Text-book of operative surgery / by Theodor Kocher.

  • Kocher, Theodor, 1841-1917.
Date:
1911
Catalogue details

Licence: Public Domain Mark

Credit: Text-book of operative surgery / by Theodor Kocher. Source: Wellcome Collection.

    528/764 (page 492)
    the presence of an abscess was inferred from the late onset of paraplegic symptoms, we were able to remove a sequestrum from the body of the vertebra without difficulty. In cases of caries of the bodies of the vertebrae, it will be noticed that an abscess which emerges through the intervertebral foramen and compresses the nerve roots and the cord, can be much more satisfactorily drained by this method than by laminectomy, which is more troublesome to perform, and which exposes the posterior aspect of the cord rather than the real site of disease. In our case the disease was completely cured, but the motor paralysis did not disappear, a result owing, no doubt, to pressure on the cord by the back of the body of the vertebra. Further treatment was refused. This method can also be employed in the treatment of other abscesses in the posterior mediastinum, and if further space is required, more than one transverse process and rib may be excised. (g*) Pleurotomy 78. Indications for Pleurotomy. Fig. 308, after Spalteholz and Pansch, illustrates the relations of the lungs and pleura, showing Avhere the pleura may be opened with¬ out injuring the lung, and also the formation of the pleural sinus by the reflection of the costal and diaphragmatic pleura. Pleurotomy is performed as a preliminary step in pneumotomy, and we have already alluded to its efficacy in other operations connected with the treatment of pleural effusions. Its latest use, according to Murphy and Rati, is to produce a therapeutic pneumothorax. We have also pointed out in the introduction how the operative treatment of pleural effusions has been lately developed, and that now drainage of the pleural cavity is always combined with aspiration. The same principle has, however, existed for a long time in the use of Potain’s and Dieulafoy’s aspirator. Revillod was one of the first to combine aspiration with permanent drainage, while Blilau demonstrated its practical use in cases where a single or repeated puncture was insufficient. Effusions of blood, lymph or serum, can be cured by a single aspiration, unless the presence of virulent organisms or new growths causes a return of the fluid. On the other hand, when the condition is due to a progressive infective process, e.<j. tuberculous effusion or empyema, drainage with aspiration must be continued till the infective source is either removed or destroyed. 79. Pleurotomy for Empyema. The following is the method most commonly employed in opening the pleura for the removal of purulent effusions. Having ascertained the presence of pus by exploratory puncture with Pravaz’s syringe, we make an incision, 4 to 6 cm. in length, along a rib in the area of dullness, a method we have adopted under local anaesthesia even on children with very little discomfort. The patient’s skin is first prepared as for all other aseptic operations, while the usual precautions are taken against sepsis. The edges of the incision are swabbed with an alcoholic solution of carbolic acid, and iodoform powder is rubbed into them in order to prevent infection of the freshly- cut surface. The periosteum is then carefully reflected and II to 2 in. of the rib is removed with Liston’s or Lüer’s forceps. The pleural cavity is then opened by incising the periosteum for a distance of I in. and is thoroughly washed out with warm saline solution, after which a drain is inserted and antiseptic dressings are applied. Empyemata, secondary to pneumonia, or following a traumatic pleurisy where suppuration has occurred in the effused blood, can be readily cured by this method, and with complete restoration of the pulmonary function ; while the lung, owing to the suction action of the chest-wall, comes to the surface again, and the discharge disappears. There can be no doubt that the majority of physicians now advocate the early and complete evacuation of purulent exudates in the pleura.