CHAPTER XLIII
.
THE THORAX AND ITS CONTENTS.
MALFORMATIONS OF THE THORAX.
[Illustration: FIG. 501
Congenital malformation of chest. (Sayre.)]
Congenital malformations of the thorax are not uncommon, yet but few of them permit of surgical remedy. One or more of the ribs may be absent or defective in formation and produce lateral distortion of the spine. The clavicle also may be defective on one or both sides, or absent. This is a defect which causes but little inconvenience, in spite of its prominence. The chest as a whole may develop defectively or irregularly, some of these conditions being expressions of intra-uterine rickets and others being due to unknown or uncertain causes. Thus we have the absolutely flat chest seen most often in connection with an unduly rounded back, the flattening appearing rather in front, while perhaps the anteroposterior diameter is actually increased. As Hutchinson has shown, this may be a persistence of the fetal type of chest. _Pigeon-chest_ or _keel-shaped chest_ may be regarded as a reversion to a more primitive type, the anteroposterior diameter being increased at the expense of the lateral. The reverse of this deformity is the so-called _funnel-shaped chest_, where the sternum is depressed and the lateral dimensions increased. In addition to the defects thus noted in the ribs and sternum, absence of a vertebra has been known, the condition not producing deformity, but rather an appreciable shortness of the spine. Malformations are seen frequently in the _sternum_, which may be _fissured_ in either direction, or may present _perforations_. With these similar defects of the ribs may also be seen, even to a degree permitting congenital hernia of the thoracic contents.
_Supernumerary developments_ find their expression usually in an _added rib_, either in the _cervical_ or in the _lumbar_ regions. This condition is practically never noted at birth and may pass unnoticed. Nevertheless a _cervical rib_ may, in adult life, produce discomfort or actual interference with function, partly by pressure upon the subclavian artery or the brachial plexus. When found it is in relation with the seventh cervical vertebra, and the space between it and the first dorsal rib is occupied by muscle developed for the purpose. The scalenus anticus may be inserted into its anterior edge. When sufficiently prominent to produce troublesome symptoms it may be recognized by palpation, and cases of doubt may be made clear by a radiograph. Should it prove troublesome it may be removed, an operation requiring considerable caution, because of its close relation to the pleura, which might easily be opened. It may be exposed by such an incision as would be used for ligation of the subclavian artery.
The _thoracic muscles_ occasionally show anomalies, either in arrangement or by their absence, the pectoralis major being occasionally wanting in whole or in part, and furnishing the most frequent illustration of these defects, which are usually unilateral. (See Fig. 502.)
_Congenital luxations of either extremity of the clavicle_ are also occasionally seen, particularly of the inner end. A peculiar displacement and relaxation are thereby permitted, with some degree of functional loss.
The _acquired malformations_ of the chest may be produced from a variety of causes. Thus in connection with non-closure of the foramen ovale and the consequent disturbance of heart action, with its overdevelopment of the right auricle, the left side of the chest may be pushed forward and the apex beat found far below its normal position. _Asymmetry_ in the young may also be produced by several different intrathoracic conditions, the most common being pleurisy and empyema, with their consequent distention of the pleural cavity, and later a tendency to cicatricial contraction. In this way marked forms of lateral curvature are produced. In a previous chapter it was stated that overgrowth of lymphoid tissue in the nasopharynx, ordinarily spoken of as adenoids, with consequent embarrassment of respiration, leads in time to stoop shoulders and poor development of the thorax. Deformity may also be produced by such defective vision as shall compel a peculiar or abnormal position of the head.
In _chronic emphysema_ there is noted a peculiar _barrel-shape_ of the chest, which is also to be regarded as an acquired deformity. Paralyses of the internal thoracic muscles will also permit of asymmetrical growth, and projection of the lower angle of the scapula, giving it a wing-like aspect.
[Illustration: FIG. 502
Congenital absence of the pectoralis major muscle of right side. (Richardson.)]
The most common cause of thoracic asymmetry or deformity is _rickets_, which may be an early or a late manifestation. By the ordinary changes permitted in the epiphyses and along the costochondral junctions is produced the peculiar appearance known as “rickety rosary.” In these cases the effect of the weight of the upper part of the body upon the soft and changeable structures of the osseous and cartilaginous ribs, as well as the vertebræ and the sternum, are to be noted. Pronounced types of deformity result from such changes, producing extreme cases of _pigeon-breast_, or of hollowing in front known as _birds’ nest deformity_, while alterations occur in the vertebræ, producing various expressions of kyphosis and scoliosis. (See Fig. 504.)
These deformities of the back thus produced require to be differentiated from those produced by Pott’s disease, the former being unaccompanied by symptoms and occurring slowly, while the latter are usually accompanied by pain and are progressive in character, as well as more or less disabling. With a softened skeleton in a rapidly growing child such trifling influences as the position assumed in the nurse’s or mother’s arm, or that habitually taken in sleep, may affect and modify symmetrical growth. Rickety deformities of the spine and thorax, if not too far advanced, permit of being checked and much improved by braces, along with the measures indicated in rachitis. Without the latter, however, the former would be almost ineffectual.
[Illustration: FIG. 503
Malformation of chest following empyema. (Sayre.)]
[Illustration: FIG. 504
Deformity of the thorax, the result of rickets. (Gibney.)]
_Malformations may also be produced by injuries_ or certain _occupations_. Extensive burns may cause cicatricial contraction; contusions may produce paralyses, and more serious lacerations may leave extensive scars, which will gradually warp the chest out of shape. Burns, for instance, which may involve the axilla and the upper arm, may be followed by such dense scars as to limit the motion of the arm. Skin grafting should be resorted to early in the treatment of lesions thus produced.
_Tight lacing_ is the source of a mild form of thoracic deformity, by which the chest capacity is reduced, the respirations made peculiar in character, the liver displaced downward, and the general welfare of the individual materially affected. Influence of the right-hand habit is frequently quite apparent in that the right side of the chest becomes overdeveloped as compared with the left. This may be seen in a large number of workmen who use heavy tools especially with the right hand. Certain occupations, as well as sports, lead to constant assumption of the stooping position, with the inevitable round shoulders and drooping head so apparent in bicycle riders.
_Tattooing._--As a local expression of a bad habit, or in some instances almost of a criminal instinct, _tattooing_ may be mentioned. This is seen usually upon the chest and arms. It is a prevalent custom among sailors, and is regarded by alienists and anthropologists as a habit indulged in by criminals and the insane. La Cassagne has spoken of tattooing as “an uninterrupted and successive transformation of an instinct.” Among the inhabitants of the Pacific Islands it is almost a mutual practice, and among them the tattoo marks are often found upon the back and upon the sexual organs. The materials usually employed are lamp-black, indigo, and India ink for the black or blue tints, and cinnabar or carmine for the red. Practised as it is by the unschooled and the ignorant it may be followed by all forms of local infection, while syphilis has been thus transmitted.
For the _removal of tattoo marks_ many methods have been suggested, but few have been found satisfactory. The minute particles of pigment have become so deeply lodged that, like powder marks, it requires infinite patience in their detection with the lens and individual removal, or those portions of the skin must be destroyed which contain them. Mechanical methods should be limited to localized stains, unless a plastic operation is preferred, and, after removal of the affected area, healthy skin may be transplanted by one of the plastic methods or we may resort to skin grafting. Actual cauterization with strong caustics or with the actual cautery will be followed by superficial sloughing, which may remove the disfigurement. It is questionable, however, if the resulting scar will be considered much of an improvement upon the previous condition.
INJURIES TO THE THORAX AND ITS CONTENTS; CONCUSSION OF THE CHEST.
As a result of a severe blow made by a blunt object there may result a form of _concussion_ or commotion, similar in its results to the conditions which were formerly described in the cranial cavity as concussion of the brain, but which are now known to be due to reflex vasomotor disturbances, by which blood pressure is seriously affected and extreme degrees, perhaps fatal, of shock or collapse produced. It is possible for fatal injuries thus produced to leave little or no evidence that may be discovered at the autopsy. Hence the term _concussion of the chest_ may be retained as descriptive of what has taken place, and implying serious symptoms produced through the agency of the nervous system, especially through its sympathetic plexus. In such instances the heart is seriously affected and may continue to beat feebly for some time, as in shock from other injuries.
Severe blows upon the chest also disturb the function of respiration, and it is possible that asphyxia, even to a fatal degree, may result from a momentary paralysis of the entire respiratory apparatus thus produced. In such cases artificial respiration will be required. In many instances patients will complain of not merely distress, but severe pain, which may require local anodyne measures as well as the administration of an opiate.
_Contusion of the chest_ leaves more visible and lasting effects upon the tissues of the chest wall. Thus extensive hemorrhages may result and hematomas form, or ribs may be broken, with or without injury to the pleura, or internal hemorrhages may occur, as from a ruptured intercostal or internal mammary artery, the consequences of such injuries not necessarily appearing at the time, but developing later. Along with these injuries to the chest there may occur other injuries to the abdominal viscera or to other portions of the body. Something will depend upon the distention or relative emptiness of the lungs at the time of injury, and whether there may have been at the same time a sudden closure of the glottis, in which case, by an external blow, something resembling an explosive effect may be produced within the air passages. The degree of stomach distention may also have its own effect. _Laceration of lung_ tissue will usually be shown by appearance of bloody froth at the mouth, as well as by more or less dyspnea. Rapidly developing symptoms of pressure upon the lung would indicate the accumulation of blood within one pleural cavity and cause the ordinary physical evidences of the presence of fluid. The _diaphragm may be ruptured_, and the proper viscera of one cavity be displaced into the other. When emphysema of the tissues of the chest occurs it is usually safe to assume that a rib has been fractured, even though the injury cannot be located or even otherwise recognized.
