Alfred Sheen, of Cardiff, Scotland, has been successful in securing permanent cures by the method that we have out lined above. and the consensus of opinion seems to be that the most radical meas ures are not indicated. When resection is practiced, a sniall-sized piece of rib, sufficient for one drainage-tube, has been found to answer all the purposes of drainage.
The most important and at the same time the most ingenious operation de vised to accomplish this has been by Dr. Carl Beck, of New York. He uses an elevator by which the rib may be cut and denuded of periosteum at the same time. The indication for the operation is, of course, in children, or those patients in whom a drainage-tube could not be in serted between the ribs. The indorse ment of John Ashhurst, of Philadelphia, is very strong in favor of operative inter ference in cases of empyema, and the mortality he reports is especially- small.
The practice of incision and drainage, of resection of ribs with the insertion of drainage-tubes, of the siphon-apparatus introduced by Mau, all subserve the purpose intended.
Thoracotomy performed in 76 cases of empyema, of which 69 per cent. were cured; about 71 per cent. were able to work within two months. The point of election for the incision is the lateral surface of the thorax, just below the axilla, selecting the fourth, fifth, or sixth rib. A tube carried in at such point will always enter the free cavity, and, with the patient in the proper lat eral position, allow the pus to flow out, a portion of the rib, about 1 eh° inches, being previously removed. If disin fectant washes are indicated, salicylic or boric- acid solutions are preferred. bandage coverin,g. the whole thorax is
used, in connection with special move ments of the body and rest in bed on the, side, inclining to the back. Koenig (Pittsburgh Med. Review, Oct., '91).
Even if the operation for empyema does not effect a cure, it does not make the patient worse. In the large majority of eases operations give great relief, and in it certain proportion, particularly in the young, they give a perfect cure. Very rarely do they cause death. J. ...kshhurst (Internat. Med. 'Mag., June, '94).
Costal trephining is simple of per formance and harmless. Preferably per formed on eighth and especially ninth rib in widest portion, posteriorly seven centimetres from costal angle. Crown of trephine one centimetre in diameter. Several openings may be made, either in the same or adjacent ribs. Rey (Lyon Med., June 23, '95).
In operating for empyema in children, circumscribing of the inferior and poste rior borders of the healthy lung advised, followed by resecting, on the diseased side, the rib situated two or three centi metres above this limit, near the verte bral column. Schultz (Jahrb. d. IIamb. Staatskr., vol. xiii, p. 200).
Ca:se of subpbrenic abscess followed by empyeina successfully treated by resec tion of a rib, drainage, and packing. McNaught (Brit. _lied. Jour., :May 22, '97).
Generally speaking, the case should be a law unto itself, and the surgical means at our command should be accompanied by early out-d.00r exercise and gymnastic performances, especially in children and young adults. The deformity sometimes following the operation may be treated by Sayre's jury-mast, and by the ordi nary remedies and measures for scoliosis.