Copyright N°^ COPYRIGHT DEPOSIT: SURGICAL DISEASES OF THE CHEST CARL BECK, M.D. PROFESSOR OF SURGERY IN THE NEW YORK POSTGRADUATE MEDICAL SCHOOL AND HOSPITAL ; VISITING SURGEON TO THE ST. MARK'S HOSPITAL AND THE GERMAN POLIKLINIK ; CONSULTING SURGEON TO THE PHILANTHROPIC HOSPITAL; PRESIDENT OF THE AMERICAN THERAPEUTIC SOCIETY ; PRESIDENT OF THE NEW YORK SOCIETY OF MEDICAL JURISPRUDENCE; FORMERLY CHAIRMAN OF THE SURGICAL SECTION, INTERNATIONAL CONGRESS OF ART AND SCIENCE, ST. LOUIS, SEPTEMBER, 1904, ETC. Mitb 16 Colored anfc 162 Qthct IMustrations PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1907 LIBRARY of CONGRESS Two Cooies Received APR, t 1907 . Copyright Entry CLASS A XXC, No/ foOPY 3.' / TU Copyright, 1907, by P. Blakiston's Son & Co. DEDICATED TO professor ^incen^ C^rrnp THE GREAT TEACHER AND FRIEND OF MANY AMERICAN SURGEONS. PREFACE. The wonderful progress of modern surgery has given an impetus to a production of special literature unheard of in the history of surgery, every organ of the abdominal cavity being the subject of at least one large and excellent treatise. It seems that the especially technical achievements of American surgeons, whose brilliancy has become most striking in ab- dominal surgery, absorbed all interest and concentrated it upon the abdominal cavity. This may account for the fact that other cavities of the human body, especially the thoracic, are in spite of their immense importance treated as a quantite negligeable. Nothing illustrates this state better than the fact that up to the present there is only one special work on the surgery of the chest. It is from the illustrious pen of Stephen Paget, who must properly be considered one of the pioneers in this great field of practice. But since the publication of his book, which bears the date of June, 1896, three great factors have arisen which transformed the character of surgical work to such an extent that many traditions and theories had to be discarded. These three revolutionists, which led to surgical possibilities hitherto not dreamed of, were: Bacteriology, Asepsis, and the Rontgen Method. I have endeavored to emphasize the great importance of these new branches of science without ignoring the notable researches and the valuable experiences of our ancestors. At the same time I have taken pains to make the book especially useful for the general practitioner by accentuating the border- line character of the work. Consequently more stress is laid upon diagnostic points than is generally expected from a book of a distinctly surgical character. vi Preface. I am greatly indebted to Messrs. Wood & Co. for the blocks of some of my illustrations printed in the "Medical Record." My thanks are also due to Professors Waldeyer, Testut, Jacob, Garre, Lejars and von Winckel for their courtesy in allowing me to copy some of their excellent illustrations. The other illustrations are originals depicted from cases treated by myself in the Postgraduate and the St. Mark's Hospitals. Most of the Rontgen illustrations were taken by my son, Dr. Eric Carl Beck. I am furthermore under special obliga- tions to my wife for preparing bibliography and index and for other valuable assistance. Carl Beck. New York, 37 East 31ST Street, March 27, 1907. CONTENTS. CHAPTER I. PAGE The Anatomy of the Thoracic Wall and the Diaphragm i General Outlines i Sternum 6 Ribs 10 Thoracic Vertebrae 16 Ligamentous Connections of the Thoracic Bones 24 Interchondral Articulations 28 Muscles, Vessels, and Nerves of the Thoracic Wall 29 Diaphragm 40 CHAPTER II. Surgery of the Thoracic Wall 43 Malformations of the Thorax 43 Injuries of the Thoracic Wall (Non-penetrating) 61 Asepsis 61 Fracture of Sternum, Rib, and Costal Cartilage 68 Burns of Chest 73 Contusion of the Thorax Associated with Injuries of the Intra- thoracic Organs 82 Penetrating Injuries of the Thorax 83 Inflammatory Processes of the Chest-wall 86 Phlegmon of the Thoracic Wall, Genuine and Tuberculous Ab- scesses ; Necrosis 90 Injection of Iodoform-glycerin 99 Tumors of the Chest-wall 101 (1) Benign Growths 101 (2) Malignant Growths 105 (3) Hodgkin's Disease 108 (4) Echinococcus of the Chest- wall 112 CHAPTER III. Intrathoracic Diseases 114 Anatomy of the Pericardium 114 Injuries of the Pericardium no Aspiration of the Pericardium 116 Pericardiotomy 1 iS viii Contents. PAGE Anatomy of the Heart 120 Injuries of the Heart 122 Anatomy of the Pleura t 125 Diseases of the Pleura 128 Serothorax (Serous Exudative Pleuritis) 129 Aspiratory Puncture of Thorax 132 Exploratory Pleurotomy 133 Pyothorax (Empyema Pleurae) 137 Hydrothorax 201 Hemothorax 201 Chylothorax 202 Anatomy of the Lungs 203 Abscess of the Lungs 206 Gangrene of the Lungs 211 Bronchiectasis 213 Echinococcus of the Lungs 2 14 Actinomycosis of the Lungs 217 Tuberculosis of the Lungs ". 219 Intrathoracic Tumors 222 Aneurysm of the Thoracic Aorta 226 Anatomy of the Trachea and Bronchi 236 Foreign Bodies in the Respiratory Passages 239 CHAPTER IV. The Value of the Rontgen Method in Thoracic Surgery 246 General Rules 246 Localization of Abscess, Bronchiectatic Cavity, Echinococcus, and Gangrene of the Lungs 249 The Rontgen Method in Pleuritis 256 The Rontgen Method in Pyothorax 257 The Rontgen Method in Hydropneumothorax 258 The Rontgen Method in Diseases of the Heart 258 The Rontgen Method in Diseases of the Pericardium 259 CHAPTER V. Subphrenic Abscess 261 Topography 262 Pathological Anatomy 267 Diagnosis 268 Prognosis 273 Varieties 276 Course 284 Therapy 285 Contents. ix CHAPTER VI. Diseases of the Breast 290 Anatomy of the Breast 290 Diseases of the Nipple 292 Inflammatory Processes in the Breast (Mastitis) 294 Mammary Cysts 304 Special Inflammatory Processes in the Mammary Gland 305 Echinococcus of the Mammary Gland 306 Mastodynia 307 Hypertrophy of the Breast 307 Tumors of the Mammary Gland 308 Adenofibroma of Breast 310 Adenoma of Breast 311 Lipoma, Atheroma, Myxoma, Angioma, Chondroma, and Oste- oma Mammae 311 Sarcoma Mammae 312 Carcinoma Mammae 314 Operative Treatment of Carcinoma Mammae 321 Rontgen Treatment of Carcinoma Mammae 335 Rontgen Treatment of Benign Diseases of Chest 348 Index 369 SURGICAL DISEASES OF THE CHEST. CHAPTER I. THE ANATOMY OF THE THORACIC WALL AND THE DIAPHRAGM. The thorax has a conical shape, its convex walls represent- ing a barrel-shaped osseous structure which is formed by the ribs, the dorsal vertebrae, and the sternum. The axis of this osseo-cartilaginous cage shows an oblique downward and forward direction. It contains and protects the principal organs of circulation and respiration, viz., the heart and its membranous bag, the pericardium, the large blood-vessels, the lungs invested by the pleurae, and the major part of the oesophagus. The boundary-lines of the cavity are, roughly speaking, the ribs, which surround the thoracic barrel like the hoops of a cask, the dorsal vertebrae, the sternum, and the costal car- tilages (Fig. i). In giving these general outlines, however, it must be con- sidered that its upper as well as lower boundary-lines are not in exact proportion with the osseous thorax, since the upper overlap the sternal end of the first rib and clavicle and also extend beyond the first dorsal vertebra. Similar conditions exist at the lower boundary-lines, where the diaphragm represents the line of division between the thoracic and the abdominal cavity. A portion of this organ extends high up into the osseous thorax, so that a considerable part of the thoracic wall also covers abdominal organs. 