The principles and practice of modern surgery

Fig. 517 shows the possibilities in a case of actual obstruction, and how different such a condition is from mere esophagismus or globus hystericus. It has been recently shown, especially by Dennis, that during or just after typhoid fever, ulcers occur in the esophagus which may produce serious stenosis. At present writing I have under observation a little girl of nine years who has an extreme condition of this kind. It is with difficulty that she can swallow fluid nourishment, and she was so nearly starved that her life was only saved by a gastrotomy. Those congenital defects which may produce esophageal stricture are usually of such a serious and extensive character as to afford no opportunity for relief.

The location and caliber of these strictures may be ascertained by the use of esophageal bougies, such as represented in Fig. 518. These are made of various sizes, and are fastened upon the end of a flexible rubber handle, which affords a degree of elasticity in manipulation. They should be used with care and caution, as minor degrees of injury produced by them may cause a spreading infection, while still more harm may be done by rupture of an ulcerated area, or perhaps the perforation of an aneurysm.

The patient should sit before the surgeon, with the head thrown backward, the mouth comfortably widely opened, while the surgeon, standing, introduces the left forefinger into the pharynx and with it depresses the tongue and guides the tip of the instrument, be it bougie or tube, along this finger, which serves as a guide. Unruly or hysterical patients will not only gag, but may attempt to bite the operator’s finger. To prevent such accidents a metal thimble is made, which, being inserted between the teeth, protects the finger, but makes the manipulation more awkward. Should the patient show any tendency to folly of this kind, it should be remembered that when the finger is forced back into the pharynx the mouth is instinctively opened. If necessary, at the same time, the nostrils may be grasped and held closed, in which case the patient is sure to open the mouth widely and thus release the finger. After the tip of the instrument is engaged in the pharynx it sometimes assists in the manipulation if the patient’s head be now tipped a little forward. This manipulation is not very different from that by which a small and long flexible rubber tube may be inserted through the nostril into the stomach for the purpose of feeding, as is frequently done with the insane who refuse to eat, or may be done in the presence of certain diseased conditions.

The intent in this exploration is to determine the distance from the upper incisor teeth of the obstruction, as well as its caliber. When the instrument is withdrawn the surgeon marks the location of the teeth by grasping it at this point with the thumb, and the distance is measured off afterward so that it may be read in inches if desired. The caliber is determined by the success or non-success met with in passing an instrument of given diameter. The size with which the attempt should be made may be determined largely by the history and statement of the patient. With a patient who cannot swallow no ordinary bougie should be expected to pass, while a small solid instrument might produce a perforation. Flexible bougies are also provided by the instrument makers, made as are the silk catheters, some of them being loaded with small shot in order to give them a certain degree of weight. A small, soft, flexible instrument may be thus passed when the ordinary probang would fail. Here, as in the urethra, an olivary bougie may pass, after which the same sort of resistance will be offered upon its withdrawal. In this case the stricture is passed twice, going and coming. A slight degree of constriction is met opposite the cricoid cartilage at the entrance to the esophagus. This should not be mistaken for a pathological condition. Information may be afforded by material brought up by the instrument, such as shreds of tissue, blood, etc. A small bougie coated with sponge may be used for the purpose of retaining and bringing back such material as it may engage.

It will be of assistance to let the patients dissolve in the mouth a tablet containing a little cocaine and swallow it, or to spray or gargle the pharynx with a weak solution. It prevents the gagging and discomfort of an operation which otherwise is almost painless.

ESOPHAGEAL HEMORRHAGE.

Esophageal hemorrhage occurs especially in connection with cirrhosis of the liver. Stockton and others have called attention to a peculiar varicose condition of the esophageal veins in certain of these cases, and the possibility of repeated hemorrhages which may terminate fatally. The same is true of obstructive jaundice with Riedel liver.

CANCER OF THE ESOPHAGUS.