A series of later lesions may result from such contusions, which may be of serious character. Thus there has been described a so-called _contusion pneumonia_, whose symptoms are similar to but milder than those of the genuine disease. It is a result of inflammatory and hemorrhagic infiltration. It may lead to a pleuropneumonia, with subsequent hydrothorax or pyothorax, or these may take place more directly and without its occurrence. The products of this disease afford foci in which, later, tuberculous expressions are commonly met. It has been shown experimentally that the blood serum of animals subjected to severe injuries of the chest and abdomen has well-marked toxic properties. Thus the appearance of sugar or albumin in the urine or of other toxemic indications may be perhaps explained.
=Treatment.=--The _treatment of these injuries_ should include the relief of pain; the performance of artificial respiration, along with the inhalation of oxygen; the customary treatment for shock, with the use of adrenalin, when needed, for raising blood pressure; absolute rest, and especially the enforcement of local physiological rest by bandaging or the application of broad strips of adhesive plaster about the thorax. In addition to these general measures special indications should be met when they arise. The occurrence of phenomena indicating the development of pneumonia or collection of fluid should be noted, as the latter may call for removal, with perhaps ligation of a vessel, if it be bloody, or later evacuation, should it be serum or pus. External extravasation will usually disappear under soothing, warm, and moist applications. No hesitation need be felt in opening a hematoma which does not show a disposition to prompt resolution. Other non-perforating injuries include, for example, severe burns or scalds, which may need the same treatment as when occurring in other parts of the body. Fluid may accumulate within the chest when there has been any such serious external disturbance.
PENETRATING WOUNDS OF THE CHEST.
Penetrating wounds of the chest are generally inflicted by stab or gunshot injury. Two serious elements of danger accompany these injuries: the first immediate, that of _hemorrhage_ from division of some vessel of importance concealed from sight; the other that of _infection_, for either by the penetrating object itself or by air or clothing which may follow it, infection may ensue, which may result in septic pneumonia, pyothorax, or some deep phlegmonous process, with always dangerous and sometimes fatal results. _Gunshot wounds_ vary, and according to the character of the missiles and the weapons from which they are discharged. Those occurring during warfare and made by bullets of the Krag or Mauser type are usually driven with such velocity that they produce a minimum of laceration, even though they pass through the chest. Such injuries have in the late wars in different parts of the world been frequently observed, and have shown a surprisingly low mortality rate, providing only that the heart itself, the pericardium, the large vessels, and the spine be not injured. Stories of the battle-field afford abundant illustration of men shot through the chest being scarcely affected by the injury, but continuing in action, at least for some time, and finally recovering. On the other hand, the ordinary revolver or pistol, with which most affrays in civil life are terminated, does not drive its bullet with nearly the same velocity, and is more likely to inflict a serious or even fatal wound. (See Plate XLVIII.)
A bullet or a stab wound almost invariably so opens the thorax as to permit the immediate entrance of air. In theory this should be followed by prompt collapse of the lung; in fact, however, this is only
## partial, and often surprisingly so. If such a bullet wound be occluded
the air thus admitted is more or less absorbed, disappearing into the bloodvessels, and the lung once more expands to its natural dimensions. Much will depend, therefore, on the size and character of the wound as to whether occlusion may occur spontaneously, or may be practised through the first-aid dressing or its equivalent.
The entrance of air may be recognized by a certain degree of embarrassment of respiration, by alteration in the percussion note, and often by its passage to and fro through the opening.
The principal indications of possible injuries, in addition to those just noted, will be the occurrence of _paroxysmal coughing_, with inspiration of blood, and the added physical signs of the presence of blood in the pleural cavity. Thus dulness on percussion, with the line of dulness altering with position, will indicate the presence of fluid, and should this occur soon after the injury it can only be regarded as an evidence of hemorrhage into the pleural cavity. A combination of abnormal tympanitic condition, as above, with the physical signs of fluid beneath, will indicate a condition of pneumohemothorax. These signs will change from hour to hour or from day to day in accordance with altering internal conditions. If they become rapidly more pronounced they indicate a condition which will probably call at least for free incision, evacuation of blood, and very likely determination of the source of its escape and proper attention thereto.
[Illustration: PLATE XLVIII
Radiograph of Chest, showing Mauser Bullet.
(From Plate X, “Use of Röntgen Ray by the Medical Department of U. S. Army in the War with Spain, 1898.”)]
An intercostal artery is of itself a small vessel, but when cut across by the edge of a knife or torn by the passage of a bullet it may pour sufficient blood into a pleural cavity to cause serious dyspnea and perhaps fatal result. To discover at the coroner’s inquest that a patient has been allowed to die because no one had the judgment to enlarge the wound and assure himself whether such a hemorrhage was not occurring is not at all creditable to those in charge of the case. The combined dangers of infection and of collapse of the lung are not so great as those of possibly fatal hemorrhage, or intrinsic disaster through septic infection from neglect of this kind.
Aside from the injuries thus produced to the respiratory apparatus there are those especially involving _the heart_. It has been supposed that gunshot wound of the heart was necessarily fatal. There is now reason to think that this is not invariably true, even in individuals not promptly operated upon, while the resources of modern surgery have enabled the surgeon to save a number of cases of absolute gunshot injury to the pericardial sac and even to the heart itself. (This subject has already been considered in the chapter on Surgery of the Heart and Great Vessels.) Every case which is not promptly fatal is worth attempting to save, if suitable help be at hand, by a resection of the chest wall, exposure of the pericardium, and of the heart itself, with the introduction of sutures or the use of the ligature wherever these may appear to be needed.
The occurrence of more special forms of traumatic lesion may be indicated by particular features. Thus if the _esophagus_ has been wounded the patient may expectorate or vomit blood, whose presence in the stomach could not be explained by other features of the case. On the other hand blood which comes into the mouth from the _lungs_ may be swallowed and its appearance in the ejected materials thus accounted for. A violent disturbance of cardiac regularity or evident paralysis of the diaphragm may be accounted for by injury to the _pneumogastric_ or _phrenic nerves_.
=Treatment.=--In regard to the general _treatment_ of these injuries the use of the _probe_ should not be encouraged, at least in the way in which it was formerly used. It is a serious matter to stir up clot or to open up a wound with a probe, thus inviting free entrance of air. Nearly all the information desired may be more accurately obtained by careful physical examination and study of symptoms. It should never be used except with aseptic precautions. It affords little information as to the course, and practically none as to the location of a bullet which has penetrated the chest wall. It may possibly be of service in searching for a bullet in the muscles of the back, but the only information it is capable of furnishing is afforded by a skiagram. Miscellaneous probing should be condemned, and in these injuries is rarely justifiable.
The first measure to adopt in cases of gunshot wound of the chest is to determine that the heart has not been disturbed; the next to estimate what injury may have occurred to large vessels, then a general determination of the other surgical features of the case. The patient who shows no depressing symptoms nor develops them during the ensuing few hours may be left with only a temporary occlusive dressing placed over the wound; but increasing embarrassment of respiration, or weakening and increasing rapidity of pulse, should be carefully watched to guard against internal hemorrhage. If it be learned that there is such internal bleeding prompt action should be taken for its control. This means anesthesia and perhaps _thoracotomy_, with resection of one or two ribs, in order to afford space through which to practise deep suture or ligation. So long as one side of the chest alone is involved--_i. e._, one lung thus exposed--the surgeon may widely open the chest and meet every surgical indication without the necessity for artificial respiration or the use of the Fell apparatus. It is, however, advisable to have this at hand for such work, while cases demanding such extreme measures can scarcely be made worse by the performance of a tracheotomy and resort to some means for forced and artificial respiration.
To simply enlarge a small bullet opening or punctured wound, in order to be sure that an intercostal artery has not been injured adds but little to the danger and much to the security of such a case. _In case of doubt give the patient the benefit of that doubt and operate_ to any necessary extent. When hemorrhage is slight and not alarming it may be sufficient to make the occlusive dressing include a tamponing of the opening between the ribs, gauze being packed in the opening in such a way as to prevent hemorrhage.
A study of the escaping blood will permit of differentiation between arterial and venous hemorrhage, that which escapes from the lung being ordinarily of the latter type. Richter has suggested an ingenious method of deciding whether hemorrhage comes from an intercostal artery or lung tissue, by introducing a sterilized piece of pasteboard, similar to a visiting card, rolled up in the form of a circular tube and flattened with a crease; should blood flow out along the groove it shows that it is an intercostal artery which is bleeding; but if it flows out of the wound through the tube the source of the bleeding is the pulmonary tissue itself. (Dennis.)
The question of the _presence of a foreign body_, bullet or otherwise, is important. This is less so when it is a question of the bullet itself than of driving in some fragment of rib or of foreign body introduced from without. A bullet, a broken knife-blade, or anything of such character will be revealed by an _x_-ray picture. The probe will rarely give this information. Clothing, objects carried in the pocket, or various other foreign material may escape detection.
The first measure of importance is the determination of the occurrence of serious _internal hemorrhage_, the second is the emergency _treatment of the injury itself_, which should include primary aseptic occlusion, to be followed later by other measures. A withdrawal of fluid is also indicated. Escaped blood may be contaminated and produce later a pyothorax. As the result of a traumatic pleurisy serum may collect within the ensuing few days, and it too should be removed. It should be first found with the exploring needle. If seen to be free from pus it may be withdrawn by the aspirator; but if it be destined to become pus, then the sooner it is evacuated by incision the better.
