SOME OBSERVATIONS ON BROMIDE THERAPY AND INTOXICATION

In the morechroniccases,it is often found that the deepsurfaceof therib hasbeendrawn in to a point, so that the cross section of the rib is triangular instead of being roughly quadrangular; and extra care is required to preventperforationof the pleura with the raspatory. It is sufficient to remove two centimetresof the first rib; one has to be contentwith lesssometimes, but division of this rib is absolutely essential, as otherwise the chest wall cannot fall in and down. Almost as essentialis the resectionof eachrib right back to the transverse process of the vertebra. If this is not done, the lung lying in the vertebral groove fails to collapseand holds up the collapseof the rest of the lung. The ribs are resectedas far forward as possible, as much as fifteen centimetres of themiddlerib beingremoved. After the removalof the ribs, the intercostalnervesare injectedwith 80% alcohol, which lessens greatly the post-operative pain. The muscle layers are closed by continuous catgut suture through the muscle sheaths,and the skin by interrupted silk-worm gut and horsehair sutures. The wound should always be drained for twenty-four to thirty-six hours by a rubber tissue drain brought out of the lower end, to prevent the formation of a hsematoma. A big dressing,appliedwith pressure,gives welcome support to the site of operation,and, what is more important, it diminishesthe tendencyto mediastinal flutter, and may be neededfor some weeks. On return to bed, the patientis kept as upright as possible to aid expectoration,with pillow pressure behind the affected side and the arm supported. After the division of the first rib thereis often a good dealof pain from tractionon the brachialplexus,and elevation of the arm on a pillow will relieve this. Morphine should be given freely, in doseswhich will diminish the pain without abolishing the coughing reflex, as it is very desirablethat the patientshould empty his cavities, and the increasedproduction of sputum which often follows the collapse for a few days rendersthis all the more necessary. The final resultsare by no meansmutilating, and the patients have recoveredfull use of their arms. The mortality rate of 50% in this series isvery high; but in every case the patient was in extremis and rapidly going down hill, all other methodsof treatment having failed to arrest the downwardprogress. And that some of these patients are alive and improved,and in some casesbackat work, three years after thoracoplastyis sufficient argument that this treatment should not be denied to any patient in whom the lung cannot be made to collapseby any other method. •