Cancer of the esophagus may be either primary or secondary, and may be either sarcoma or carcinoma. Its first expression will be ulcerative or stenotic, according as it originates on the inner surface or not. Sooner or later it will produce stricture, with the ordinary evidences thereof, and is to be detected in the same way. Cancer is usually of the carcinomatous type or squamous epithelioma. The disease is more common near the lower than the upper end of the canal. The disease spreads and involves the adjoining lymphatics, as well as various other structures. In addition to the ordinary evidences of stricture it is accompanied by a certain degree of pain, which is likely to be referred to the interscapular region or the back of the neck. The emaciation which always accompanies it is not merely an expression of the disease itself, but of the starvation which stricture in time produces. Frequent expulsion of bloody mucus or shreds is extremely indicative.

Esophageal cancer admits only of esophagectomy, as a very unusual method of relief, or gastrostomy, which is a palliative measure intended to prevent death from starvation, but not affording exemption from the advance of the disease.

OPERATIONS UPON THE ESOPHAGUS.

Operations upon the esophageal canal include:

• 1. Dilatation;
• 2. Internal esophagotomy;
• 3. External esophagotomy;
• 4. Esophagectomy.

1. Dilatation is practised ordinarily with olivary or conical-tipped bougies. The former are usually metal or ivory tips fastened to a firmer handle, while the latter are fashioned like silk catheters having more or less conical tips. These are introduced until they are engaged within the stricture, after which the amount of pressure or force used should be graduated to the character of the trouble, the density of the tissues, and the tolerance of the patient. Daily dilatation may be practised either for the prevention or relief of strictures following cicatrices due to caustic fluids and the like. A small passage may in time be stretched up to nearly the normal diameter, after which instruments may be passed at regular intervals, as the tendency to recontraction is inevitable. These methods of dilatation have taken the place of more complicated mechanical procedures performed with instruments like those intended for use in the urethra. The writer has, however, in one or two instances used with advantage the Otis dilating urethrotome in cicatricial strictures of the gullet.

2. Internal esophagotomy is practised either with instruments carrying concealed blades, like those used within the urethra, or by a method suggested by Abbe, where the stomach is first opened, and a retrograde divulsion effected, or at least a small bougie is pushed upward from beneath. When its tip is felt in the mouth there is firmly attached to it a strong silk thread which, as the instrument is withdrawn, is brought down into the stomach and then out through the stomach opening. With one hand in the stomach and the other in the mouth this thread is then manipulated in such a way as to saw through the strictured passage. It is well, should the surgeon use silk in this way as he would use a Gigli saw, to pass it through a piece of rubber tubing, both above and below, in order that its sawing effect may be limited to the esophagus proper. This is a procedure which should be done with great precaution. The operator should stop at short intervals, and, by using a bougie, satisfy himself whether the strictured passage has been enlarged. When the desired result has been attained the thread is withdrawn, the stomach and abdominal wounds closed, and dilatation resorted to every day or two in order that the benefit gained may be maintained.

The use of the esophagoscope may permit the exposure of a cicatricial band or an annular stricture, so placed that it may be divided by a fine knife directed through the tube. Whatever cutting is done in this region should be done cautiously, so as to avoid injuring adjoining structures.

3. External esophagotomy is easily performed for the removal of foreign bodies. When done from below it may be combined with a gastrotomy, the cardiac end of the esophagus being thus exposed and exploring instruments or those intended for either removal of foreign material or division of stricture being thus introduced. After the measure is complete the stomach is first closed and then the abdomen.

4. Esophagectomy is an operation undertaken from without, and is seldom performed for other purposes than for the removal of malignant growths. A cancer of the esophagus should be seen early and be favorably located in order to be amenable to such a radical measure, yet cases of this kind have been successful. Too often, however, they are done too late. The esophagus is exposed by the same incision as that described for esophagotomy, namely, on the left side along the anterior border of the sternomastoid, the vessels and nerves being retracted to either side in such a way as to permit its clear exposure. The portion to be removed is then isolated by blunt dissection and resected. This leaves two ends of the canal, which can usually be brought together by sutures, after the fashion of an end-to-end intestinal anastomosis. The principal difficulty met with will be adhesions and infiltration caused by extension of disease, and these of themselves in well-marked cases would be contra-indications to operation.

Transthoracic Resection of the Esophagus.