2 Anatomy of Thoracic Wall and Diaphragm. The transverse diameter of the thoracic cavity is widest along the attachment of the diaphragm. The boundary-lines are the ensiform process in front, the lower two ribs, the anterior parts of the false ribs, and the common costal cartilage, which Floating ribs Fig. i. — The Thorax, Front View. — (Morris' "Anatomy.") connects these ribs with the sternum, on the side, and the twelfth dorsal vertebra behind. The exterior aspect of the chest measures, according to the perimetric observations of Wintrich, 89.52 centimetres at Perimetric Figures. 3 the highest point in the axilla, 86.64 on a level with the mammilla, and' '81.88 at the junction of the ensiform process with the sternal body. These figures comprise the average condition Fig. -Six-months-old Embryo Skiagraphed through Amnion, Showing Thoracic Relations. found in men of twenty-five years. Perimetric figures, gained from the thorax of women of twenty-five years, show Si. 90 4 Anatomy of Thoracic Wall and Diaphragm. centimetres at the highest point of the axilla, 81.00 in the middle, and 78.00 below. The embryonic thorax and that of new-born children (Fig. 2) show a marked difference, the lungs especially being but little distended at the early period of life while the liver is ex- tumely large (Fig. 3). This explains the projection of the Fig. 3. — Thorax of New-born Child, Skiagraphed. lower thoracic sphere at that age (Fig. 4). The average trans- verse diameter of the thorax in men amounts to 28 centime- tres on a level with the eighth rib, the sagittal on a level with the base of the ensiform process 20, and the vertical 35.5 at the posterior and 15.5 at the anterior wall. In women the posterior vertical diameter is, on the average, about 2 centi- metres less. The normal female chest is more round-shaped Thoracic Landmarks. 5 than the male, but has a smaller general capacity. Its ster- num is somewhat shorter, the proportion of its superior open- ing being larger. It may also be said that the upper ribs are more movable in the female, an important circumstance which permits of easier respiration during pregnancy. For proper localization the following landmarks should be borne in mind: The median line, alongside the middle of the sternum. The sternal lines, alongside the lateral margins of the sternum. & M Fig. 4. — The Thorax at the Eighth Month. — (Morris' "Anatomy.") (On the left side eight cartilages reach the sternum.) The mammillary or papillary lines, through the nipples. The parasternal lines, in the middle between the sternal and mammillary lines. The axillary lines, dropped from the middle of the axilla. Clinically an anterior and a posterior axillary line is distin- guished, the anterior extending from the lower margin of the pectoralis major muscle, the posterior beginning at the lower margin of the latissimus dorsi. The scapular lines, which begin at the lower angles of the scapulae. 6 Anatomy of Thoracic Wall and Diaphragm. The sterno-costal lines, which follow an oblique direction and extend from the sterno-clavicular junction to the tip of the eleventh rib. The exterior aspect of the thorax is best divided into an anterior region (sternal), two lateral (costal) regions, and a posterior (spinal) region. STERNAL REGION. The sternal region is bounded by the jugular fossa above and the ensiform process below, in the parasternal lines, two inches from the sternal margin, laterally. The tissues under- neath the integument are represented by their connective tissue, which connects the skin with the sternal periosteum in front and the sterno-costal ligament at the sides. The Sternum. The sternum (os or scutum pectoris, os xiphoides, ari t 0o<;, by Hippokrates — hence the term " stethoscope"), a flat and narrow bone, is situated in the median line of the anterior portion of the thorax, directly opposite the spinal column. Its peculiar shape recalls the short ancient sword of the Romans, which justifies its division into handle, blade, and point (Figs. 5 and 6). The handle (manubrium), which has a triangular shape, represents the upper and broadest portion. It is somewhat nearer the spinal column than the lower, sternal end. Its anterior surface is slightly convex, while the posterior is con- cave. The superior margin of the manubrium, which is the thickest, shows the pre-sternal notch at its centre and an oval articular surface on each side. The inferior margin is straight, the thin layer of cartilage covering its rough surface articulating with the upper portion of the blade. On each side of the pre-sternal notch a saddle-shaped articular surface Clavicular notch For first costal cartilage Xiphoid foramen The Sternum. Interclavicular notch Sterno-mastoid Pectoralis major Rectus abdominis Xiphoid or metasternum Fig. 5. — The Sternum, Anterior View. — (Morris' "Anatomy.") 8 Anatomy of Thoracic Wall and Diaphragm. Clavicular notch Sternohyoid Sterno-thyroid Triangularis sterni For first costal cartilage Diaphragm Fig. 6. — The Sternum, Posterior View. — {Morris' "Anatomy.") Sternal Blade. g serves for purposes of articulation with the sternal end of the clavicle. The lateral margins slightly converge toward the blade and continue in it. The blade (syn., meso-sternum, body, gladiolus) is three times as long as the manubrium, but much thinner and nar- Single centre for manubrium ~^r~ sterni ^ifc Single centre for i each of the four ' pieces of the gladiolus Single centre for / ensiform process \y _ Centre for man- ubrium sterni Accessory centre Single centre for first piece of gladiolus Bilateral centres for second, third, and fourth pieces of gladiolus Single centre for ensiform process Fig. 7. — Ossification of the Sternum. — {Morris' "Anatomy") A, Common arrangement of the ossific centers. B, Showing accessory centre in the manubrium sterni, and bilateral centres in the second, third, and fourth pieces of the body. rower. Its anterior surface shows three transverse lines which cross it opposite the third, fourth, and fifth articulation- surfaces. They are the indications of the union of the four separate osseous nuclei during the era of development (Fig. 7). The slightly concave posterior surface also presents these three lines, but less distinctlv. io Anatomy of Thoracic Wall and Diaphragm. The superior margin has an oval surface with which the manubrium articulates. The narrow inferior surface artic- ulates with the xiphoid process. The point (syn., meta-sternum, processus xiphoideus or ensiformis or mucronatus) is much smaller and thinner than the other pieces of the sternum. During the stage of develop- ment it remains cartilaginous throughout and only becomes ossified in adults. Its upper margin articulates with the lower end of the sternal body, while its lower end furnishes the attachment for the linea alba. The end is generally sharply pointed, but sometimes it is also found broad or bifurcated, and in rare cases perforated. The lateral borders of the sternum articulate with the inner ends of seven costal cartilages. The synchondrosis between manubrium and gladiolus does not ossify before early manhood, while in infants, espe- cially if there be disturbances of respiration, as in pertussis or in narrow-chested children, it may be extremely movable. The connection of the sternum with the elastic cartilages of the true ribs permits so large a degree of flexibility that even a great amount of violence exerted upon it from before is not apt to fracture it. If the sternum is insufficiently developed a hiatus forms, through which the heart may protrude from the thoracic cavity (ectopia cordis). THE RIBS. The ribs (costae), which are twelve in number on either side, represent elastic osseous arches which extend from the spinal column to the sternum. Each rib consists of an osseous portion and its cartilag- inous continuation, which is termed the costal end. If a cartilaginous portion of a rib reaches the lateral border of the sternum, we speak of it as a true rib (costa vera or genuina), the upper seven being true ribs. If