Increasing embarrassment of the heart’s action, which is not caused by the collection of blood, may be due to _pyopericardium_. So soon as the physical signs indicate gradual enlargement of the cardiac area the exploring needle should be used. A _traumatic pericarditis_ may simply require aspiration of the pericardium, whereas the presence of pus in the pericardial cavity will not only necessitate aspiration, but occasionally open _incision_, with or without drainage. The appropriate manner of affecting these procedures will be found more fully discussed in the section on the Heart.
INJURIES TO THE THORACIC VISCERA.
In general, and without regard to the nature of the accident, _injuries_ to the _thoracic viscera_ include wounds of the _pleura_, the _lung_, the _diaphragm_, the various large and small _vessels_, the _pericardium_, the _heart_, the _thoracic duct_, and the _nerves_.
=Wounds of the Pleura.=--Injuries to the _pleura_, including rupture, are produced by severe blows which do not inflict fractures, although these are rare in the absence of such injuries. They are usually not accompanied by external markings, but are indicated rather by dyspnea and cough, with involuntary limitation of respiratory motions and by the physical signs of escape of blood (hemothorax) or air (pneumothorax), or by some crepitation at the site of fracture, which may be recognized with the stethoscope. In many instances lacerations of the pleura are accompanied by more or less injury to the lung, perhaps with perforation of air cells or small bronchi and the inevitable pneumohemothorax. With a wound situated near the twelfth rib the lung, which extends normally only to the tenth, may escape injury. A small wound of the pleura is of little consequence. By itself it is of serious import only as it is accompanied by more serious disturbances of the lung which it envelops, or the heart which it contains.
When air passes freely to and fro through the opening in the chest wall, without expectoration of froth or bloody mucus, it may be assumed that the lung itself has not been injured. To this condition the name _traumapnea_ has been given.
Uncomplicated cases of _pneumothorax_ usually take care of themselves, the air being gradually absorbed by the bloodvessels. In certain cases this air may be withdrawn by the aspirator. A small amount of _blood_ within the pleural cavity is usually absorbed. An amount sufficient to embarrass respiration should be withdrawn either with the aspirator or by incision. For the latter purpose the wound may be utilized when properly situated.
=Wounds of the Lung.=--Wounds of the lung are made immediately dangerous by injury to its bloodvessels or are given a serious aspect by the possibilities of various forms of infection, including septic pneumonia. In serious cases this may proceed to _abscess_ formation or _gangrene_. Should either of these be sufficiently localized no surgical procedure directed to evacuation or to excision or removal of the gangrenous tissue can be more dangerous than the condition left to itself. The surgeon may, therefore, be impelled to perform a pneumotomy or a pneumectomy.
When the lung tends to protrude or prolapse through an external injury the condition is referred to as _pneumocele_, or sometimes as _hernia_ or _prolapse of the lung_. This is rare, and occurs usually in connection with punctures or stab wounds placed anteriorly and generally low. The lung may be entangled, after having been forced out by violent coughing, and the external portion has been known to be strangulated in such a way as to slough off. Should this occur the mass may be permitted to slough, or it may be removed by cautery or by ligature, the wound being left to heal by granulation. In rare instances the pneumocele has been covered by the parietal pleura, as is abdominal hernia by parietal peritoneum.
Another form of pneumocele is the later consequence of injury, the soft, crackling, or crepitating tumor presenting beneath the skin and returning the usual breathing sounds when auscultated. It may increase and diminish in size with the respiratory movement. Such a hernia may occur beneath a scar or through ruptured intercostal muscles. It is of small surgical consequence, and, if troublesome, may be retained by a suitable pad.
The lung is occasionally _ruptured_ by a violent concussion of the chest, as is also the heart. Its consequences will be emphysema, pneumohemothorax, with vomiting of blood, and later infection.
The later consequences of hemothorax, simple or uncomplicated, may be troublesome pleuritic adhesions, by which freedom of respiration is impaired, and, it may be, chest motions interfered with and chest development limited. The pleural surfaces are usually gradually drawn toward each other by the development of granulation tissue and its subsequent contraction and condensation.
=Wounds of the Diaphragm.=--The diaphragm may also be lacerated by the compressing effects of violent blows, either upon the chest or abdomen. In consequence there may be passage of viscera (_hernia_) from either cavity into the other. Accurate recognition of these cases will scarcely be possible, but the development of distinct abdominal symptoms or noticeable displacement of the heart or of the abdominal viscera may lead to exploratory section, which shall reveal the location of the rent and possibly permit of appropriate repair or suture.
=Injuries to the Thoracic Duct.=--The thoracic duct is occasionally injured by penetrating wounds, while, at the base of the neck, it has been known to be divided in the course of the removal of deep and adherent tumors. In the latter case the escape for a short time of the milk-like _chyle_, which it carries, will give evidence of the injury. Several cases on record show the comparatively innocent nature of the injury and its tendency toward spontaneous recovery without the necessity for further intervention. The very low pressure of the fluid in the duct is a contributing cause to this exemption from serious harm. Should the duct become obliterated near its upper end doubtless collateral circulation will enable the right and smaller duct to take up its work and continue it.
=Injuries to the Upper Nerve Trunks.=--In regard to injuries of the upper nerve trunks in the chest it is necessary to add but little to statements made regarding injuries to the same nerves in the neck. The writer has collected over fifty cases of destructive injury to the pneumogastric, in over one-half of which recovery followed. It has been shown that unilateral resection of the vagus is almost devoid of danger, though when it is required the nerve is rarely in a normal condition. Unless the nerve be attacked or involved below the branch which forms the recurrent laryngeal, laryngeal symptoms may be certainly expected. Irritation to the cervical _sympathetic_ is usually followed by dilatation of the pupil, widening of the palpebral fissure, some degree of protrusion of the bulb, and paresis of that side of the face, while absolute sympathetic paralysis, such as follows division, will produce dilatation of the pupil, ptosis, and increased flushing of that side of the face. The sympathetic nerve may have to be extirpated in certain cases of excision of malignant tumors. Again, it has been deliberately resected, as recommended by Jonnesco and others, for the cure of epilepsy, of exophthalmic goitre, and of glaucoma. This will demonstrate the fact that injury to it is not necessarily of itself a severe accident.
In certain injuries to the chest branches of the _brachial plexus_ will be divided or compromised, or displaced by fragments of bone or otherwise. When nerve pressure can be recognized the compressing cause should be removed. If a nerve be divided every attempt should be made to suture it.
## Partial or complete division of the large _vascular trunks_ is usually
too promptly fatal to justify much consideration here. On the other hand, injuries to the _intercostal_ and _internal mammary_ vessels are not uncommon and should not be fatal if only they can be properly recognized and treated. It is stated that even an intercostal artery may pour four pounds of blood into the pleural cavity in case of gunshot or stab wound. The presumption would be that one of these vessels, if injured, is wounded at the site of the evident puncture. While this is usually true it is possible that a bullet penetrating may have divided an intercostal on the opposite side. If a ligature is to be applied it should be done on each side of the wound, whereas a tampon used to check hemorrhage may be packed in such a direction as to completely meet the indication. While many methods have been suggested for arresting bleeding, the surgeon will enlarge the puncture, seek out the source of the hemorrhage, and then resort to ligature or to tamponing, as the case may indicate. When the tampon is used it is well to push ahead of it a piece of gauze like a glove finger and fill this with the tampon, in order to ensure complete removal of the whole mass at the proper time.
This is true also of injuries to the _internal mammary_. Dennis mentions five cases, quoted to him by Langenbeck, of perforation of the chest with a sword-blade, as the result of duels among university students of Göttingen, of which number two died. The latter also stated that up to 1876 there never had been a successful ligation of this artery. The vessel, leaving the subclavian between the two heads of the sternomastoid muscle, lies in its course just to the inner side of the sternum, with the vein on its inner aspect. Near the clavicle it lies on the pleural sac, where if injured the pleura will not escape. Lower down the pleura is not necessarily opened, although it rarely escapes. As Dennis shows, the inference from this is that tamponing the wound in the two upper intercostal spaces is impracticable, while below these it might succeed, as the triangularis sterni lies between the pleura and the artery. The mortality of the injury has been stated to have been nearly 70 per cent. Diagnosis is not difficult so long as the blood escapes externally. With a wound properly situated and rapid accumulation of blood within the chest, and increasing collapse, assumption of the injury or provisional diagnosis will scarcely prove fallacious.
The _internal mammary_ when injured should be secured. The operator need never hesitate to resect a portion of the sternum, or the rib ends or cartilage, in order to expose it, since no danger can be so great as that of not finding it. Incision may be made along or between the ribs, parallel to them, or over the known course of the artery. After retracting the tissues down to the bone a sufficient amount of the bone should be removed to afford space for the examination. The pleura should be first separated, care being taken not to inflict upon it more than a minimum of injury. A T-shaped incision will afford more room when the case is complicated. The ends of the vessel having been found and secured, it becomes then a question of emptying the chest of the blood already accumulated. This is preferably done by incision placed laterally and sufficiently low, with the introduction of a drainage tube. Should the blood be already coagulated the incision should be made sufficiently wide to permit of breaking up the clot and completely removing it.