—Bryant and others have shown how the esophagus may be exposed from the posterior aspect of the thorax by a posterior thoracotomy, made in the third and fifth intercostal spaces, where, by resection of the ribs and dissection, the esophagus may be exposed behind the hilum of the lung. The azygos vein which crosses it at about this level should be either retracted or divided after a double ligation. Experimentation has shown that it is possible at this point to stretch the tube in such a way as to permit of restoration of its caliber, if but a small amount have been removed, but great care should be exercised, otherwise tension would be extreme. Because of the doubt regarding the success of such a resection Mikulicz has suggested the following procedure of externalization of the esophagus: After exposure the distal end of the esophagus is closed and dropped back. An opening is next made along the anterior border of the sternomastoid, where the esophagus is exposed, pulled up and out of its situation—i. e., dislocated—and brought out through the upper opening, which can be done because of its loose connective-tissue surroundings. A third incision is then made over the second intercostal space in front, where a bridge of skin is lifted up, the esophagus drawn down beneath it and fastened, the intent being to connect this opening with the stomach through a gastric fistula by means of some special apparatus, thus making it possible to again feed the patient through the mouth. The incisions in the back are closed by layer sutures. The principal objection to this method is that the passage of fluid through the externalized portion of the esophagus would have to be accomplished by massaging the part and forcing it down through the tube. Sauerbruch and others have shown that in animals at least it is possible to make a transdiaphragmatic anastomosis of the stomach and esophagus. By much the same method as that last above described, i. e., through a posterior opening, the esophagus can be exposed near its lower end, resected, and then turned into an opening in the stomach, the latter having been brought up through an opening in the diaphragm. It is hardly necessary to go into details of this operation here, since the occasions which would justify it are almost as rare as the individuals who could be entrusted with its performance.

OPERATIONS UPON THE THORAX.

Exploratory puncture, either of the pericardial sac or of a pleural cavity, is an exceedingly simple matter, the ordinary hypodermic needle sufficing for many instances, while in some cases the contained fluid will be too thick to flow through a finer needle and will necessitate the use of a larger one. Such needles are furnished, with so-called exploring syringes, and their use is a convenient preliminary to the use of the aspirator—i. e., thoracentesis—or open division—i. e., thoracotomy. It is essential that both the patient’s integument, the instrument, and the operator’s hands be absolutely clean. When several points are explored at one time and fluid is found at but one it is well to indicate this with a little nitrate of silver or tincture of iodine, which will make a temporary mark. Thoracentesis implies a withdrawal of fluid through a hollow needle, which will make a small puncture that will promptly close, a vacuum apparatus of some kind being attached to it. The needle may be introduced at various points to enter either the pericardium or the pleura. Ordinarily no harm pertains to exploratory puncture and but little to withdrawal of fluid, providing certain precautions are used, though fatal syncope has been known to immediately follow it. Beyond absolute sterilization the most important feature is to withdraw fluid slowly rather than rapidly, and to desist so soon as symptoms of a serious nature appear, such as faintness or collapse. When a collection of fluid has existed for some time in one of the pleural cavities it may have gradually so displaced the heart that its too sudden withdrawal may permit a too sudden restoration to its normal position—so sudden, in fact, as to place extra stress upon it and perhaps to seriously embarrass or completely check its action. This is always a matter requiring attention. The position of the patient also should be regarded, and a patient who is seated in a chair, in order that fluid may gravitate to the lower part of the chest cavity, should be promptly placed in the recumbent position so soon as alteration in pulse or coughing or serious embarrassment of respiration are noted.