the costal cartilage does not The Ribs. n reach the sternum, as is the case with the live lower ribs, then we term them false ribs (costa spuria or mendosa). The cartilages of the first three false ribs are attached to the cartilage of the rib above, while the two lower have a loose, free end in front, wherefore they are called floating ribs (costae fluctuantes) (Fig. i). Each rib, the first excepted, shows an external surface which is convex and an internal which is concave. There is also an upper border which is slightly round-shaped and a lower one. The interior surface of the inferior border contains a deep groove (sulcus costalis) which runs parallel to the border, and lodges the intercostal nerve and vessels (Fig. 8). There are two extremities, viz., a sternal and a vertebral. The intervening part is called the shaft (body). At the vertebral extremity head, neck, and tuberosity must be distinguished, the head showing an articular surface of renal shape, which is divided into two articular facets by a hori- zontal projection (Fig. 8). The neck represents the flattened part, which forms the direct continuation of the head and is one inch in length in the adult. Its situation is right in front of the transverse process of the inferior of those two vertebras which serve as the articulation with the head. Near the lower margin and on its posterior surface a slight prominence, called the tubercle or the tuberosity, presents itself. The inferior half of the tuberosity is provided with a small articu- lar surface for the extremity of the transverse process of the inferior of the two vertebrae which articulate with the head. The other half presents a rough eminence to which the poste- rior costo-transverse ligament attaches itself. The body is flat and thin. Its smooth and convex external surface is characterized by an oblique eminence, termed the angle, to which a tendon of the ilio-costal muscle attaches itself. Here the rib is slightly bent in two different directions. The distance between the tuberosity of the neck and this ans^le [ 2 Anatomy of Thoracic Wall and Diaphragm. Subcostal groove Sternal end for costal cartilage Fig. 8. — The Seventh Rib of the Left Side, Seen from Below. — (Morris' "Anatomy.") Costal Body. 13 gradually becomes longer from the second rib on to the tenth. The rib-portion intervening between the tuberosity and the sternal extremity is twisted on its own axis. Near the sternal portion it is also marked by an oblique line, termed the anterior costal angle. As to the sulcus costalis, see above. The flattened sternal end of the shaft shows an oval-shaped, concave articular surface for the reception of the costal carti- Single facet (some- times two facets are present) Single facet (this rib has an angle, but no tuberosity and no neck) Single facet (this rib has neither tuber- osity, angle, nor neck) Fig. 9. — The Vertebral Ends of Tenth, Eleventh, and Twelfth Ribs. — (Morris' "Anatomy.") lage. All ribs are similar to each other, but they vary in their length, in the degree of their curvature, the direction, the relations of the body to the neck (see above) and the relation of the costal cartilages to each other. The length of the ribs gradually increases from the first to the eighth and decreases in the same way from there to the twelfth, the latter being shorter than the first. As far as the direction is concerned, it is observed that the superior ribs i 4 Anatomy of Thoracic Wall and Diaphragm. are less oblique than those further down, the highest degree of obliquity being attained at the ninth. The length of the costal cartilages corresponds with that of the various ribs. Their shape appears more flattened at the upper ten, while the eleventh and twelfth are round-shaped (Fig. 9). The direction of the three upper cartilages is nearly horizontal, Levator costae Accessorius (insertion) Cervicalis ascen- dens (origin) Serratus posticus superior (in- sertion) Scalenus posticus Third digitation of serratus magnus Fig. 10. — First and Second Ribs. — {Morris'' "Anatomy") while those below, in contrast to the ribs, ascend obliquely toward the sternum. The relations of the ribs among themselves are such that they leave a space between each other. This is termed the intercostal space (spatium interosseum) . As to the peculiarities of some ribs, it may be said that the Tuberculum Lisfranci. 15 first rib, which is the shortest and most curved of all, is flat and very broad and shows a most important tuberosity at its superior surface near its inner margin, which separates two shallow grooves (Fig. 10). The anterior groove is for trans- mitting the subclavian vein, while the posterior is for the cor- Epiphysis for the head. Appears at fifteen; fuses at twenty-three Epiphysis for tubercle. Appears at fifteen; fuses at twenty- three The cartilaginous shaft com- mences to ossify at the eighth week of intrauterine life Fig. 11. — Rib at Puberty. — {Morris' "Anatomy.") responding artery. The tuberosity, called the scalene tubercle or tuberculum Lisfranci, serves as a valuable landmark in the surgery of the region. As to the stage of ossification, it may be said that the first ten ribs show three nuclei at the early period of life, one repre- senting the head, another the shaft, and the third the tubercle. 16 Anatomy of Thoracic Wall and Diaphragm. The eleventh and twelfth show no tubercle-centre. Ossifi- cation of the shaft begins at the eighth week of intrauterine life, while that of head and tubercle appears between the sixteenth and twentieth years (Fig. 1 1). The number of ribs may be increased by the presence of a supernumerary one, either at the lumbar or at the cervical ends of the series. While the lumbar variety, which seldom reaches considerable size, is of little surgical importance, the cervical type demands the most thorough consideration. (See Figs. 39, 40, and 41). The movements of the ribs are different in proportion to (M/ c Fig. 12. — Diagram of Axis of Rib-mo vemext, which is Likened to the Move- ment of a Pump Handle (a, b). — (Morris, after Kirkes.) their different shapes. The extremities of the first few ribs move up and down, the costal heads and tubercles acting like hinges. The bodies and angles of the ribs below rise as high as the extremities, the tubercles moving up and back during the act of inspiration (Fig. 12). THE THORACIC OR DORSAL VERTEBRA. The fundament of the trunk is formed by the spinal column (rhachis), which is composed of a series of thirty-five bones termed spondyli or vertebrae. Seven belong to the cervical, twelve to the dorsal, five to the lumbar, five to the sacral, and Vertebral Processes. 17 Cervical vertebra Costal process Transverse process Neuro-central suture Cervical rib Transverse process Costo-transverse foramen Neuro-central suture Rib Transverse process Lumbar rib Neuro-central suture Costal process Fig. 13. — Morphology of the Transverse and Articular Processes. — (Morris* 3 " Anatomy.") 