SURGICAL MEASURES. — Among the surgical measures, pneumonotomy, or simple incision into the lung, is the preferable operation. It is indicated, according to Reclus, when the cavity, though distinctly circumscribed, is large, and when there are evidences of tox winia through retained putrid contents.
Case of a man treated surgically for gangrene of the lung. An incision being made in the left second intercostal space, the lung-tissue covered by pleura was seized with a pair of forceps. The pleura and the lung were then successively in cised, about two centimetres of lung having to be traversed before the puru lent cavity, which had a capacity of 2 iluidounces, was reached. The cavity was carefully disinfected, its parietes washed with camphorated naphthol, and finally two large drainage-tubes secured in it by suturing on each side. All coughs, expectoration, and morbid phys ical signs disappeared. Wrier (Lancet, Apr. 2, '92).
Pneumonotomy performed in a case of gangrene of the lung in which the ex pectoration had been abundant and fetid for two years. The wound healed in three weeks. Podreze (Revue G6n. de Clin. et de Tiler., Nov. 16, '95).
Of the three varieties of pulmonary gangrene,—the diffuse, the circumscribed, and the pleuro-pulmonary,—the last two are best treated by operation. Portions of one or more ribs are removed, the gangrenous cavity is entered, and all pus pockets broken up. Free drainage is established. If the pleura is not ad herent, the risk of the operation is in creased, but the most serious complica tion is hemorrhage, which can be stopped only by firm packing. H. Vulliet (Revue Feb. 20, 1900).
The fears formerly entertained that collapse of the lung would follow pene tration from the surface have been allayed by modern experimentation, and small portions of the lung have been re moved without untoward results, re covery following in the majority of cases.
Pneumonotomy consists in making a free incision down to the pleura, resect ing one or more ribs if needed. The cautery-knife is then used to penetrate the pulmonary cavity. When the lung is adherent to the chest-wall, this step of the operation is easy. When, how ever, it is not, the majority of surgeons prefer to elevate the portion of lung overlaying the cavity and to fasten it to the external wound by a row of sutures. Adhesion taking place in a few hours, the cautery may then be used to open the gangrenous focus. Success, how ever, has also followed incision through pulmonary tissue.
In gangrene the mortality without operation is about SO per cent. In cer tain eases of diffuse gangrene operation is out of the question, and the case is hopeless. In circumscribed gangrene operation offers to the patient a fair chance of recovery.
The operation, if otherwise indicated, should be performed, adhesions or no ad hesions.
Heydweiller collected 40 cases treated by operation prior to 1892, with 22 re coveries, 4 improvements, and 14 deaths. The more recent cases of number 14 operations, 11 of the patients being cured, 1 being improved, and only 2 having died. Editorial (Med. News, Feb. 13, '97).
The cavity is carefully emptied of its contents, gently relieved of all detritus, disinfected, and drained.
In establishing free drainage in cases of gangrene, it is of the first importance to have a soft tube of suitable and meas ured length, so as to avoid irritation, coughing, and erosion of the larger blood vessels. The putrid expectoration and fever should diminish or cease soon after the operation. In 55 eases of gangrene following pneumbnia recovery took place in 39; in 4 eases following bronchiec tasis only 1 recovered; in 7 embolic cases only 2 recovered. Tuffier (La. Ceram. 316d., Aug. 21. '97).
Adhesions between the two pleural sur faces should be secured before incising the pleura, to prevent collapse of the I lung by deep sutures before the pleural incision is made. Irrigation is danger ous after the operation; it causes cough ing and may thus contaminate the healthy lung-tissue. Tamponade has the advantage over drainage that it is hemostatic, while it induces drainage. The patient must not be allowed to lie too long on the healthy side to pre vent infecting the healthy lung with the gangrenous secretions. Fritz Berndt (Wiener klin. Rundschau, May 27, 1900).
Pneumonectomy, or exsection of a portion of the pulmonary tissue, merly failed, according to Delageniere, because surgeons were content merely to drain the gangrenous focus, instead of extirpating it as completely as possible. The pleura should be opened very freely at the side by an L-shaped or U-shaped incision, or behind by a vertical one, ac cording to circumstances. The opera tor should not hesitate to resect sound ribs, if necessary. The operation is con cluded in the same manner as the latter, by drainage. Strict antisepsis is an all important element of success.