The skin over the point selected for puncture may be anesthetized with the freezing spray or with a sterile cocaine solution. The needle point should be driven in sufficiently to secure fluid and not such a distance as to puncture the heart or the lung within. The better aspirating needles are provided with rounded points rather than with sharp ones, in order that scratching with a sharp end may be thus avoided. When using a more blunt needle of this type it is well to make a trifling puncture in the skin with a small knife-blade. While the more elaborate instrument outfits sold by the dealers are pleasing to use, fluid may be siphoned through a needle and tube with a fountain syringe just as in lavage of the stomach. Consequently it is not necessary in emergency cases to have anything more than a satisfactory needle. Care should always be given that no air is introduced. Thus in managing the last-named expedient the tube and the needle itself should be filled with fluid before the latter is introduced. Then the bag may be lowered in order that no fluid escape into the chest. It is an advantage to have a piece of glass tubing connected with the apparatus, in order that the character of the fluid first withdrawn may be easily ascertained. If the patient begin to cough or to have a feeling of oppression the operator should temporarily cease, and if symptoms are not ameliorated he should withdraw the needle, renewing the procedure a day or two later. A lung too suddenly forced to expand by removal of fluid may not only give distress to the patient, but there is a possibility of hemorrhage.

Thoracotomy.

—The term thoracotomy implies an incision made through the chest wall, usually for withdrawal of fluid, with or without removal of some portion of its bony structure. Thoracotomy performed for pericardial collections of fluid has been described. That for removal of ordinary empyemic collections is usually a simple measure. It may be practised under local anesthesia. In a general way the extent of the fluid collection is made out by percussion, and its character by exploratory puncture. The endeavor should be to make the opening laterally and posteriorly near the lower aspect of the cavity to be emptied in order that it may drain by ordinary force of gravity with the patient in the dorsal position. Unless it be intended to remove a portion of rib the incision need not be more than one inch in length.

Ordinarily the skin is pushed a little one way or the other so that a rib can be seen underlying it, in order to steady it for the external incision. Then it is allowed to glide back to its normal position and the knife-blade is so directed as to at once enter the thoracic cavity. Only rarely is it necessary to make a careful dissection. It is not often that vessels of importance will be divided, and one may usually proceed boldly with the incision. It will be promptly followed by appearance and usually by forcible expulsion of fluid, perhaps even in a jet, for which a basin should be provided. In fresh cases this fluid will be thin; in old empyemic cases there will be so much caseous material mixed therewith that it may obstruct the opening and check escape of fluid. In these cases it may be pushed aside with forceps or by the introduction of a finger. When such material is present, however, there is need also for its evacuation, and in such cases the incision should be extended and an inch or more of rib may be removed in order to afford sufficient exit.

The objection above mentioned regarding speedy evacuation applies theoretically rather than practically to this procedure, for when it is necessary to open the chest cavity widely it is because the walls of the cavity thus opened have already become so thickened or stiffened by the disease process that there is not the danger of sudden change of position of the thoracic viscera which obtains in the less serious and more acute cases.

The fluid having been removed the next question is one of irrigation. This is only rarely necessary or even justifiable. Even in cases where the evacuated pus has a more or less offensive odor it is found sufficient to remove it, while experience shows the inadvisability, sometimes the practical danger of prolonging the procedure and trying at this time to wash out the chest cavity. If irrigation be practised it should be with a bland fluid, for antiseptics are here peculiarly irritating.

The third question is one of drainage. In recent cases it will often be sufficient to insert some flexible material, like a piece of oiled silk folded upon itself, secured externally by a safety-pin, or stitched to the skin in such a way that it shall not be lost within the cavity. In the older and more serious cases more complete drainage should be provided. This is usually effected with a short piece of rubber tubing, which needs to be amply secured against loss, either with a large safety-pin or by being stitched to the skin with silk rather than with gut, lest the latter soften too soon. This tube should ordinarily be quite short, in order that it may not irritate the pleural surface of the expanding lung. It is rarely necessary to make valve-like protection of the opening, nor is it usually advisable to insert any sutures in the external wound. These openings in most instances close too soon rather than too slowly.

The surgeon should avoid making the opening too low, lest the diaphragm, having been pushed downward by the accumulation above it, rise and cover the end of the tube. Well-marked cases of empyema will often improve more quickly if a counteropening be made. It is an easy matter to introduce the end of a long forceps and determine the best point at which to make this opening. The forceps being then held at this point, one may easily cut down upon its end, force it through, and utilize it for drawing backward, completely through the chest, a long piece of perforated drainage tube, which perhaps may be eventually replaced by a few strands of silkworm gut. A very large and copious external dressing should be applied, and changed as often as need be, in order to receive and provide for such discharge as may take place. Sometimes this will be quite considerable, and necessitate, for the first two or three days, a change every few hours.