18 Anatomy of Thoracic Wall and Diaphragm. four to the coccygeal region, the latter simply figuring as an appendage. All vertebrae consist of two characteristic portions, a body in front and an arch behind. Two pedicles and two laminae form the latter and support seven processes altogether, namely, a spinous, two transverse, and four articular. While the vertebrae of the various series differ more or less, the most essential parts are constructed on a common plan. As to their previous mode of development see Figs, n and 13. The dorsal vertebra, in which we are especially interested, being the paradigm for the others, we will confine ourselves to the description of this special type of bone (Figs. 14 and 15). The dorsal vertebrae, larger than the cervical and smaller than the lumbar, are the carriers of the ribs and therefore pro- vided with small cartilaginous surfaces for articulation with the costal heads at the side of their bodies. The heart-shaped bodies are like those of the cervical and lumbar series, in general, but differ inasmuch as they are much thicker ante- riorly than posteriorly, where they are concave, while their front shows a convexity. At each side two cartilaginous demi- facets, an upper and a lower one, present themselves near the pedicles. As mentioned above, they serve the purpose of receiving the heads of the ribs. The pedicles consist of two short and constricted osseous columns, the concavities of which are termed vertebral notches. They are four in number. By the contact of two vertebrae their notches form the intervertebral foramina, which permit of communication with the spinal canal and transmit the spinal nerves as well as the blood-vessels. The laminae consist of two broad osseous plates which enclose the small circular spinal foramen. By overlapping each other they appear like assorted tiles on a roof. Their connection with the body is effected by the pedicles. The long and triangular spinous process projects back- Transverse Processes. 19 ward and downward from the point of union of the laminae and ends in a slight tubercle. One process overlaps the other. Demi-facet for head of rib Superior articular process Pedicle Facet for tubercle of rib Transverse process ■ Spinous process Fig. 14. — A Thoracic Vertebra, Side View. — {Morris' "Anatomy.") ■ Spinous process Pedicle Demi-facet for head of rib Transverse process Fig. 15. — A Thoracic Vertebra. — (Morris' "Anatomy.") The two transverse processes are long, thick, and mas- sive, and extend obliquely backward and outward from the 20 Anatomy of Thoracic Wall and Diaphragm. arch at the point of union between the pedicles and the laminae. They end in a clubbed extremity which contains an oval facet for the corresponding articulation-surface of a rib-tubercle. The flat articular processes are four in number. They spring from the superior and the inferior part of the pedicles. The direction of the two superior processes is posterior and slightly exterior, while that of the inferior is anterior and slightly interior. The first dorsal vertebra resembles the seventh cervical very closely, its greatest diameter being transverse and its lateral margins showing two prominent lips. At each side of its body it presents an articular facet for the reception of the head of the first rib and a half facet for the superior half of the second. The ninth dorsal vertebra is characterized by the absence of the demi-facet below, while above it shows well-developed semi-facets. The tenth dorsal vertebra has an entire facet at each side of its upper border and lacks the demi-facets below. Both the eleventh and twelfth dorsal vertebrae resemble the lumbar, the articular facets for the costal heads being of very large size. The pedicles on which the facets are chiefly placed are so much stronger and thicker in accordance. The twelfth dorsal vertebra distinguishes itself by its very short transverse processes and the presence of three elevations, viz., the external, superior, and inferior tubercles, corre- sponding to the transverse, mammillary, and accessory processes of the lumbar vertebrae (Fig. 16). The vertebral bodies consist largely of cancellous tissue. If a section is made through the centrum, this tissue appears to be horizontally and vertically arranged (Fig. 17). Among all the bones of the body the spinal column shows the first signs of ossification in embryonic life. There are three primary and five secondary ossification centres at the early period of development, the primary ones Peculiarities of Dorsal Vertebrae. An entire facet above; a demi-facet below. In shape the body resem- bles that of a cervical vertebra Usually a demi-facet above (sometimes it has a demi-facet below) Usually an entire facet above. Occasionally this facet has been in- complete. The facet on the transverse proc- ess is usually small An entire facet above. None on transverse process, which is small . This is the anti-clinal vertebra An entire facet above; no facet on transverse process, which is trip- artite; centrum |large. Inferior articular proc- esses turn outwards as in a lumbar vertebra Fig. 16. — Peculiar Thoracic Vertebra. — {Morris' "Anatomy") 22 Anatomy of Thoracic Wall and Diaphragm. Fig. 17. — A Vertebral Centrum in Section to Show the Pressure Curves. — (Morris' "Anatomy.") forming as early as the seventh week of embryonic life. The nuclei of the bodies divide early and may remain bilobed during lifetime (Fig. 18). Fig. 18. — A Divided Thoracic Vertebra. — (Morris, after Turner.) At the time of birth there are three bone-pieces, viz., a body and two side pieces, which are connected by hyaline cartilage (Fig. 19). Lateral mass Neuro-central suture Centrum or body Fig. 19. — A Vertebra at Birth. — (Morris' "Anatomy.") Relations of Sternum. 2 3 Anterior chondro- sternal ligament An interarticular ligament The plate of fibro- cartilage between manubrium and meso-sternum Fourth rib ^^ Fifth rib "?££ Interchondral capsular ligament Fig. 20. — The Sternum. — (Morris' "Anatomy") (Left side, showing ligaments; right side, the synovial cavities.) 24 Anatomy of Thoracic Wall and Diaphragm. LIGAMENTOUS CONNECTIONS OF THE THORACIC BONES. The connections of the ribs are to be divided into those which are formed by the true ribs and into those of the false. The true ribs connect with the spinal column at their posterior extremities, while at their anterior ends they attach them- selves to the lateral margins of the sternum by their cartilages. Both connections form the articulations which are known as costo-sternal and costo-spinal articulations. Fig. 21. — Anterior View of Sterno-costo-clavicular Joint. — (Morris 7 "Anatomy.") (The capsule is cut into on the left to show the interarticular fibro-cartilage dividing the joint into two cavities.) The costo-sternal articulations (Fig. 20) are of the arthrodial type and include the ribs from the second to the seventh. The first costal cartilage attaches itself to the ster- num without forming a joint, the union therefore being of the synarthrodial character. In rare cases, however, a true articulation between the first costal cartilage and the manu- brium sterni is observed (Figs. 21 and 22). With the growing popularity of the Rontgen rays, it may be found that this condition is a frequent one. Joints of Costal Cartilages. 25 The joint of each costal cartilage consists of a synovial Sternohyoid Sternothyroid Fig. 22. — Posterior Surface of the Manubrium (Pre-sternum), with Sternal Ends of Clavicles and the First Costal Cartilages. — {Morris' "Anatomy") capsule, which is strengthened by ligamentous fibres called interchondral ligaments, internally as well as externally. The interarticular fibro-cartilage The joint between the sternum and second costal cartilage Fig. 23. — Section through Sternoclavicular Joint. — {Morris' "Anatomy") The joint formed by the second costal cartilage and the 26 Anatomy of Thoracic Wall and Diaphragm. sternum frequently contains a fibrous cartilage, which must be regarded as a continuation of the cartilage situated between the gladiolus and the manubrium of the sternum. This cartilage, by traversing the joint horizontally, divides the joint-cavity into two separate spaces (Fig. 23). Of the other ligaments, the ligamentum costo-xiphoideum, which springs The interarticular ligament The superior or ante- rior costo-transverse ligaments The stellate ligament Fig. 24. — Showing the Anterior Common Ligament of the Spine, and the Con- nection of the Ribs with the Vertebrae. — (Morris' "Anatomy.") from the sixth and seventh costal cartilages and attaches itself to the xiphoid process, is notable. As evident from the description of the vertebrae, the costo- spinal articulations, that is, the joints between them and the posterior extremities of the ribs, are double for the first ten ribs, wherefore they are properly divided into costo- central (costo-vertebrales), that is, those which are formed Costo-central Articulations. 