=Treatment.=--In general, with regard to the treatment of all these injuries, it should be said that, in addition to whatever local measures may be indicated, general rest of the parts should be secured by as complete immobilization of one or both sides as can be effected. This should be made a part of the treatment of all fractures, simple or compound, as well as of all perforating injuries. Anodynes, hypnotics, and the like need to be used both to restrain motion and to allay cough, either of direct or reflex origin, by which harm is always done.
THE THORACIC WALLS.
The complex structure of the thoracic walls is not exempt from the infections and other diseases which may involve skin, muscle, cartilage, and bone. Thus upon its surface all sorts of phlegmonous lesions may occur, assuming carbuncular or localized type, or occasionally ending in widespread gangrene, usually of that particular type which is due to the morbid activity of the gas-forming bacilli, whose first expression is a _gangrenous emphysema_. These infections occur not only in consequence of some external irritation, but are seen after the infectious fevers, as well as in connection with syphilis, tuberculosis, scurvy, actinomycosis, and other forms of infection. Tuberculous disease beginning on the exterior of the chest wall may spread to the interior and even deeper, and, _vice versa_, tuberculous lesions beginning within the chest spread to the adjoining bone, producing caries, and then to the exterior surface, the resulting sinuses being irregular and sometimes opening at a point at considerable distance from the origin of the trouble.
All the infectious processes, whether slow or rapid, need radical attack, including free incision, curetting, removal of diseased bone, cauterization of the affected area, and suitable dressing and packing. _Carious ribs or portions of the sternum_ may be removed without fear, it being necessary in certain advanced cases to remove nearly the entire sternum. Any concealed focus of disease is sure to spread and do more harm than will a well-directed attempt to eradicate it. Infection originating within the bone may spread in either direction, and may give rise to pleurisy, with adhesions, and possibly even subsequent abscess of the lung. The same is true of the diaphragm, while products of infection travelling in the proper direction may cause the beginning of an extensive subphrenic or hepatic abscess.
[Illustration: FIG. 505
Erosion of sternum, the result of pressure of an aneurysm. Wood Museum. (Dennis.)]
[Illustration: FIG. 506
Erosion of vertebræ, the result of pressure of an aneurysm. Wood Museum. (Dennis.)]
The pressure of advancing tumors will sometimes cause surprising changes, not so much the result of ulceration as of mere absorption in the path of the advancing mass. Thus _aneurysms_ will gradually erode the sternum or the ribs, and in time form bulging projections from within the chest, which may ultimately rupture and thus terminate the case. Even upon the vertebral column the effects of such pressure are pronounced. Figs. 505 and 506 illustrate what may happen under circumstances just detailed.
Remarkable expressions of subcutaneous _emphysema_ may be seen in certain cases of fracture of ribs, with perforation of the lung, air escaping into the tissues and puffing up the whole upper part of the body and neck, giving it an appearance and shape very different from the original. For this condition there is no particular treatment, save immobilization, by which respiratory efforts shall be limited. Ordinarily the tissue distention quickly subsides. Should, however, putrefactive organisms enter with the air there may arise emphysema, terminating in gangrene, with fatal septicemia.
Painful affections of the thoracic walls are associated with lesions, either of the intercostal nerves or the ganglia or special nerves with which they are connected, which produce _intercostal neuralgia_ of various types, including that with its peculiar eruption known as _herpes zoster_, or as the laity call it, “shingles” (being a corruption of the Latin _cingulum_, meaning a girdle). Neuralgia may also be caused by inclusion of nerve branches in callus which is formed around a badly united fracture of the ribs. The diseases of the vertebræ which lead to softening and changes of shape will also permit of pressure upon nerve centres and trunks, which cause more or less pain, referred more often to the distribution of the nerves involved than to their origin. Thus the referred pains of spondylitis (Pott’s disease) are to be thus explained and are sometimes very pronounced. We give the term “neuralgia” to those painful affections for which there is no satisfactory explanation, and thus we are told that in intercostal neuralgia there are three points of tenderness, known as those of Valleix, whose determination confirms the diagnosis--the first being at the point of exit of the spinal nerve from the vertebral canal, the second in the axillary line, and the third close to the costosternal articulation. Abrams has shown that if a freezing spray be applied over the first spot the neuralgia will at once subside if it be of peripheral, but not if of central origin. Again, if one pole of the galvanic current be placed on the affected side and the other upon any one of the above spots the pain, if neuralgic, will disappear. If the current employed be the Faradic, and the pain subside, its cause is located in the muscles, as the induced current does not influence the pain of a genuine neuralgia. (Dennis.) So far as the treatment of these painful affections is concerned it is rarely surgical; although it was the relief afforded by the accidental stretching of an intercostal nerve which first suggested to Nussbaum the utility of nerve stretching as a more general procedure, and it was thus introduced to the profession. The treatment of _herpes_, _i. e._, of that form of neuralgic affection which is characterized by the appearance of papules which soon become vesicular, which collect in clusters and appear along the course of certain intercostal nerves, is rarely surgical. It is not difficult to distinguish this from ordinary eczema, which does not follow the nerve distribution and is not accompanied by the severe pain of herpes.
THE MEDIASTINUM.
MEDIASTINITIS.
The principal interest attaching to diseases in either mediastinum pertains to the consequences of spreading infection, which will be practically always of the phlegmonous type, and which will produce clinical expressions varying much with its location and the direction of its course. These are included under the general head of acute or chronic _mediastinitis_, which might be the result of an extension from above, as from cervical abscesses, spondylitis of the cervical vertebræ, deep cervical phlegmons, and the like; or the result of perforation, or of foreign bodies impacted in the esophagus or elsewhere; or may again come from the osseous structures of the chest proper, spine, ribs, and sternum. Doubtless certain cases of subphrenic abscess are the result of suppuration begun in the mediastinum. Instances are also occasionally seen after typhoid and the other infectious and contagious fevers.
The _indications of mediastinitis_ consist of intrathoracic soreness and pain, increased upon coughing and deep inspiration, difficulty of deglutition, disturbances of respiration and of heart action. Any irregularity of the pupils is evidence of irritation along the sympathetic nerves. Displacement of the heart means accumulation in its neighborhood and pressure disturbance. The lesion which will produce this will probably give dulness on percussion, and alterations of the ordinary chest sounds. With trouble high in the thorax the recurrent laryngeal may be involved, with the inevitable change in the voice. If the pneumogastric be compressed there will be rapid and irregular heart
## action. If the esophagus thus suffer dysphagia will result. Should the
presence of pus be suspected a differential blood count may do much to clear up the diagnosis. Should pus come near the surface it will probably give the ordinary surface indications which one should be quick to appreciate and to relieve. Collections of pus within the chest tend always to migrate and pus may burrow to a considerable distance.
=Treatment.=--The treatment of phlegmonous mediastinitis mainly depends upon recognition of the lesion and its degree of accessibility. Certain deep forms are hopeless, since they tend to kill before even pus can be located and evacuated. So soon as there be found any surface indication surgical attention should be promptly given. Any of these cases may be complicated by septic conditions within the lung or accumulations within the pleural cavity. The latter at least may be recognized and relieved. The proper use of the exploring needle may afford much information, and, in the presence of suitable indications, the sternum should be trephined and exploration made behind it. The main thing in all these cases is to distinguish between pressure effects produced by phlegmon and those due to aneurysm or tumor. Only rarely, and then only by surgeons of wide experience, should radical measures be attempted for the latter. Chronic processes, of tuberculous character and leading to formation of cold abscesses, will usually produce symptoms much less urgent, while the nature of the relief to be afforded will scarcely be left in doubt.
[Illustration: PLATE XLIX
Neurofibroma of Skin.]
TUMORS OF THE THORAX.
_Primary tumors of the chest wall_ constitute less than 1 per cent. of those occurring in general practice; this, of course, not having reference to secondary developments from cancer in the breast, which are somewhat frequent. Of the benign tumors those which most frequently appear upon the surface are the _lipomas_, which are seen either in circumscribed or diffuse form, as illustrated in Figs. 507 and 508.
[Illustration: FIG. 507
Circumscribed lipoma of back. (Dennis.)]
[Illustration: FIG. 508
Congenital diffuse lipoma of back. (Mixter.)]
They are sometimes multiple and perfectly innocent, save as they may attain large size or ulcerate from surface irritation. The _granulomas_, especially those of syphilis and tuberculosis, are common, appearing either as superficial tumors which ulcerate, or as deeper ones which may break down in the course of months or years, after perhaps involving the ribs or a considerable portion of the chest wall. _Actinomycosis_ is perhaps as often seen in this region of the body as anywhere.
The _fibromas_ are seen more commonly in the axilla and beneath the thoracic musculature. The chest is a frequent site for those pedunculated fibromas which have been described under the term keloid. A most striking case of neurofibroma of the skin is portrayed in Plate XLIX.
_Chondromas_ of the chest are slow-growing, usually painless, may involve a considerable area, both of bone and cartilage, are not infrequently the seat of cystic changes, and often undergo a final sarcomatous degeneration. All this is true in lesser degree of the _osteomas_, which are of the cancellous type.
The malignant tumors of the thorax proper are mostly _sarcomas_ which assume various types, according to their cellular characters, the round-cell sarcomas growing rapidly, becoming extremely hemorrhagic and fungous, and tending to kill early, while the larger and more spindle-cell and the giant-cell forms grow relatively more slowly, and may even be successfully removed (Figs. 509 and 510.)
[Illustration: FIG. 509
Sarcoma of rib and pleura, result of injury by a base-ball. (Dennis.)]
_Carcinoma_ of the chest wall is generally the result of extension from cancer of the breast or of some other epithelial structure. Advancing carcinoma spares nothing, and may not only perforate the chest but involve the lung beneath, with or without later ulceration, and the occurrence of pneumothorax.