Some surgeons have endeavored to make drainage more complete by a vacuum irrigating apparatus, on the Bunsen pump principle. Should it be necessary to resort to this the more complicated older methods may be supplanted by the simple procedure, illustrated later in this work, for continuous drainage or siphonage of the bladder.

One should never attack a case of this kind without being prepared to remove a section of one or more ribs. Indications for this will be found in the character of the contained fluid, or in the thickness of the wall of the abscess, i. e., the old pleural cavity. The difficulty usually is that these openings tend to close too promptly, and that, especially in children, the proximity of the ribs to each other affords too small space for the maintenance of drainage. When it becomes necessary to remove a piece of one or more ribs there is little object in trying to preserve the periosteum, and the operation may be made within a few seconds by simply retracting the skin wound and the musculature, introducing the bone-cutting forceps, with which the rib or ribs are divided at points one inch or more apart, the intervening portion being promptly lifted out with forceps and cut away with strong scissors. The operation of dividing the rib will often so compress the intercostal arteries that there will be little hemorrhage from this source. Should they bleed too much strong forceps should be used to compress the lower edge of the rib, and, by crushing it produce hemostasis, as though the artery were itself seized with forceps, or the vessel itself may be seized and secured. A special form of forceps for dividing ribs, known as the costotome, has been devised and has proved serviceable, since it is so made as to prevent easy slipping of the rib from the grasp of the blade.

The larger opening thus made is treated in practically the same way as the smaller. Through it the fingers or a blunt spoon may be inserted and any cheesy material lifted out, or a sponge or gauze swab held in the grasp of a long forceps may be introduced, and with it the cavity thus opened may be wiped out or swabbed. In this way a considerable amount of caseous material or shreds of membrane may be removed. The more that can be removed the better, since there is so much less to come away later. Such manipulation is, however, sometimes attended by embarrassment of respiration, and one should use discretion in the extent to which he practises it. Hemostasis having been secured, it will depend on the case and its extent whether any effort is made to partially close the wound or whether it should be left open. Even large defects thus made usually heal kindly and fine or careful suturing is rarely needed.

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.

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).

This procedure may be modified to suit the indications of any given case, and simply includes what may be done in extreme cases. The surgeon who thus for the first time uncovers such a cavity will be surprised at its interior appearance, and at the shreds of tissue and debris which hang from its walls. The measure thus described provides for collapse of the chest wall. Fowler and others have shown, however, that even now the principal obstacle to expansion of the lung is not removed, and have suggested what Fowler has aptly described as decortication of the lung—namely, a removal of its thickened pleura by a process of dissection and stripping, which may be made partial or complete, as circumstances permit. In some respects this adds to the gravity of the case and will perhaps better be done at a second operation. Should it, however, be justified by the condition of the patient it is best done in connection with the resection of the chest wall.

When decortication cannot be practised Fowler has advised that a series of incisions be made, and that by thus gridironing the thickened membrane it may be weakened or caused to lose its inelasticity and thus a mild degree of similar effect secured. Fig. 521 illustrates the end result of such an extensive thoracoplasty.

Pneumotomy.

—This is a term applied to an attack upon the lung itself, it having been exposed by a thoracotomy. It is necessary in cases of gangrene, abscess, hydatid cyst, and occasionally in large bronchiectatic cavities. It is not ordinarily a difficult procedure when the lung has attached itself to the chest wall in the course of the disease process. Here the lesion having been located a part of one or more ribs is removed, as may be needed, thus exposing the lung surface, the cavity is then opened either with a knife or by dilatation with the blades of a forceps, or preferably with the thermocautery blade, by which hemorrhage is better controlled and possibilities of absorption reduced. If such a cavity can be located it may be opened with a large trocar and cannula, which should be introduced with great care, lest it be thrust too far, the method by incision being therefore preferable. If after opening the chest the lung be found non-adherent, it depends on the character of the lesion whether adhesion should be provoked or the cavity itself attacked. In the former case adhesions may be produced by stitching the exposed lung surface to the margins of the wound, and waiting for sufficient exudate to be poured out to ensure that the pleural cavity has been hermetically sealed. The same result may be obtained more crudely by packing gauze around the opening.

