4. Resection of the ribs affords the surest method of thoroughly evacuating the pus. Under chloroform amestliesia, an incision about 6-8 cm. in length is made directly to the middle of the rib (8-9 rib in the posterior axillary or scapulary line). The periosteum is elevated with the periosteurn elevator, and about 5-6 cm. of the rib is cut away with the bone forceps (placed vertically from edge to edge, the periosteum elevator being interposed). A special rib-shears, such as has been in use for twenty-five years at Hagenbach's Clinic in Basle, is useful (see Fig. 92).
The ends of ribs not covered by periosteum and soft parts must not be allowed to remain. The pleura is then incised, the pus slowly evacu ated, and the wound in the pleura enlarged according to the size of the piece of rib which has been removed. Schede recommends an additional transverse incision through the middle of the pleura, the intercostal artery being tied, in order to be able to oversee the pleural cavity and to thoroughly remove large coagula with sponges. No irrigation. Scherle places several very thick but very short drainage tubes in the wound, which reach merely to the pleural cavity, and are cut off at the level of the skin and fastened by means of large safety pins. A piece of protec tive silk the size of a hand and fitting snugly to the skin is placed over them. Over this a thick, aseptic dressing is applied, which may- remain for several days if it does not become saturated. At any rate the second dressing should be allowed to remain for a long time, as this is impor tant for healing. Dining the first dressing the lung often comes in con tact with the chest wall once more (Schetle), and expands again within a few days (Kissel). Therefore, the disadvantages of a pneumothorax, which the advocates of the siphon drainage denounce, do not exist. The drainage tubes are soon removed with the exception of one, which is removed only when the discharge ceases and the vesicular breathing is heard next to the wound.
Rib resection may be undertaken by any physician, and is a much easier operation than for instance tracheotomy. It is an operation that brings extreme gratitude, since in favorable cases great relief is experi enced, the fever disappears in from one to two days, and recovery rap idly takes place. As usual pneurnococcic empyema furnishes the best prognosis, as it is cured in about six weeks. The prognosis depends materially upon the underlying disease. Of 2SS collective cases 13.9 per cent. died of rnetapneumonic empyema, 32 per cent. of secondary and metastatic enapyema. But even a pure pneumococeus pneumonia which often collies to operation in a hopeless condition may terminate fatally, from collapse or sepsis following the operation, or later from pulmonary abscess, sacculated portions of an empyema not having been touched by the operation, from purulent pericarditis, metastases, bronchopneumonia, etc.
Empyeina neeessitatis also requires operative interference; and like wise empyema rupturing through the bronchi, if recovery does not take place spontaneously. In bilateral empyema, one side is first operated upon, and the side which is only to be operated upon after some time is aspirated. It is of interest that bilateral resection of ribs undertaken simultaneously has been done without any bad results. Long-standing
fistulous openings are especially observed in cases operated upon late, in which extensive adhesions and perhaps sacculated areas are present, or when an insufficient number of ribs have been resected, the pleural opening having been made too small.
In old empyema with tough cavity formation simple resection is frequently without result, but on the other hand Estlander's multiple resection of ribs or thoracic resection advised by Schede, i.e., the removal of the ribs and the tough intercostal portions within reach of the ernpyenia cavity, are useful. Recently, in difficult cases even the stripping off of the thickened pleura from the puhnonary surface is advocated.
Reviewing the different methods of treatment of empyema, we can not give preference to any one method. Thoraeotorny, especially if combined with costal resection, always gives the most certain results. These measures should also always be used where the children are still strong and in older cases. Most surgeons, as well as many pediatrists (Hagenbach-Burkhardt, Baginsky), prefer costal resection from the first. In frail or debilitated children where it is desirable to omit amestliesia the siphon drainage may be trivet in fresh cases; but one must always be prepared for failure. I myself have seen but little good result. In ichorous, in old empyema, in strepto- and staphylococcic empyema, in pyopneumothorax, it is to be discarded from the first. In a large num ber of cases under similar conditions, Schede found that costal resection yields far better results as regards mortality and recovery than the siphon drainage.
The treatment of the remaining disturbances (thickening, contrac tions) following a successful operation for enipyerna is the same as for the sequelm of serous pleurisy (see above).
Peripleuritis or phlegmon endothoracica is described as a rare ab cess formation between the costal pleura and chest wall. The affection may occur primarily' following injuries, or secondarily in perforating empyerna, caries of the ribs, or actinonlycosis. It causes circumscribed dulness and may rupture externally, causing numerous fistula,. The difficult differentiation front a circumscribed empyerna is made possible by the presence of the normal pulmonary sound below the dulness, and by good motility of the lungs during respiration.
Pneumothorax presents scarcely anything special in children, ex cept in the manner of origin.
It is much rarer than in adults, and occurs more frequently, inde pendently of pulmonary tuberculosis, as ill the course of bronchopneu monia and gangrene of the lungs, quite frequently in measles, next in pulmonary emphysema, diphtheria, whooping-cough, in foreign bodies in the lungs (Zuppinger), rupture of softened bronchial glands, and after injuries. I have seen a well-marked case without external injury, fol lowing a fall from a tree.
The symptoms and treatment are the same as in adults. In the presence of pleuritic adhesions only a partial prietimothorax is the result. At a later stage pyopneumothorax often develops. In a case where valvular pyopneurnothorax and rapid general external emphy sema of high grade developed after a subcutaneous fracture of rib in a four year old boy, threatened death was averted by thoraeotomy (von Muralt).