[Illustration: FIG. 510
Skiagram of a large sarcoma of the thorax and humerus, whose bloodvessels were injected previous to taking the _x_-ray picture. (Lexer.)]
While these are the more common forms of tumor of this region there are no known growths which may not occasionally be met here.
=Treatment.=--The treatment for all these tumors is _extirpation_. With benign growths outside of the ribs proper this is usually a simple matter. When the whole or nearly the whole thickness of the chest wall is involved it becomes then a serious problem how far to proceed in the effort to extirpate. This is true alike whether sternum or ribs are involved. The entire sternum may be separated from its surroundings and lifted out of place, and this would be justifiable when dealing with an osseous or cartilaginous growth. If, however, it were distinctly sarcomatous it would be hardly worth while. If in such an operation the pleura be spared and air not admitted to the pleural cavity almost anything is allowable. If, however, it appear that it will be necessary to open the pleural cavity caution should be observed. Of late years, however, less hesitation has been felt in this regard, and Parham and others, including myself, have shown that extensive portions of the thoracic wall may be resected without the necessity for employment of the elaborate operative methods suggested by some recent experimenters. For instance, Sauerbruch has devised a “pneumatic cabinet,” the patient’s head resting outside when the anesthetizer administers the anesthetic. The balance of the body rests within the cabinet, which is sufficiently large to accommodate the operator and two or three assistants, and which, being closed, is subjected to a lowering of atmospheric pressure equivalent to 10 Mm. of mercurial column, or to a difference in atmospheric level of 1000 to 1200 feet. The patient breathing air at external pressure does not suffer the collapse of the lung, thus exposed, which would otherwise take place. The operation being completed within the cabinet, the dressings are applied and hermetically sealed, and the door then opened and pressure equalized. Subsequent dressings can be made in the same way. Thus has been afforded a scientific method of doing that which the experience of many American surgeons has shown to be only theoretically indicated. Sauerbruch’s device is ingenious in theory and complicated in operation.
A simpler method is to apply the Fell-O’Dwyer apparatus over the face and thus keep up artificial respiration. It is not, in theory, so ideal as to open the trachea and practise this procedure as is done in the experimental laboratory, but is much simpler and will usually suffice, should anything of the kind be required.
A malignant tumor of the chest wall whose overlying skin is seriously involved, and whose removal would leave a defect which it would not be possible to cover with integument, should not be disturbed. It might be possible in certain cases to partially transplant the breast in such a manner as to permit closure of a defect thus made. Nevertheless it is questionable if any cancer advanced to the extent of requiring this procedure is to be considered operable.
Nor should any malignant tumor of the chest wall be operated if, in addition to its own presence, there be indication of the involvement of the lymphatics or other structures within the chest, such indications including, for instance, cough, loss of voice, dyspnea, dysphagia, disturbance of pneumogastric control of the heart, displacement of the latter, or great accumulation of fluid in any of the chest cavities. The only exception to this statement is possibly when the lung has attached itself to its interior surface, but yet not so extensively but that removal of a small amount of lung tissue will not interfere with extirpation of the growth. Cases of recurring carcinoma where the chest wall is completely involved rarely justify operation.
TUMORS OF THE LUNG.
Tumors of the lung proper might be made amenable to surgery, in certain instances, if an exact diagnosis could be made. Occasionally this is possible, though but very rarely. Particles of lung tumor have been expectorated and their minute character recognized, so that actual diagnosis has been made. As in the abdomen, cancer of the thoracic viscera will usually lead to an accumulation of serous fluid, and, in both instances, thus obscure rather than simplify recognition. Quincke has shown that the presence in such pleuritic effusions of fat cells (hydrops adiposus) is significant, since they rarely if ever occur in any other exudates.
Primary tumors of the lung are usually _sarcomas_ or _endotheliomas_. _Carcinoma_ is exceedingly rare, save as secondary to cancer in the breast. Even sarcoma is itself usually secondary to disease in some other part of the body, metastasis having occurred through the blood channels, instead of through the lymphatics, as is the case with carcinoma. Tumors arising in the pleura may be of endotheliomatous type and are usually accompanied by the presence of bloody serum. Extremely rare tumors within the chest are those of _dermoid origin_, connected more often with the pleura than with the lung proper. These may suppurate and communicate either externally or internally. One known case mentioned by Dennis was that in which such a tumor communicated with a bronchus, so that the patient coughed up hair. _Syphilitic gummas_ are also found in the lung, either in multiple small form or in masses of considerable size. They are slow in development and may give rise to no special disturbance. Dennis has described instances in which these growths have become encapsulated.
Two other forms of tumor are not very rare in this situation: one is that produced by _actinomycosis_; the other occurs in _echinococcus_ disease and in the formation of _hydatid cysts_. The former, developing within the lung proper, tends to migrate toward its surface, to include the pleura, and finally to invade the chest wall. Such a tumor when exposed in either location can scarcely be differentiated from a breaking-down sarcoma, except by the recognition in it of the small, calcareous particles which are so pathognomonic of this disease. (See
## Actinomycosis.) In the living patient the sputum will frequently
contain these particles, while under the microscope the peculiar club-end, thread-like fungus formation may be recognized. The disease is usually of slow development, but occasionally, especially when mixed with a secondary infection, may be rapid. Significant tumors may also occur in other parts of the body. Actinomycotic tumors upon the surface may be attacked with curette and cautery. Injections of iodine are also of value. For actinomycosis of the lung proper potassium iodide and Lugol’s solution are indicated as well as copper sulphate.
_Hydatid cysts_ occur within the lungs in about 10 per cent. of cases of echinococcus disease. Their contained fluid is alkaline, of low specific gravity, colorless, and contains the characteristic hooklets which are pathognomonic of this disease. A circumscribed collection of fluid within the chest, shown to be due to this condition, may be tapped or incised and drained. When occurring in the lung it not infrequently leads to secondary pyothorax, while operation for the latter may reveal the existence of the former. Any hydatid cyst of the lung which can be recognized, or be made accessible, may be treated by incision and drainage, the lung, if not already adherent, being first fastened to the chest. Inasmuch as the condition develops in the lower lobe and on the right side this is occasionally a practicable procedure. As the diagnosis is usually made only after the primary cyst has ruptured and small cysts are cast off, producing more or less pleuritic effusion, the attempt may still be made to do this by a free incision of the chest wall, perfecting the diagnosis and completing the procedure at this time.
THE HEART.
There is but little to be said about the heart in addition to that elsewhere stated, where such injuries as gunshot wounds, stab wounds, etc., are considered. _Rupture_ of the heart without external injury is possible under conditions of fatty degeneration or softening produced in consequence of embolus or thrombus. _Aneurysms of the heart_ are also known by which it is weakened and permitted later to give way. The final rupture is usually the consequence of some emotion or extra exertion, although it may occur with injury to some other part of the body, as after a blow upon the abdomen. Death may be instantaneous, or occur more slowly as the result of filling of the pericardial sac and rapidly increasing embarrassment of heart action.
_Wounds of the heart_ produce syncope and shock, restlessness, extreme anxiety, with dyspnea and such disturbance of heart activity as to materially change the sounds heard on auscultation.
The treatment of such cases not primarily fatal should include opium narcosis, but not stimulants intended to excite the heart to extra
## activity. The operations justified under these conditions are elsewhere
described.[50]
[50] Borchardt has collected 83 cases of operations upon the heart, of which 78 included heart suture. Of these 78, 46 died and 32 recovered. He quotes a statement of Billroth, made when this surgeon was sixty years of age: “Paracentesis of the pericardium is an operation which, according to my view, closely approaches to what might be considered a prostitution of surgical art, or, as some surgeons would call it, a surgical frivolity, an operation which altogether has more interest for the anatomist than for the physician. Possibly a later generation will regard it differently. Internal medicine is constantly becoming more surgical, and those physicians who concern themselves especially with internal medicine will find themselves compelled to make the most daring operation.” The rapid advances made in surgery during the past three decades cannot be better illustrated than by contrasting Billroth’s statement of a few years ago with the standard practice of today.
_Pericarditis_, either of idiopathic or traumatic origin, may produce a degree of distention, either _hydropericardium_ or _pyopericardium_, calling for surgical intervention--in the former case with the aspirating needle, in the latter either with the needle or the knife. When a pericardium is greatly distended with fluid there is marked change in the position of the apex beat, with embarrassment of heart
## action, accompanied by distress and distention of the veins of the
upper part of the body, as well as much alteration of the ordinary physical signs, the area of dulness being correspondingly enlarged and the lung sounds being lost over the area occupied by the distended sac. Great distention, with marked precordial trouble and distress of heart and lung function, always requires _paracentesis_.
_Paracentesis pericardii_ is performed ordinarily by puncturing (a previously sterilized area) 3 to 5 Cm. to the left of the left border of the sternum, and in the fifth intercostal space, with a sterilized needle. Here are found the internal mammary artery and the pleura. Too rapid withdrawal of fluid may lead to syncope. It should, therefore, be allowed to escape slowly. Should it prove purulent it may be incised, passing the knife-blade along the needle; or the sac may be emptied, when, if fluid re-collect, a free incision should then be made. Roberts has shown that recovery follows in at least 40 per cent. of cases of empyema of the pericardium thus treated. Gauze drainage may be provided, but irrigation of the cavity should not be practised.