In case of urgency it would probably be best to attach the lung to the chest wall with sutures and secure it there. This is a comparatively safe method in dealing with hydatid cysts, and will give a fair measure of success in many other instances. The suppurating or gangrenous cavity being opened its contents should be removed, dead or sloughing tissue excised, and the cavity then packed for drainage purposes, the external wound being kept open until it can be safely allowed to close.

Pneumonectomy, that is, removal of a portion of the lung substance, may be done with comparative safety upon animals, but rarely upon human patients. It is occasionally required in connection with the removal of malignant tumors of the chest wall, to which the lung has affixed itself. In exceedingly rare instances it may be justified for localized tumors of the lung itself. It would be equally valuable for circumscribed, primary tuberculosis of the lung, were it possible to recognize this in time. This an Italian surgeon once thought that he had done, in the case of his fiancée, and proceeded to resect the upper lobe of one of her lungs. His lack of success quickly led to his own suicide a few days later.

The lung is exceedingly vascular and at the same time bears sutures well. The suturing, however, should be accurate in order to prevent secondary hemorrhage and favor the process of repair.

Other operations may be practised upon the chest wall for relief of such conditions as acute osteomyelitis of the ribs or sternum, caries of the ribs, necrosis, and the like. It should be scarcely necessary to give explicit directions, save that the pleural cavity should never be opened unless the pleura itself be involved in the disease. Every case demanding such operative relief should be measured by its own needs, and the operative procedure adapted to them. Necrosed portions of bone may be completely removed. The suppurative and carious conditions necessitate rather a sufficiently wide exposure from without and then a judicious use of the bone curette. One need never hesitate to remove so much bone as is diseased, this being true even of the sternum.

THE THYMUS.

The possibility of suffocative and other disturbances proceeding from enlargement of the thymus has been discussed, as well as the use of long trachea tubes in cases of this character which call for tracheotomy, as they usually do if they permit of any surgical intervention. The thymus is seldom the site of primary malignant disease. Certain acute lesions are due to a peculiar form of hypertrophy in the young, which takes place instead of that spontaneous disappearance which should have occurred during the earliest months of infancy. Its connection with the status lymphaticus, with thymic asthma, and laryngismus stridulus has already been mentioned. While it can hardly be considered absolutely exempt from ordinary infections and the like it nevertheless is rarely involved.

The thymus has been removed by operation, usually with success. Should it become necessary to resort to such a measure it should be preceded by the removal of the sternum, for only in this way can sufficient exposure be obtained, and sufficient opportunity for checking such hemorrhage as might result from its enucleation.

THE AXILLA.

The axilla as a surgical region belongs as much to the thorax as to any part of the body, although none of its diseases are peculiar to this area.

It is frequently the site of furuncles of local origin, which occasionally assume carbuncular type, and which are expressions of local infection along the hair follicles or mammary ducts. It is full of lymph nodes, through which are filtered the lymph streams coming from the upper extremities. In this way there are entangled therein septic germs, which frequently give rise to small or large phlegmons proportionate in size to the magnitude of the lesion beyond them. It takes but a trifling infection of the finger, for instance, to produce such involvement of axillary lymph nodes as to make them palpable under the finger. Such lymph nodes once genuinely inflamed frequently coalesce, and the resulting abscess cavity may be large, especially if neglected. The sooner these phlegmons are incised and cleaned out the better for the patient. In order to do thorough work an anesthetic is usually required.

In the axilla also are frequently seen tuberculous manifestations, the result of propagated infection from some part of the arm or hand. These may be involved in a mixed infection and quickly break down, or may assume the type of the chronically enlarged nodes, which undergo caseation and more or less encapsulation, with such infiltration of the surrounding tissues that when extirpated considerable difficulty is met in the dissection.