27 between the costal heads and the vertebral bodies, and into costo -transverse (costo-transversales), that is, those which are between the neck and tubercles of the ribs and the transverse processes (Fig. 24). The costo-central articulations are arthrodial in type and consist of a capsule, which contains bundles of ligamen- tous fibres (anterior costo-vertebral, or stellate ligament, or ligamentum capituli costae anterius or radiatum) (Fig. 25). Anterior costo- central or stel- late ligament Costo-central synovial sac Costo-transverse synovial sac Posterior costo-transverse ligament Fig. 25. — Horizontal Section through the Intervertebral Disc and Ribs- (Morris' "Anatomy") These fibres radiate from the anterior portion of the costal head. The interiors of the first ten joints contain the ligamen- tum trans versum capituli costse, which springs from the crests of their heads, to be attached to the corresponding intervertebral discs. This ligament is absent at the last two ribs and also at the head of the first whenever the groove for the head is formed by the first dorsal vertebra alone, the seventh cervical vertebra not participating. The structure of this ligament is fibro-cartilaginous. 28 Anatomy of Thoracic Wall and Diaphragm. The costo-transverse ligaments (Fig. 26) consist of a thin capsule which is supported by a strong fibrous band, called the ligamentum costo-transversale posterius, which covers the pos- terior region of the joint. The costo-transverse articulations permit of slight physiological displacement of the ribs, as necessitated by their excursions during respiration. The transverse processes of the vertebrae prevent any backward deviation of the ribs during that process. It is evident that the eleventh and twelfth ribs, on account of their small size Spinous process of seventh cervical vertebra Capsular ligament of the first costo- transverse joint Capsular ligament of first costo-central joint Fig. 26. — The Capsular Ligaments of the Costo-vertebral Joints. — (Morris' "Anatomy.") and deep situation, are so well protected against dislocation that they do not need any protection by transverse processes. The anterior and posterior ligamenta colli costaa also secure the position while elevated during the act of inspiration. INTERCHONDRAL ARTICULATIONS. The articulations of the costal cartilages with each other take place in such a manner that the margins of the sixth, seventh, and eighth, sometimes also of the ninth and tenth, unite with each other by small oblong facets. A thin capsular Muscles and Vessels of Sternal Region. 29 ligament lined by a synovial membrane, and supported by interchondral ligaments passing from one cartilage to the other, encloses them. COSTO-CHONDRAL ARTICULATIONS. The ends of the costal cartilages articulate with a cup- shaped depression at the costal extremities, firm union being effected by the periosteum. ARTICULATIONS OF THE COSTAL CARTILAGES WITH THE STERNUM. The joints formed between the cartilages of the true ribs and the sternum are, excepting the first, of the arthrodial type. As mentioned above, the first joint has a synarthrodial character, since its union with the sternum is a direct one. MUSCLES, VESSELS, AND NERVES. Sternal Region. The muscles of the sternal region are the pectoralis major with its sterno-costal origin, the median portion of the internal intercostales muscles behind the pectoralis major, and the triangular sternal muscle at the posterior side of the sternum. The artery of the sternal region is the internal mammary, which arises from the anterior and lower part of the subcla- vian, where the latter is opposite the vertebral, passing behind the clavicle and the vena anonyma and then descending along- side the posterior surface of the costal cartilages, parallel with the sternal margin. From the internal mammary the arteriae thymicae, medias- tinals anteriores, and pericardiaco-phrenicae branch off to the thoracic cavity, while the rami perforantes, the intercostales 30 Anatomy of Thoracic Wall and Diaphragm. anteriores, and the rami sternales go to the chest wall. The internal mammary terminates in the sixth intercostal by dividing into the superior epigastric and the musculo-phrenic arteries. Phrenic nerve Subclavian artery Subclavian vein, cut Anterior intercostal branch Anterior intercostal branch Musculo-phrenic artery Common carotid artery Internal jugular vein Subclavian vein, cut Scalenus anticus muscle Sternum Triangularis sterni muscle Perforating branch Superior epigastric artery Deep epigastric artery Deep circumflex iliac artery Fig. 27. — Scheme of the Right Internal Mammary Artery. — {Morris, after Walsham.) The veins of the sternal region are divided into subcu- taneous and deep. The subcutaneous veins form a large net on the anterior fascia of the pectoralis major muscle, which Muscles of Costal Region. 31 communicates with the external jugular veins above, and the inferior subcutaneous epigastric veins below. Lateral anas- tomoses are formed with the axillary veins. The deeper veins are formed from the internal mammary vein and its branches. The lymph -vessels correspond with the sphere of the branches of the internal mammary artery. The nerves of the sternal region are represented by the anterior thoracic and the termini of the intercostal nerves. The latter supply the internal intercostal muscles as the triangularis sterni. Costal Region. The costal region is bounded by the parasternal line in front, the scapular lines behind, the first rib above, and the last below. The thin and movable integument of this region covers a stratum of loose connective tissue, which is interspersed with fat. Its fascia is firmly coherent with the superficial muscles. The muscles are the serratus anticus major and the in- ternal and external intercostal, besides the pectoralis major and minor and the subclavius. The pectoralis major muscle originates from the anterior surface of the inner half of the clavicle, the corresponding half of the anterior part of the sternum, the cartilages of the true ribs with the occasional exception of the first and seventh, and the aponeurosis of the external oblique muscle of the abdomen. It inserts itself at the anterior lip of the bicipital groove of the humerus. The pectoralis minor muscle originates from the outer surface as well as the upper border of the third, fourth, and fifth ribs close to their cartilaginous portions and from the aponeurosis which covers the intercostal muscles. The subclavius muscle originates from the cartilage of the first rib in front of the li^amentum rhomboideum clavicular 32 Anatomy of Thoracic Wall and Diaphragm. and inserts itself at a groove on the under surface of the middle third of the clavicle. The musculus serratus anticus major originates by nine fleshy digitations from the outer surface and the upper Aponeurosis of external oblique External intercostal Fig. 28. — The Pectoralis Major and Deltoid. — (Morris* "Anatomy") border of the eight upper ribs and inserts itself into the anterior lip of the posterior scapular border. The external intercostal muscles (Fig. 29) are eleven in number on each side of the body and extend from the rib- tubercles behind to the insertion of the rib-cartilages in front. Intercostal Muscles. 