. Manual of operative surgery. rved elevator being round the rib, pull it (the elevator) with force back to orbeyond the angle of the rib and forwards to the junction of the rib and costalcartilage. Divide the rib at its junction with the cartilage bj^ means of acostotome. Seize the end of the rib and pull it outwards. Pass a finger alongthe visceral side of the rib to its head, to protect the pleura. Twist the ribuntil it comes away. (Sometimes the head of the rib is torn from its connec-tions; sometimes the neck of the bone is fractured.) PNEUMOLYSIS 317 Step 5.—Repeat Step 4 on each rib unt
. Manual of operative surgery. rved elevator being round the rib, pull it (the elevator) with force back to orbeyond the angle of the rib and forwards to the junction of the rib and costalcartilage. Divide the rib at its junction with the cartilage bj^ means of acostotome. Seize the end of the rib and pull it outwards. Pass a finger alongthe visceral side of the rib to its head, to protect the pleura. Twist the ribuntil it comes away. (Sometimes the head of the rib is torn from its connec-tions; sometimes the neck of the bone is fractured.) PNEUMOLYSIS 317 Step 5.—Repeat Step 4 on each rib until the second is removed. Step 6.—With gauze and sharp dissection remove the intercostal musclesfrom the pleura. The twisting away of the ribs obliterates the intercostalarteries. (Duration of operation up to end of Step 6 was twenty-five minutes inthe case seen by the author.) Step 7.—Apply ligatures. Replace the flap and unite the divided muscleswith catgut. Place a drain along the deep wound corresponding to the heads. Fig. 434.—{Friedrich.) of the ribs. Close the skin wound. Apply abundant dressings. Opera-tion on the right side is much more dangerous than on the left because ofcardiac dislocation. After-treatment.—Administer hypodermatically i camphor oil forty percent. (40 per cent.) every hour by day and every two hours by night. Givedigitalis freely. Each night inject i3^ L. salt solution in the inguinal salt solution has a most favorable influence on respiration. Administeroxygen frequently. Of eight cases only two died and these had advanced secondary lesionselsewhere. Of course, after recovery, medical and climatic treatment must be continued. 3l8 OPERATIONS OX THE CHEST Figs. 433 and 434 show the extent of compensatory emphj-sema establishedin the sound lung and the great displacement of the heart. In a few weeks the sputum has diminished from 150 or 200 to 20 or even5 and the patients have lost their fever and gained weight. The
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