In syphilis, also, the lymph nodes become involved, frequently enlarging to a degree making them palpable, and sometimes participating in a mixed infection in such a way as to break down into abscesses.

Again, in the axilla are occasionally seen conspicuous evidences of Hodgkin’s disease. Any disease of constitutional character which precipitates trouble in one axilla will cause nearly duplicate alterations in the other, whereas disease of local origin is usually confined to one side.

Any phlegmonous cavity or tuberculous lesion which has been incised through the axilla should be carefully cleaned out and then drained, lest the external incision close before the deeper parts are ready for it. Incisions made in the axilla should be parallel with the great vessels and nerve trunks, by which they are better exposed and avoided. A wound made in the axillary vein may be sutured or the vein be doubly ligated. The former is much the better course, very fine silk sutures being employed. In some lesions where it has not been possible to discover the bleeding point the writer has not hesitated to secure it with the ends of pressure forceps and to leave these forceps included in the dressings for forty-eight hours. He has never seen harm result from this procedure.

Finally the axilla is almost always involved in cases of malignant disease of the breast, of the arm itself, and sometimes of the regions adjoining. Primary malignant disease in this region is rare, while secondary cancer is not unusual. According to the modern plan of treatment of cancer there is reason for scrupulous extirpation of every particle of infected tissue and all involved lymphatics, and in dealing with such cases the surgeon need not hesitate to divide or extirpate the pectoral muscles, in order to permit of thorough work. The disease being present nothing can be so serious for the patient as to allow any particle of it to remain.

THE DIAPHRAGM.

The diaphragm may show certain congenital defects, consisting mainly of fissures or openings which permit displacement of viscera, usually from the abdomen below into the thorax above. This is often fatal, constituting a form of diaphragmatic hernia, which is particularly liable to strangulation. Fig. 522 indicates a case of this kind, showing the hopelessness of the condition.

Anatomically it is worth while to recall that the diaphragm may rise to a level with the third cartilage during forced expiration, and descend to the level of the fifth intercostal space on the right side, and a little lower on the left, during forced inspiration. When forced upward by pressure from below it may rise even higher than stated above. These facts are of surgical interest in considering the possibility of injury or perforation of the diaphragm in connection with gunshot and other perforating injuries to the thorax or abdomen.

Diaphragmatic paralysis is the necessary result of injury to the phrenic nerve. It may occur as the result of injury to the thoracic viscera, especially those of the posterior mediastinum, or injuries to the cervical or upper dorsal vertebræ, usually fractures or dislocations, followed by ascending degeneration and involvement of the phrenic nerve roots. Double phrenic paralysis is in these cases obviously fatal. Paralysis of a single side will cause at least serious embarrassment of respiration. An hysterical form of diaphragmatic paralysis has also been described.

Primary tumors are exceedingly rare in this muscular partition. Advancing growths, however, attach themselves to it or perforate it, as may also aneurysms.

Aside from the ordinary injuries which the diaphragm may suffer from without, and already mentioned, there are peculiar forms of rupture, the result of force applied from below, usually at right angles to the surface of the body, this being permitted on account of the dome-like shape of the muscle. When thus ruptured abdominal viscera may be forced into the chest and even out through openings between the ribs. A gunshot wound of the diaphragm will be serious mainly in proportion to other injuries involving the viscera above or below it. These injuries produce no typical symptoms, but are nearly always accompanied by severe pain radiating toward the shoulders, with dyspnea and a substitution of abdominal for diaphragmatic respiration. When the viscera have been forced upward they will displace the heart, and this may produce cardiac symptoms. It is said that the so-called “sardonic grin” is still observed on the faces of corpses who came to sudden death from some injury to the diaphragm.

Thus diaphragmatic wounds are not of themselves of serious import. When inferentially present they may, therefore, be disregarded so long as no serious symptoms are produced. On the other hand, exploratory celiotomy should be performed at any time, should conditions seem to justify it.

SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS.