33 The direction of their fibres is downward and forward. They originate from the outer lip of a groove on the lower rib- border and are inserted into the upper border of the next rib below. Fig. 29. — The Intercostal Muscles. — (Morris' "Anatomy.") The internal intercostal muscles (Fig. 29) are also eleven in number, communicating at the sternum and anterior ex- tremities of the false ribs and extending to the costal angle be- hind. The direction of their fibres is downward and backward. They originate from the cartilages of the false and true ribs 34 Anatomy of Thoracic Wall and Diaphragm. and the inner lips of the groove on the lower border of each rib and insert into the upper border of the next rib below. The triangularis sterni muscle (Fig. 30) originates from the lower part of the sternal side, from the inner surface of the ensiform cartilage and the costal cartilages of the four lower true Sternohyoid Sternothyroid Transversalis abdominis Fig. 30. — The Muscles Attached to the Back oe the Sternum. — {Morris' "Anatomy") ribs, and inserts into the lower border and the interior surface of the cartilages of the second, third, fourth, and fifth ribs. The endothoracic fascia is a thin membrane which is attached to the outer side of the parietal pleura. It unites the exterior portion of the costal pleura with the interior side Arteries of Costal Region. 35 of the ribs and the intercostal muscles and also adheres to the pleural domes, the posterior sternal portion, and the vasa mammaria interna. With the phrenic pleura it covers the convex part of the diaphragm, thus connecting both organs firmly. It ends at the anterior side of the spinal column in the loose connective tissue, which surrounds the organs situated at the posterior portion of the mediastinal space. The arteries of the costal region are the axillary branches ; viz., the superior thoracic, the acromial thoracic, the thoracica longa (external mammary) and the thoracico-dorsalis, and the intercostales anteriores and posteriores and the intercostalis suprema. The small superior thoracic branches off above the upper border of the pectoralis minor muscle and passes forward and inward between the pectoral muscles. There it is distributed and forms anastomoses with branches of the internal mammary and the intercostales of the first and second intercostal spaces. The large acromial thoracic branch originates from the anterior aspect of the axillaries, passes forward on a level with the upper margin of the pectoralis minor muscle and separates into two sets of diverging branches, that is, one losing itself in the thoracic wall and the other outwardly toward the acromion. The thoracica longa passes alongside the lower margin of the pectoralis minor muscle in a forward and inward direc- tion until it reaches the mammary gland, wherefore it is also called the external mammary. The thoracico-dorsalis is a branch of the subscapular artery, from which it turns backward to the extent of five centimetres from its point of origin. The posterior intercostal arteries, nine in number, originate directly from the posterior aortic wall. Those of the right side pass to the [corresponding intercostal spaces before 36 Anatomy of Thoracic Wall and Diaphragm. the bodies of the dorsal vertebrae, behind the oesophagus, the thoracic duct, the vena azygos, and the termini of the sym- pathicus. Those on the left side, which are somewhat shorter, pass behind the sympathicus and the vena hemiazygos. After having entered the intercostal space a small dorsal ramus branches off, which by its ramus spiralis communicates Scalenus anticus muscle Deep cervical branch First dorsal nerve First intercostal nerve Subclavian artery 'Second intercostal nerve Inferior cervical ganglion Superior intercostal artery Arteria aberrans Anterior inter- costal artery Third intercostal nerve Arteria aberrans First aortic inter- costal artery Second aortic in- tercostal artery Intercostal ves- sels of third space Intercostal vessels of fourth space Fig. 31. — Scheme of the Right Superior Intercostal Artery. — (Morris, after Walsham.) with the spinal cord. After having given off the ramus dorsalis, the intercostalis passes forward alongside the inter- costal space between the external intercostal muscles and the parietal pleura and finally anastomoses with the anterior inter- costal arteries of the internal mammary. The superior intercostal artery (Fig. 31) arises from the Superior Intercostal Artery. 37 posterior part of the subclavia near its lower border and close to the inner margin of the musculus scalenus anticus. In its course, which at first is backward, it gives off the arteria pro- funda cervicis, which anastomoses with the arteria prin- ceps cervicis, thus establishing an important collateral connec- Longissimus dorsi Internal division of muscular branch Semispinalis dorsi and multifidus spinae Retroneural branch Medullary branch Prenearal branch Spinal cord Anterior spinal artery External division of muscular branch Ilio-costalis f Spinal branch Intercostal artery Vena azygos minor Vena azygos major Thoracic duct (Esophagus Anterior intercostal Internal mammary artery - Anterior perforating branch of internal mammary artery Sympathetic Upper or main branch of aortic intercostal Lateral cutane- ous branch Lowerbranch of anterior inter- costal Mammary glan- dular branch Upper or main branch of ante- rior intercostal Fig. 32. — Scheme of Intercostal Artery. — {Morris, after Walsham.) tion. The artery passes downward and backward, then in front of the neck of the first rib, sometimes also of the second, and loses itself in the first or second intercostal space. It is well to remember that the first dorsal ganglion of the sympathicus is situated on the inner side of the artery, just opposite the neck of the first rib. The superior intercostal artery sends 38 Anatomy of Thoracic Wall and Diaphragm. off branches to the posterior spinal muscles, to the first or second intercostal spaces, and to the spinal cord and its membranes. M. pect. major M. medianus M. pect. min. A. axillaris A. trior, acromialis R. perf. ant M. intercost. ext. A. thor. suprema A. thor. long. X. thor. longus A. thor. dorsal. R. perforans lat. Indentation of M serrat.maj. Diaphragm S Fig. 33. — Vessels and Nerves of the Left Thoracic Region. — (After Waldeyer.) The subcutaneous veins of the costal region anasto- mose with the veins of the neck, of the axilla, and of the ab- dominal wall. The most important collateral circle is formed Veins of Costal Region. 39 by the vena thoracico-epigastrica longa tegumentosa, which after passing the thoracic side anastomoses either with the vena epigastrica inferior subcutanea or directly through the oval fossa with the femoral veins. Upward there are anastomoses with the axillary veins. Pectoralis major Brachial plexus Supraclavicular branch of cervical plexus Serratus magnus Fig. 34. — Cutaneous Nerves of the Thorax and Abdomen, viewed from the Side. — {After Henle.) The deep veins of the lateral thoracic sphere are repre- sented by the vence inter co stales posteriores. Each one of these veins accompanies an arteria intercostalis posterior, as vena comitans. Ten of the venae intercostales posteriores dextrae anastomose with the vena azygos. The upper, that is, those 4o Anatomy of Thoracic Wall and Diaphragm. accompanying the arteria intercostalis suprema dextra, anas- tomose either with the vena azygos or upward with the vena anonyma dextra or the vena cava superior. The four left lower veins of the intercostales posteriores unite in one common branch, called the vena hemiazygos inferior, which finally also anastomose with the vena azygos. The four upper unite as the vena hemiazygos superior (accessoria), which com- municates with the vena azygos inferior and the vena inter- costalis superior sinistra. Anteriorly the venae intercostales posteriores anastomose with the branches of the vena mam- maria interna down to the sixth rib. Further below, that is, from the seventh to the tenth rib, they communicate with the vena musculo-phrenica. The last two intercostal veins do not have any anterior anastomotic connection. The lymphatics of the costal region are also superficial and deep-seated, the latter passing through the intercostal spaces. The nerves (Fig. 34) originate mainly from the thoraco- dorsal nerves, only the musculus serratus anticus major being supplied by the nervus thoracicus longus from the brachial plexus. The anatomy of the mammary gland is referred to in the chapter on Diseases of the Breast. DIAPHRAGM. The diaphragm (Fig. 35) represents the dividing septum which separates the thoracic from the abdominal cavity. Its circumferential attachment being more deeply situated than its ventral tendon, its convexity gives it the shape of a dome while in a passive state. In order to permit of the passage of important organs, it is provided with three large openings. These are: (1) the oesophageal, a muscular opening at a level with the ninth dorsal vertebra, which permits of the passage The Diaphragm. 