Allingham has suggested to open the pericardium from below by an incision three inches in length, carried along the lower margin of the seventh left costal cartilage, to separate the cartilage from the abdominal muscles, pull outward and upward the lower surface of the diaphragm, expose the cellular interval between its attachment to the cartilages and to the tip of the sternum, to expose and enlarge by blunt dissection, until there appears a mass of fat which belongs above the diaphragm in the interval between the pericardium behind, the sternum in front, and the diaphragm below. When this is removed the pericardium is exposed and can here be opened. Throughout the procedure injury to the pericardium which lines the upper surface of the diaphragm should be avoided. By this method the pleura need not be opened and better drainage may be secured. (Dennis.)
_Abscess in the heart wall_ is an exceedingly rare lesion, usually accompanying pyopericardium, but occasionally met without it. It was the writer’s experience in one case, in puncturing for what was supposed to be a pyopericardium, to withdraw pus and give temporary relief. Later postmortem examination showed that this pus came from a large abscess in the wall of the heart, which had been thus entered by the aspirating needle without immediate bad consequences, but, on the contrary, with temporary relief.
THE LUNGS.
In the fact that the lung never completely fills the pleural cavity we find explanation for the kindred fact that small effusions produce little if any compression symptoms. Collapse of one lung after opening the chest is never _complete_ if the other lung be uninjured and functionating. Moreover, a partial collapse on the affected side will be quickly atoned for when the pressure of the external atmosphere is taken off.
Two or three serious pathological conditions of the lung occasionally require surgical intervention.
HYDATIDS OF THE LUNG.
Hydatids of the lung have been mentioned (see above). Seventy-five per cent. of these cases terminate fatally without surgical help, and in reality more prospective benefit can be offered by it than without it. Serious and even fatal collapse has attended the sudden withdrawal of fluid from hydatid cysts in this location. Aspiration may be made, but even this is scarcely less dangerous while it is less satisfactory than free exposure and drainage.
## ACTINOMYCOSIS OF THE LUNG.
## Actinomycosis of the lung may be recognized by the sputum and also by
the pus discharged from any breaking-down cavity within the affected area. (See section on the Pleura.) If a localized focus could be diagnosticated or recognized after exposure the portion of the lung thus involved might be removed.
ABSCESS OF THE LUNG.
Abscess of the lung is always the result of some local or distant infectious process. The mechanism of production of the multiple metastatic abscesses which characterize pyemia has been described in the earlier portion of this work. For such conditions surgery affords no aid. Circumscribed abscess may be the result of the presence of a foreign body--_i. e._, a bullet or a parasite--or it may result from embolism with infarct, in consequence of such affections as ulcerative endocarditis, puerperal septicemia, sloughing fibroid, an otitis media, or a septic pneumonia produced from any cause. It may be the result of extension from an osteomyelitis of some portion of the bony wall of the thorax, which itself may result either from injury or from local infection. Abscess of the lung is seen not infrequently in connection with _empyema_, and often results from suppurating tuberculous _bronchial nodes_. It may be produced, also, by extension of trouble from below the diaphragm, as hepatic abscess, subphrenic abscess, and the like. It is always a secondary rather than a primary affection.
Such abscesses are to be recognized by the character and offensiveness of the sputum, the pus discharged being colored green or brown, containing shreds of tissue, with masses of bacteria and crystals of fat. Some believe the presence of elastic fibers to be pathognomonic. When pulmonary abscess is diagnosticated it is necessary, in addition, to determine whether multiple lesions or a circumscribed collection are to be dealt with. In the former instance it is of little avail to intervene. In the latter the physical signs will usually furnish evidence of adhesions between the lung and the chest wall, by whose presence the operative procedure is simplified.
The term _pneumotomy_ is applied to the exposure and evacuation of pus in the lung, whether it be found in connection with an ordinary abscess or a suppurating hydatid cyst. It is essentially a thoracotomy, plus the added measure of whatever may be done to the lung itself, and will be described in connection with other operations upon the chest.
If a tuberculous abscess could be located it also might be treated upon the same general principles. Thus Lane and others have suggested early operations for relief of tuberculous lesions. For obvious reasons, however, the method has not found general acceptance.
GANGRENE OF THE LUNG.
Gangrene of the lung is the terminal stage of a local infection, and unless relieved may prove fatal to the patient. It is due to the causes above mentioned as producing abscess in the lung, while to them may perhaps be added a few others, especially expressions of embolism or thrombus of the pulmonary circulation by which, the blood supply being cut off, death of tissue occurs before there is time for phlegmonous development. Thus it is met with occasionally after the acute exanthems and the infectious fevers and after violent pertussis. When diffuse it is of the miliary type. When circumscribed it may be due to more localized causes. In any event it is more frequent in the lower portions of the lung.
Pulmonary gangrene may be recognized by the extreme condition of the patient, offensive odor of the breath, and expectoration of sputum which may at first be frothy and bloody, but becomes rapidly purulent and finally necrotic in type. Meantime, the function of the lung being materially interfered with, respiration is rapid and there will be more or less cough, pain, and finally collapse. When the sputum is allowed to stand in a test tube there will form an upper layer, opaque and frothy; a middle, more frothy layer; while the lower and denser portion will be of a dirty green color and contain shreds of dead tissue with bacteria, crystals of triple phosphates, fat debris, and pus. According to the nature of the case the cavity or the area of dead lung may be outlined by physical signs. There is a form of _fetid bronchitis_ which has been mistaken for pulmonary gangrene, but the character of the sputum and the progress of the case will be quite different.
Gangrenous areas of limited size have in certain favorable cases cleared up and the patients have recovered, but ordinarily for this condition surgery affords the only prospect of relief, the operation being begun with a _thoracotomy_ and completed by the _removal of the gangrenous lung tissue_. The operative procedure is essentially the same as that for abscess and above described.
_Septic pneumonia_ is the term applied to those forms of pneumonitis which occur in connection with septic lesions in other parts of the body, or with the less typical forms--_e. g._, aspiration pneumonia, due to the passage into the finer bronchioles of material from the mouth or nose. It gives rise to the same physical signs, though it is perhaps more often irregularly located than is the consolidation of the ordinary lobar pneumonia. Viewed in this way it will be regarded as a serious complication of various other conditions, many of which are surgical, and it is frequently a primary expression of infection. The physical signs by which it may be recognized are scarcely different from those of ordinary pneumonia, except that, in addition to the latter, there may be distinct expressions of general septic infection and of profound toxemia, and that the disease may progress to the point of producing pulmonary abscess or gangrene. While the milder types of septic pneumonia are not necessarily fatal, it is always a serious complication, and, as such, dreaded by the surgeon. It is not, however, essentially a surgical complication, but calls for the treatment generally given to pneumonia, plus whatever may be needed for the primary condition behind it.
CHYLOTHORAX.
This implies a collection in one of the pleural cavities, usually the left, of fluid which is practically unchanged chyle, which has probably escaped from the thoracic duct. The number of cases on record is not over fifty, of which about one-third have followed unrecognized injury with probable rupture of the duct. Most of these cases have occurred in connection with fracture of the spine. The duct may be opened by the progress of ulcerative disease, and carcinoma is often the predecessor of chylothorax. Rupture may also occur in connection with tuberculous lymphatics about the course of the duct, and when the condition occurs in children this is the usual explanation. It should be differentiated from so-called _chyloid effusions_ into the pleural cavity, which are more often seen in connection with cancer than tuberculosis, the fluid in this case being mixed with fat and degenerated leukocytes or cells. Pure chyle contains sugar, while chyloid fluid contains but a trace of it. The former also is thicker, and compares with the latter as does cream with skimmed milk.
The prognosis is not usually favorable. Nevertheless recovery has ensued without operation. Mere pressure of the effusion may occlude the opening through which it occurs until the latter shall heal. When the fluid gives rise to severe symptoms the chest should be aspirated.
HYDROTHORAX; HEMOTHORAX; PYOTHORAX.
Under these terms are included the presence of fluid in the pleural cavity, between the lung and the chest wall; this fluid, in the first instance, being _serum_, which may be slightly admixed with pus and blood; in the second, _blood_; and in the third, _pus_.
Hydrothorax may be a primary condition, the result of pleurisy with effusion, or of pleuropneumonia. It may also occur as does a similar collection in the abdomen, as the result of disease of the chest wall, the lung itself, or in consequence of serious cardiac or renal disease, with tendency to dropsical accumulations in various parts of the body. Thus it is seen in connection with tuberculous disease or cancer of the lung, as well as cancer of the chest wall. There is, moreover, a miliary expression of tuberculous pleuritis in which hydrothorax is always a complication.
The serious features of hydrothorax result from the compression which it may make upon a lung with consequent embarrassment of lung function and from the possibility of infection by pyogenic organisms and the consequent conversion of a hydrothorax into a pyothorax.
Collections of serum within the pleural cavity which manifest a kindly tendency to disappear by resorption do not require surgical intervention, but all such accumulations which do not quickly evince this tendency should be removed by the operation of paracentesis, which, applied to the thorax, is called _thoracentesis_, _i. e._, aspiration through the hollow needle. No lung should be allowed to have its capacity long reduced by compression.
_Hemothorax_ may be idiopathic or traumatic. In the former case it is an expression of malignant disease, or of advanced septic lesions which have permitted erosion of bloodvessels and escape of blood. It may also result from rupture of an aneurysm, and will then prove fatal. It is seen in surgical cases in connection with injuries to the chest wall or its contents, as in compound fracture of a rib or perforation of a rib fragment into the chest, with injury to the lung.