While this is a condition pertaining, strictly speaking, to the abdominal cavity, it nevertheless arises so frequently from intrathoracic causes as to justify its consideration here, as well as because of its close relations to the diaphragm. It was Volkmann who, in 1879, first showed how these abscesses could be successfully and surgically treated. The term is applied to collections of pus beneath the diaphragm, usually between it and the liver, which, however, may extend to and later involve surrounding viscera.

The causes may be divided into those met with above the diaphragm and those below. The former may include empyema, pus having escaped beyond the normal pleural limits, advancing tuberculous disease from any of the structures above the diaphragm, echinococcus in the lung, or suppurative mediastinitis. From below the diaphragm the infectious process may travel from the direction of a gastric or a duodenal ulcer, hydatid disease in the liver, phlegmon around the liver or kidney. The contained pus may, on culture, show the presence of colon bacilli or pneumococci, as well as the ordinary pyogenic cocci and tubercle bacilli. If connected with hydatid disease hooklets may be seen in pus which is not too old.

Subphrenic abscess may result in large collections of pus, which may travel a considerable distance, separating the peritoneum from the diaphragm and from the lateral abdominal walls, appearing even low down in the pelvis. The same is true of escaping pus from a case of empyema. The primary trouble gives rise to a localized peritonitis or perihepatitis, by which are produced certain barriers that serve to retain pus within bounds, and to keep it from spreading save as above mentioned. Should it be due to extension of abscess or disease within the liver it may be confined by adhesions about it. Fig. 523 illustrates the relations which such a collection may sustain to the liver and the diaphragm, as well as how the opening by which it may be best evacuated should be made through the thoracic walls. Even with this condition produced by disease below the diaphragm it is not infrequent to find some collection of fluid or evidence of exudate above it.

A study of this condition will nearly always lead one back to a history of some illness which may furnish the explanation for the commencement of the trouble. Thus, there may be obtained a history of pulmonary tuberculosis, of empyema, of gastric ulcer, of gallstone trouble, or of abscess in the liver or in or about the kidney. When the result of perforation from above, the chest wall may furnish signs which will be sufficiently indicative.

The symptoms will include swelling, pain, tenderness, with fixation of the liver, and apparent enlargement of its boundaries, because it is pushed away from the diaphragm. The abdominal wall will frequently be edematous. The ordinary signs of the presence of pus are rarely absent, including the evidences furnished by a differential blood count. Diagnosis is proved by the use of the exploring needle. The disease is nearly always situated upon the right side. The more distended the abscess cavity the less respiratory murmur will be heard over the lower part of the chest, while the line of the hepatic dulness may be considerably above the normal. Sometimes a succussion sound may be obtained.

Should pus be withdrawn from the lower part of the chest by the exploring needle there might still be doubt as to its actual location, whether above or below the diaphragm. The absence of cough and of indications of pleural involvement would prove much in favor of the latter.

Subphrenic abscesses tend in time to evacuate themselves. Thus they sometimes perforate the diaphragm and escape into the pleural cavity, or through a lung which has attached itself at its base, and thus afforded an outlet for pus through the bronchi and the mouth. On the other hand, pus may burrow downward and appear in the flank or beneath the skin near the liver and in front of it. The nearer it comes to the surface the more easily it is recognized.

Treatment.

—The treatment of subdiaphragmatic abscess, like that of all other abscesses, consists in evacuation of the contained pus, with provision for drainage. In some instances this may be done with an ordinary trocar and cannula, but serious cases are best treated by incision, with resection, if necessary, of a portion of a rib. When the chest wall is entered the best place is between the ninth and tenth ribs in the axillary line. Nevertheless pus which is presenting at any other point may be best reached by taking advantage of the indication thus afforded. An opening having been made the question of counteropening may be raised. This should be decided in each instance upon its merits. While an opening made in front does not drain so well as one placed posteriorly it may be made to drain by keeping the patient upon the side or face for a portion of the ensuing few days. When it seems desirable to go through the chest wall it should be incised carefully, and if the pleura has been opened before reaching the abscess, the pleural surfaces may be either stitched together or packed; after waiting a day or two for protective adhesions to form the abscess may then be opened. The less extensive operations may be performed with local anesthesia. Rib resection and extensive incision will usually require general anesthesia.