The subsequent management of such a case is usually simple. After the first few days it may be advisable to practise irrigation. According to the age of the case will be found the expansile capacity of the lung. The lung itself expands by relief of pressure and by its own inherent tendencies and returning function. Again by a process of granulation it is gradually made to attach itself to the chest wall and is thus withdrawn toward its surface. The combination of these agencies will usually in time produce satisfactory results. The functionating power of the lung may be determined by filling the cavity with fluid, the patient lying upon the other side, and then noticing the difference between the amount of fluid held in extreme inspiration and extreme expiration.
Thoracoplastic Operations.
—In old and neglected cases of empyema, especially of tuberculous type, the pleura itself becomes more or less thickened and stiffened, and affords such an obstacle to lung expansion as to justify more radical measures. These have sometimes to be undertaken as secondary operations, while in other instances, where there has been spontaneous perforation and escape of purulent overflow, perhaps for months or years, the necessity for such measures may be foreseen. This necessity was first appreciated by Warren Stone, an American surgeon, but the procedure was first formally placed before the profession by Estlander, of Helsingfors. The principle upon which it and all similar operations has been based may be likened to the various efforts which it is necessary to make when a person tries to collapse an ordinary barrel whose heads have been knocked out. So long as the hoops of the barrel are intact the staves cause it to retain its cylindrical form. If, however, the hoops be divided it easily falls apart. In the case of a human chest, the lung, having been so long bound down, is incapable of expansion, and the chest walls are rigidly maintained by virtue of the hoop-like arrangement of the ribs. It is necessary then to divide and remove a section from several of these ribs, in order that the wall, falling in, may meet, at least half-way, the lung, which may be expected to partially expand to meet it.
Fig. 519
Incision for resection of thorax. (Bergmann.)
Fig. 520
Trap-door thoracotomy. (Lejars.)
The original Estlander operation has been modified by Schede, and as now practised is made by a long incision passing obliquely across the lateral aspect of the chest, from the origin of the pectoralis major, at the level of the axilla, to the tenth rib in the posterior axillary line, and then ascending to a point between the spine and the scapula. The large flap thus outlined is made to envelop all the tissues outside the ribs. The ribs thus exposed are resected from the tubercles forward to their insertion into the costal cartilages. The large area of the chest wall thus exposed is then removed with the underlying pleura, and all hemorrhage checked. This flap includes the periosteum, the intercostal muscles, the ribs, and the pleura, and thoroughly uncovers the entire abscess cavity. It makes a formidable procedure, but is more often life-saving than the reverse. Over the opening the skin flap may be later drawn down and tacked in place at points sufficiently near to each other to properly hold it in place ([Figs. 519] and [520]).