In case of the sudden escape of fluid into the chest, with symptoms of collapse and lung compression, it may be assumed that an acute hemothorax affords the explanation. Fluid accumulating _rapidly_ under any circumstance is more likely to be blood than serum. The exploring needle may be relied on to furnish the deciding test, in addition to the ordinary physical signs afforded by auscultation and percussion.
_Pyothorax_ is frequently referred to as _empyema_, the latter term indicating a collection of pus in a previously existing cavity, and, by common consent, made to refer to the pleural cavity unless some other be mentioned. Empyema is seldom a primary condition. Generally it is the result of a hydrothorax, which has become contaminated either by direct or by indirect access of germs. Under these circumstances it indicates the conversion of a relatively innocent collection of serum into a collection of pus, with all its attendant dangers. It may be looked for in cases of perforating injury of the chest, _e. g._, compound fracture of the ribs, gunshot wounds, and the like.
While returning the ordinary physical signs met with in fluid collections in this location, and being discoverable with the exploring needle, empyema has this additional feature, that the pus may, when long retained or accumulated in large amount, burrow and attempt to escape through whatever path may offer least resistance. In this way strange freaks will occur, as when it escapes behind a mammary gland and pushes the latter forward, thus forming a large retromammary abscess, which requires not merely the ordinary incision, but a thoracotomy and ample drainage as well. It may penetrate at other points and thus escape. The most remarkable illustration that the writer personally has known of this travelling of pus was in a colored man, in whom it perforated the diaphragm, then separated the peritoneum from the abdominal wall over a large area, collected in large amounts between the peritoneum and the abdomen in front, and even extended down into the pelvis. This man had such a peculiar abdomen that he was supposed to have dropsy. When the trocar was inserted there was a discharge of over a pailful of almost pure pus.
In addition to the ordinary embarrassment which a considerable amount of pus thus collected causes, there should be reckoned the peculiar septic and toxic features, which can be easily accounted for by the nature of the contained fluid. Pyothorax will nearly always have septicemic in addition to local features, which give it an individuality of its own.
The operations practised for relief of these conditions are discussed at the conclusion of this chapter.
THE ESOPHAGUS.
Anatomically, the esophagus is a musculomembranous tube with downward projection into the thorax, its uppermost portion blending with the lower constrictor of the pharynx, the tube proper beginning at the level of the cricoid cartilage, and opposite the sixth cervical vertebra. Its conclusion opposite the tenth dorsal vertebra marks the cardiac orifice of the stomach. In its upper portion it is placed centrally, then inclines a little to the left, and, at the level of the third dorsal, lies about half an inch to the left of the middle line. This furnishes the reason for approaching it upon the left side in doing external esophagotomy. From here it passes to the middle line again until opposite the ninth vertebra, where it once more inclines a little to the left. It has an anteroposterior curve corresponding to the shape of the spine. Between it and the trachea, in the neck, lies the recurrent laryngeal nerve. Its nervous supply is derived from the sympathetic and the pneumogastric, and its lymphatics connect with the mediastinal nodes, the latter point being of importance in connection with cancer of the esophagus. Its average caliber is about three-quarters of an inch, save where it is crossed by the left bronchus and at the diaphragmatic opening. There is also a slight constriction at its upper opening.
CONGENITAL MALFORMATIONS OF THE ESOPHAGUS.
Congenital malformations include its absence, at least throughout some of its course. Communication between it and the treachea, so-called tracheo-esophageal fistula, has been noted. Its upper portions, into which may open the incompletely closed branchial clefts, are also subject to malformations with incomplete obliteration of the latter and consequent diverticula. Irregular dilatation is also occasionally of congenital origin, as well as acquired, in the latter case being due to fatty degeneration of muscle fibers. These dilatations should be differentiated from those which are mostly found on the proximal side of any constricted tubular passage, and which are produced by accumulation and distention from behind of whatever should be passed through it.
The most common _malformations_ of the esophagus which are not of the stenotic character are so-called _diverticula_, which appear in two forms--namely, _distention_ and _traction_, these being both acquired forms, while congenital formations of this character are also occasionally met.
_Congenital diverticula_ may appear anywhere along the course of the tube, but are probably more common in its upper portion. They constitute more or less irregular tubular sacs which lie alongside of and parallel to the main tube. The openings by which they connect may be large or small. These saccular defects, always small at first, may assume increasing proportions, because of the entrance therein of food and their consequent distention by foreign material, as well as by products of decomposition of the same. Thus slowly and insensibly a very mild form of such defect may in time assume serious proportions.
The _acquired diverticula_ of the _distention_ type are usually met with in the upper part, and are practically hernial protrusions of at least the mucosa through the fibers constituting the muscular portion of the tube, and cannot occur save by some preceding pathological change. _Traction diverticula_ are the results of adhesions to breaking down lymph nodes or other pathological conditions, by which the esophageal wall is first pulled out of position, then gradually sacculated, and the condition still further aggravated by accumulation therein of foreign material. The acquired diverticula attain considerable size, and when emptied one may be astonished at the accumulation which has occurred. Such a tube having been completely emptied may be again filled by the first food which is subsequently taken. After being filled, the balance of the food may then pass into the stomach, with partial or complete comfort or satisfaction to the patient.
The principal indication of an esophageal diverticulum, beside dysphagia, is regurgitation or vomiting of food. When food which has undergone decomposition is occasionally rejected, and when, at the same time, the stomach is shown to be not dilated and not at fault, the suspicion of a diverticulum may be considered well founded. Its opening into the esophagus may be so placed as to always engage the instrument which may be passed down for examination, either bougie or stomach tube. Should this be a constant phenomenon the diagnosis may be easily established. In such a case it may be possible to first empty and then distend the sac with food mixed with bismuth subnitrate, or perhaps to inject it with an emulsion of the same. If this can be done, the fluoroscope or a good radiograph will show a distinct shadow, and in this way a pictorial outline of the condition may be obtained.
=Treatment.=--The treatment of these diverticula is of great difficulty, especially when the sac has attained a size which permits of retention of material. Sacs which contain decomposing matter should be emptied by the stomach tube and washed out at frequent intervals. If it be then possible to pass the tube beyond them the patient should be fed through it, or it may be possible to place the patient in the recumbent position, with the head lower than the body, and cause food or fluid to be swallowed in this attitude. It will then probably enter the stomach instead of the sac. Such measures as these failing, and nothing else affording relief, operations are occasionally undertaken. Much will depend upon the location of the sac, especially its height. A diverticulum in the neck may be more easily reached than one in the chest, and Richardson and myself have had remarkable success in the relief of aggravated cases of this kind. Cushing has shown the advantage of the administration of atropine before these operations, in order to limit the flow of saliva and keep the parts dry. The sac having been exposed by a long incision in front of the sternomastoid, it may be filled with a solution containing methyl blue, by which it may be identified, or it may be filled with paraffin, which, solidifying, will serve admirably for its identification. It then may be attacked as would be any solid tumor. The sac having been identified and extirpated its opening into the esophagus is then closed by sutures and the neck wound cared for as usual, with provision for drainage (Figs. 511 and 512).
[Illustration: FIG. 511
Diverticulum freed from its attachments and delivered from the wound. (Richardson.)]
[Illustration: FIG. 512
Shows the external layers of the esophagus closed by interrupted Lembert suture of silk. (Richardson.)]
Traction diverticula may be amenable to surgical intervention. Should the esophagus be diverted by adhesion to an advancing aneurysm nothing should be attempted. Among the operations which may be practised upon the thorax there may be mentioned a method of posterior exposure and attack upon some of these conditions which may or may not afford advantages, according to the nature and location of the various conditions.
_Cardiospasm_ (see chapter on the Stomach) produces a sacculation of the gullet often mistaken for diverticulum, and requiring to be differentiated from it.
FOREIGN BODIES IN THE ESOPHAGUS.
Foreign bodies may be lodged in any portion of the esophageal tube and cause a variety of troubles, according to their size, shape, location, and nature. There is scarcely any conceivable object which may be introduced into the mouth which has not been known to be impacted in the esophagus and produce more or less serious symptoms. Young children, imbeciles, and the insane may suffer unwittingly in this way, while the condition is usually accidental and unintentional.
The accompanying figures (Figs. 513 and 514), portraying in one case a jackstone lodged in the esophagus, a coin in the other, a case of my own, will furnish illustrations of what has just been said. (See also page 674.) The young and the insane may make no statement which will furnish a clue for the distress caused in attempts to swallow or the actual impossibilities of the act. In most instances, however, a history of impaction and a statement as to the nature of the foreign body may be obtained. The _symptoms_ produced are those of partial or complete inability to swallow, of more or less pain accompanying the act, and of the regurgitation often of blood or of bloody mucus. The object may be sufficiently large to produce dyspnea and suffocative symptoms, _e. g._, a plate with false teeth.
[Illustration: FIG. 513
Jackstone lodged in esophagus. (Phelps.)]
[Illustration: FIG. 514
Coin lodged in esophagus, successfully removed by external esophagotomy. From the Author’s Clinic. (Skiagram by Dr. Plummer.)]
The condition being suspected or made known, the location of the foreign body may be determined by the esophageal bougie and by the use of the _x_-rays. With certain irregularly shaped objects the latter prove a desirable help, especially when irregular plates containing false teeth, or toys have been passed into the esophagus. They afford an indication not only as to their exact situation and emplacement, but also as to the best method of attack, that is, whether from without or within. Considerable distress may be produced by even small particles, as chips from an oyster-shell, small pieces of glass, and the like.
