or air may be evacuated early by aspiration.
4. Children should be carefully ex amined. in cases of continued fever, sweats, and hectic, and prompt measures taken to remove the possibility of puru lent collections, by exploration.
(b) Operative treatment.
5. Incision and drainage.
G. Trap-door for exploration in cases of tuberculous deposits of caseous ma terial.
7. Estlander's operation for the old and stubborn cases of fistulous empyema.
S. Schede's operation for thickened pleur, and resistance to the recourse to Estlander's operation or to Delorme's, Quenu's, or Gaston's modifications of flap-operations.
9. Iodoform or plain sterilized gauze tamponage for stimulating the granula tion and securing constant drainage.
10. Permanganate-of-potash solutions for offensive discharges.
The successful results which have fol lowed Estlander's and Schede's opera tions in certain severe cases of empyema have led some surgeons to take the too extreme position of advocating resection of the rib in all eases. Incision, the insertion of a drainage-tube, and irriga tion with mild antiseptic solutions con sidered as the treatment most suitable for the g-reat majority of cases. Edmund Andrews (Jour. Amer. Med. Assoc., Mar. 4, '99).