41 of the oesophagus as well as of the pneumogastric nerve. (2) The aortic, a tendinous opening which is at a level with the twelfth dorsal vertebra and permits of the passage of the aorta, the vena azygos, and the thoracic duct. (3) The foramen quadratum, also a tendinous opening situated opposite the ninth dorsal vertebra, which permits of the passage of the vena cava ascendens. Sternal origin (Esophagus Costal origin Ligamentum arcuatum internum Left crus Ligamentum ar- cuatum externum Transverse proc- ess of second lumbar verte- bra Fourth lumbar vertebra Quadratus lumborum Fig. 35. — Diaphragm. — (Morris 7 "Anatomy") The diaphragm muscle originates from the ensiform cartilage in front, while on the sides it begins at the osseous portions of the seven lower ribs and the ligamentum arcuatum externum and internum as well as the lumbar vertebras behind. Its insertion is at the central tendon of the diaphragm. Of the ligamentum arcuatum internum it must be said that it represents a tendinous arch which extends over both 42 Anatomy of Thoracic Wall and Diaphragm. psoas major muscles. Its connection is with the bodies of the first and second lumbar vertebrae at its inner extremity, while the outer is attached to the transverse process. The ligamentum arcuatum externum virtually represents the thickened upper edge of the anterior lamella of the fascia transversalis, which arches across both quadrati lumborum muscles. Its attachment is to the transverse process of the second lumbar vertebra at its inner extremity and to apex as well as the lower edge of the last rib at its outer extremity. The anatomy of the intrathoracic organs is dealt with in the chapters on their diseases. CHAPTER II. SURGERY OF THE THORACIC WALL. (A) MALFORMATIONS OF THE THORAX. Congenital malformations of the thorax are rare. Most important among them are the median fissures of the sternum (Fig. 36) by arrested growth. Such sternal clefts may Fig. 36.— Two Stages in the Formation of the Cartilaginous Sternum.— {Morris, after Ruge.) be circumscribed, in which case they could have diagnostic interest only. The narrow median gaps as well as the inter- rupted sternal clefts, which are generally of an oval shape 43 44 Surgery of the Thoracic Wall. (Fig. 37), may be confounded with injuries as well as diseases of the chest. For differentiation the Rontgen method will serve as a reliable guide. In cases of total absence of the sternum the ribs insert themselves into a broad fibrous band, which has the shape of the sternal bone. Differentiation is also difficult sometimes in the case of con- Fig. 37. — Hiatus in Sternum. genital absence of one or more ribs. The defect is usually found at the point of insertion on the sternum, a thin band generally substituting the rib-portion, which is not strong enough to resist the expanding lungs, so that a pulmonal hernia (pneumatocele) may develop. Ectopic conditions of the lungs may also be the result of in- juries, like costal fractures. The defect may be closed by Cervical Ribs. 45 osteoplastic operation after Vulpius, which consists in bisect- ing the rib portions adjacent to the gap, longitudinally, and connecting the flaps, after mobilizing them, with the neigh- boring ribs (Fig. 38). Among the malformations of the chest the cervical ribs may also be mentioned here. They are undoubtedly very much more frequent than supposed, but before the Rontgen era their presence was but rarely detected. While the supernumerary ribs of the lumbar vertebrae possess of Fig. 38. — Vulpius' Method of Osteoplastic Operation in Costal Defects. an academic interest only, the accessory rib of the cervical portion of the spinal column commands practical consideration. Literature does not contain a single case in which the lumbar rib has caused any discomfort whatsoever. In contrast hereto, the observations concerning more or less great dis- turbances, which were due to cervical rib, are multiplying with each year. Since the Rontgen rays have illuminated this region also we may hope for more ample statistics. At the same time we can figure on more accurate anatomical understanding. 46 Surgery of the Thoracic Wall. To this is added the fact that at the time we can inform ourselves of the anatomical success of our operative activity. We have learned besides to regard the Rontgen picture as our valuable guide in outlining the plan of operation. Naturally it was the anatomists w r ho gave us the etiology at a period when we did not as yet value the clinical impor- tance of cervical rib. As the pioneer in this direction we may consider Hunauld. 1 Later Grube was able to demonstrate 76 cases in 45 bodies and 2 in the living. Pilling 2 mentions 129 cases. But these were mostly all ob- served in the dead body. Grube differentiated the different grades of the anomaly according to their several stages of development. On the basis of his viewpoint we may divide the different types as follows : (a) Slight degree: The cervical rib reaches beyond the transverse process. (b) More advanced: The cervical rib reaches beyond the transverse process, either with a free end or touching the first rib. (c) Almost complete: The connection between the car- tilage of the first rib is formed either by means of a distinct band or the end of its long body. (d) Complete: It has become a true rib and possesses a true cartilage, which unites with the cartilage of the first rib. In general, we can assume that the cervical rib is double in 67 per cent, of all cases and single in only 33 per cent. A completely developed cervical rib on both sides is to be regarded as rare. One such case is described in the above mentioned monograph of Pilling. An additional rib which runs from the sixth cervical vertebra is to be regarded as a very rare condition. With the exception of the author's case, illustrated 1 " Sur le nombre des cotes moindres au plus grands qu' a 1' ordinaire," Mem. de l'academie royale des sciences de Paris, 1743. 