[Illustration: FIG. 515
Esophageal forceps.]
[Illustration: FIG. 516
Horse hair probang, expanded and unexpanded.]
=Treatment.=--A foreign body which produces the slightest discomfort or recognizable symptoms should be removed. Only occasionally can this be done by making the patient endeavor to swallow something else, this being too uncertain a method of procedure; although I have known a peach-stone impacted in the esophagus to be pushed into the stomach by the passage of an esophageal bougie. The situation and the nature of the object being known, one then decides how best to proceed. The available methods of operation are:
1. The introduction of a bougie and the enforced passage of the object into the stomach (questionable).
2. The use of the esophageal snare.
3. The use of the esophageal forceps or similar means of extraction.
4. The more directly operative methods by external incision.
The _esophagoscope_ is an instrument of comparatively recent device and perfection. We owe it largely to the ingenuity of Mikulicz. It is to the esophagus what the endoscope is to the urethra, and may be regarded as essentially an enlarged endoscope. Its introduction is comparatively easy, but its retention is distressing to the patient, so that opportunity may thus not be afforded for profiting by its use. The employment of cocaine anesthesia, and perhaps of morphine hypodermically, will sometimes enable it to be used satisfactorily. It may also be used for exploratory purposes previous to commencing a formal operation under general anesthesia. There are furnished with the instrument itself forceps and extractors, by which it may be possible, when the object is once seen, to grasp and withdraw it. The use of the esophagoscope is, moreover, not limited to these lesions, since it can be used in revealing the character of strictures, small wounds, diverticular openings, and the like. Endeavors may be first made to locate the body by those possessing such an instrument and expert in its use.
The _esophageal snare_ is a simple instrument which, after being introduced, is shortened in such a way as to cause to protrude a basket-like meshwork of bristles in which, as the instrument is withdrawn, a small object may be entangled and so withdrawn. In the same way an ingeniously made _coin catcher_ is furnished, which, in cases of impacted coins or similar shaped objects in the esophagus, may be introduced beyond them and then withdrawn, the object being caught in a miniature cradle, from which it cannot escape until brought up into the pharynx. Esophageal forceps are made with long blades, curved like all the instruments used within the pharynx, and serving admirably for grasping objects impacted high in the tube (Figs. 515 and 516).
Dislodgement being impossible by either of the above-mentioned expedients, recourse may be had to the operation of _external esophagotomy_. This may require to be done as an emergency measure, but is practically always indicated when an impacted object cannot be otherwise removed. A dangerous location for a foreign body in the esophagus is at a distance of about nine inches from the upper incisor tooth, at which point it will be located directly behind the arch of the aorta, at which level ulceration would perhaps result disastrously, as Richardson has shown. The operation was devised by Goursault, in 1773, and has proved a satisfactory surgical measure. It is performed upon the left side of the neck. The incision is made along the anterior margin of the sternocleidomastoid from the middle of the neck downward. The larynx and trachea are separated to the inner side, the muscles and the large vessels to the outer side, the omohyoid divided, the descendens noni and the recurrent laryngeal nerves, which lie in the groove between the trachea and the gullet, are protected from injury, and the esophageal tube thus exposed. The surgeon will feel more secure in opening it if he now pass downward through the mouth a bougie or instrument upon whose beak or tip he may cut down. The esophagus being opened, the margins of the wound are secured by sutures which serve as retractors, and the interior of the tube is then subjected to the necessary manipulation. Even now it may not be an easy matter to dislodge a pointed object, which may have become partially impacted. Thus it may be dislodged at first by pushing it down a short distance and turning it, the direction having been already indicated by an _x_-ray picture. The manipulation should be as gentle as possible. Extraction having been accomplished, the esophageal wound is closed by the sutures introduced for traction purposes. Over this the external wound is closed, with suitable provision for drainage, as it is almost certain to have been infected during the procedure. In rare cases it has been necessary to combine a _gastrotomy_ with this operation, in order that by combined manipulation a peculiarly shaped object may be dislodged.
_Gastrotomy_ will be necessary in but few instances, as, for instance, when an object known to be one which cannot pass through the pylorus has been dislodged into the stomach by pressure from above--as plates containing false teeth, and various similar objects. It will probably be safer to open the stomach and remove the object than to leave a patient to his otherwise uncertain fate. On the other hand objects which are sure to be in time dissolved or disintegrated by the stomach juices may be allowed to remain to await this event.
WOUNDS OF THE ESOPHAGUS.
Wounds of the esophagus occurring in other ways than those above indicated may be the result of gunshot and various perforating injuries. The tube may be also partially cut across in so-called _cut-throat_.
Any external wound of the esophagus which can be recognized should be closed with sutures, and the parts brought together, if possible, with provision for drainage. Those lacerated wounds constituting some forms of cut-throat, however, permit of very little in this direction, for when seen they are too infected. Through an esophageal opening thus inflicted the patient may be fed for a time by a tube, the wound being left to close later by granulation or by a secondary operation. When the esophagus has been anywise injured it would be better to abstain from feeding or else to introduce food through an esophageal tube.
RUPTURE OF THE ESOPHAGUS.
Rupture of the esophagus has been known to occur in consequence of severe vomiting, there being some twenty-five cases of this character now on record. (Dennis.) A tear is rarely complete, but it may be followed by hernia and formation of a diverticulum. The accident will be indicated by violent pain following severe vomiting in connection with an effort to dislodge a foreign body. There will be more or less shock and perhaps collapse, with escape of blood. Emphysema of the neck and upper part of the chest may result and the injury prove fatal. The condition being suspected, it would be advisable to do an external esophagotomy or else to carefully introduce a stomach tube and leave it _in situ_.
PERFORATION OF THE ESOPHAGUS.
Perforation--_i. e._, rupture _without traumatism_--may result from the existence of ulcers or from the advance of malignant disease. It may occur in either direction. Thus while the mediastinum may be infected from entrance of septic material into it the direction may be reversed and an abscess or other lesion of the surrounding tissues may evacuate itself into the esophagus. Should this prove to be an aneurysm the patient will die with uncontrollable escape of blood. The treatment of such a case, if any be permitted, will depend entirely on the nature of the exciting cause. Perforation has also followed injudicious use of bougies when exploring or treating strictures (especially cancerous) of the esophagus.
ESOPHAGISMUS.
Esophagismus, or spasmodic contraction of the esophagus, is usually an expression of hysteria, or else is a reflex spasmodic effect due to the presence of some neighboring irritation. In the esophagus, as in the urethra, there may be spasmodic stricture, which will afford considerable obstruction. Thus I have seen it as a functional neurosis, absolutely without explanation, in an apparently healthy workingman. It is noticed also in connection with hemorrhoids and with hepatic lesions. It is seen in pregnancy, and a certain degree of it will complicate many cases of gastric ulcer, gastritis, or esophagitis such as is produced by swallowing mild caustics. While producing dysphagia and obstructive phenomena it is intermittent and interposes little real obstacle to the passage of a full-sized bougie or tube. It is frequently accompanied in the hysterical by globus hystericus, and by regurgitation of whatever food the patient attempts to swallow.
The local treatment consists of dilatation by the passage of full-sized instruments at frequent intervals. If a neurosis the patient may require other treatment, addressed either to the nervous system or to any well-marked constitutional condition.
STRICTURE OF THE ESOPHAGUS.
Stricture of the esophagus has an etiology practically identical with that which pertains to stricture of any other passage of the body. It may be due to extrinsic or intrinsic influence. Among the former may be mentioned the presence of tumors, either benign or malignant, or of cicatricial tissue, while among the latter should be mentioned the injuries resulting from the presence of foreign bodies, the extensive ulcerations due to the swallowing of various caustic fluids, and the cicatricial contraction which may follow other lesions like ulceration. Those cases which are due to serious congenital defects will usually die early. Of the ulcerative lesions which lead to stricture the most common are the cancerous. Syphilitic and tuberculous ulcerations may occasionally produce the same effect. By far the most common causes are the traumatic, which are connected either with foreign bodies or with the unfortunate accidental use of caustics.
_Esophageal strictures_ are recognized by the difficulty in swallowing which they produce and the later dilatation of the esophagus above, which is the frequent result of their long existence. The degree of difficulty experienced by the patient in deglutition is to a considerable degree a measure of the extent of contraction. It may be nearly always assumed that such a stricture as is produced by the swallowing of caustic fluids will leave a tortuously contracted passage-way, and the instrument passed for its recognition, while arrested in its upper portion, may give little or no correct idea as to the arrangement below. In some instances it may be possible here, as in the case of diverticula, to introduce sufficient bismuth emulsion into the esophagus to make it cause a shadow in an _x_-ray picture, and in this way to give pictorial information not otherwise attainable.
The surgeon should distinguish between hysterical spasm or esophagismus and cicatricial stenosis. The former will offer but little obstacle to the passage of a full-sized bougie. In fact it will be frequently benefited, usually cured by it, while in the latter instance this is almost impossible.
[Illustration: FIG. 517
Stricture of the esophagus. (Dennis.)]
[Illustration: FIG. 518
Esophageal bougies.]
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.
[Illustration: FIG. 519
Incision for resection of thorax. (Bergmann.)]
[Illustration: 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).
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.
[Illustration: FIG. 521
End result of an extensive thoracoplasty. (Park.)]
=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.
[Illustration: FIG. 522
Congenital diaphragmatic hernia, with other congenital defects. Wood Museum. (Dennis.)]
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.
[Illustration: FIG. 523
Transthoracic opening for subphrenic abscess. (Beck.)]
=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.
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