POSTERIOR TnonacoromY.—The pur pose of this operation is the removal of tumors from the posterior mediastinum, or the extraction of foreign bodies lodged in the bronchi or the oesophagus above the ninth rib. The operation has been performed only a few times, usually for obstruction of the right bronchus (opposite the angle of the fifth rib, on a level with the tip of the spine of the fourth dorsal vertebra). A musculo cutaneous flap covering three ribs is turned back toward the spine. A seg ment of the central rib is resected with a chain-saw, great care being taken not to injure the pleura. The two adjacent arteries are then tied, and the upper and lower ribs resected and turned back with the soft parts. The pleura, thus ex posed, is pulled away. The oesophagus is then recognized by a boogie inserted into it, the bronchus by its incomplete rings of cartilage. An electric head light enables the operator to see the bot tom of the deep hole. The foreign body or tumor is seized and removed, drain age is inserted, and the wound dressed aseptically.
The operation is rarely indicated and still more rarely successful.
Pneumotomy. — Paracentesis of the lung for the purpose of aspirating pus or of injecting antiseptics is to be con demned. Paracentesis for diagnosis, but incision always for treatment.
For hydatid cysts and localized gan grene or abscess, especially if caused by foreign bodies, the operation is clearly indicated as the only probable means of relief from a condition always serious and usually fatal. The operation has also been performed for the drainage of tubercular and bronchiectatic cavities. In the latter class it has been fairly suc cessful when the single suppurating cavity constituted practically the whole disease; but in tuberculosis the wide distribution of the lesions, as well as the unfavorable reaction of the disease to stimulation, forbid any operative inter ference.
—The scat of disease having been determined by the physical signs and aspiration, the superficial tis sues are divided and one or more ribs reseeted, great care being taken to avoid injuring the pleura until it has been ex posed. If adhesions are present the knife is discarded and the pleura and lung incised with the actual cautery heated to a dull-red glow. The seat of disease is thus freely laid open and the patient rolled over to encourage outflow of its contents. Drainage by gauze and
tubes is established and hoemorrhage checked by pressure.
In case the pleural adhesions are ab sent the operation is much more difficult and the prospect poor. Not only may the sudden influx of air carry off the patient in shock, but incision and drain age of the fluttering lung is extremely difficult. Suturing the lung to the chest-wall as a preliminary to incision.
of the pleura is no simple matter, and does not prevent partial pneumothorax.
Irrigation of a cavity in the lung is liable to drown the patient.
Pneumectomy. — Rabbits have sur vived complete extirpation of a lung. Man has not. The excision of tumors and tubercular foci has been practiced along the same lines as pneumectorny. But, to dismiss the subject briefly, tumors are either benign or malignant. If benign they require no interference; if malignant they cannot be entirely moved. As for tuberculosis, Koenig says: "To perform such an operation the surgeon must ignore absolutely all his knowledge of pathology" (Peyrot). Inflation of the Pleura.—Inflation of the pleura with nitrogen-gas to "splint" the tuberculous lung has been mended as a cure by Dr. Murphy, of Chicago. The technique is that of centesis, mutatis mutandis. Nitrogen gas is used, since it remains in the chest unabsorbed for weeks, while other gases are absorbed in a few days.
[I learn from Dr. J. Edward Stubbert that he has been very successful in check ing severe hmmoptysis by inflation of the pleura. EDWARD L. KEYES, JR.] Paracentesis Pericardii.—Puncture of the pericardium is usually performed in the fifth left intercostal space two inches from the border of the sternum, in order to avoid the internal mammary artery. The preparations are the same as for thoracentesis; but the needle is only plunged into the muscle, and then introduced slowly until the pericardium is reached. While the fluid flows away a finger is kept on the pulse, and the tapping interrupted or stopped if the heart's action becomes weak or irregular. Aspiration should not be employed. TxmcATIoNs.—Interference with the heart's action by serous pericarditis calls for paracentesis. TIcemopericardium and pyopericardium demand pericardotomy (See PERICARDIUM).