2 "Ueber die Halsrippen des Menschen," Inauguraldissertation, Rostock, 1894. Diagnosis of Cervical Rib. 47 by Figs. 39, 40, this anomaly was observed twice only in litera- ture. It is significant for the difficulties of the diagnosis which naturally presented themselves before the Rontgen era, that by far the most of the reports speak of accidental discovery at the autopsy. Consequently if no marked disturbance was caused, the possessor of the cervical rib undoubtedly took his " special marks of identification" with him, unknown, to his grave. Although this anomaly is of congenital origin the com- plaint does not make itself felt until about the twentieth year, a fact which is hard to explain. From most reports we learn that by far the greater number of patients had passed the age of twenty years — a few had even reached the age of fifty-five years. In a number of cases it was possible to refer to trauma as a precursor of the complaint, in others the presence of con- stitutional diseases, such as anaemia, chlorosis, rheumatism, scrofula, or even tuberculosis, was observed. Whether the loss of fat causing a diminution of padding in these diseases is the reason for the greater manifestation of the discomfort, must remain to be seen. At any rate an addi- tion of special circumstances, the nature of which is still un- known to us, must form an important factor in the maturing of the disease besides. It is to be assumed that the tissues adapt themselves to the rib during the period of development, and that no discomfort arises where a certain amount of elasticity or yielding tendency exists. Thus the age of the patient as of diagnostic moment is valueless. If it seems probable now that the presence of cervical rib, when giving no disturbance, remains unnoticed, we would expect that if such symptoms should appear, the possibility of an anomaly would suggest itself. But such, at least before the Rontgen era, was not the case. For in most cases one more readily thought of everything else, especially of tumors of all kinds, rather than cervical rib. 48 Surgery of the Thoracic Wall. Tilmann, 1 who has gained special credit in the investiga- tion of these cases, could collect only 26 cases among the , living, and of these one half represent accidental findings. There cannot be the least doubt that the actual number of cases is by far a much greater one. This will in the future have to be proved by the Rontgen fays. As the principal symptoms of the anomaly the hump-like prominence in the lateral cervical region, the superficial pulsa- tion of the subclavian artery, and the appearance of pressure symptoms in the brachial plexus are regarded. Prickling and lancinating pains in the arm, general loss of flesh, and especially atrophy of the muscles supplied by the median nerve, numbness and diminished compressive power of the hand of the respective side, cold sensations, and further- more pains in the neck on stretching it have also been observed. At times it goes as far as to form an aneurysm of the subclavian artery. 2 A striking fact is that even after the diagnosis has been made it is often attempted to master the trouble by internal means. But as soon as the physician becomes familiar with the anatomy of the cervical rib he must acknowledge that he has to deal with a disturbance placed in the way of the normal blood- and nerve-paths which has attained the prowess of a foreign body. Thus the treatment for the difficulties arising therefrom can only be a mechanical one, i. e., surgical. Mas- sage, electricity, hot and cold packing, etc., can only be of temporal*} 7 benefit and possess the disadvantage that much valuable timejs_wasted. Then the disturbance may become permanent. A radical cure can be effected only by the removal of the cause of pressure, that is, of the rib itself. But it is just as unwise to remove a cervical rib which causes no disturbance 1 "Deutsche Zeitschrift fur Chirurgie," Bd. xli. 2 Wiltshire: "Lancet," p. 633, London, i860; Boyd: "Internat. Med. Mag.," 1893. Removal of Cervical Rib. 49 as it is to leave one that does until lasting tissue changes have been brought about. The operative measure, if timely, removes all discomfort at once. At times the technic for the removal of the rib is very simple. In the majority of cases, however, one encounters difficulties, wherefore the operation should only be done by an experienced surgeon. The difficulty of the removal is magnified by the fact that it is necessary to remove the peri- osteum with the rib, for if the much easier sub-periosteal removal is undertaken one must expect a recurrence due to the regeneration of the bone. The field of operation grazes the lower two cervical nerves, the upper dorsal nerve, and the lower cervical ganglion of the sympathetic. Furthermore it touches upon the large vessels and the pleura, the latter being especially thin here and very easily wounded. Of course, the adhesions which form between the costal and pulmonal pleurae in most of these cases give a certain amount of protection against the development of a pneumothorax, if an injury had been caused. In a case of Planet, 1 it seems to have been impossible to avoid injuring the pleura, so that a pneumothorax was caused, but without any grave disturbance. The extirpation of small rudiments whose ends do not reach the subclavian artery, is naturally simple. Where we have to deal with a fully developed rib the various steps of the operation must be so carried out that the artery is avoided from the beginning. Some of the operators place their incision along the posterior border of the sternomastoid. Others advise a longitudinal in- cision between the trapezius and the jugular vein. The author finds that a triangular flap-incision, running directly downwards along the trapezius and then conducted towards the sternum about one inch above the clavicle, fully ex- 1 "Tumeurs osseuses de cou," These de Paris, 1890. 5° Surgery of the Thoracic Wall. poses the field of operation. If the trapezius cannot be suffi- ciently retracted with broad retractors a transverse incision must be made into the muscle, for next to strict asepsis the success of the operation depends upon extensive exposure of the field of operation. The brachial plexus, which usually runs across the rib, must also be pushed aside. The subclavian is best pulled for- ward. The scaleni are carefully divided at their point of insertion. This is best done by using a Cooper shears and, Fig. 39. — Cervical Rib Inserting at First Rib. advancing layer by layer, lifting the several muscle fibres with the flat of the scissors and using the instrument as one would handle a grooved director. By means of the author's ring- shaped periosteotome (Fig. 86) the rib is then freed of any small muscular appendages. The division can easily be accom- plished by means of the author's beak-shaped rib-shears. (Fig. 87). Some prefer the Gigli saw. Any remains are nipped off with the rongeur forceps. Fig. 39 illustrates type c in a small anaemic girl of twenty-one years, whose family history did not reveal any Symptoms of Cervical Rib. 51 event of special interest. When she became twenty years of age, she sustained a fall, after which she began to suffer with pain in the right side of the neck. This was, however, regarded and treated as rheumatic. Two months later the pains began to extend into the arm and were accompanied by prickling and numbness of the ringers. She was then treated by neu- rologists until a slight bulging of the right side of the neck and a corresponding osseous tumor which could be traced from the spinal column to the neighborhood of the sternoclav- icular joint was diagnosticated by Dr. J. Heckmann at the Fig. 40. — Stump of Cervical Rib. German Poliklinik. Pulsation was marked. The presence of an accessory cervical rib was confirmed by means of a Rontgen plate (Fig. 39) . Now the anterior portion of the rib was exposed by means of an incision running along the posterior border of the sternomastoid muscle. Both the brachial plexus and the subclavian artery were found passing over it. After the resection of this portion the plexus as well as the artery dropped back into the newly formed cavity. As the cause of the pressure had been removed it was decided to let the posterior remnant of the rib take care of itself. The symptoms of complaint gradually disappeared, 52 Surgery of the Thoracic Wall. but returned with undiminished vehemence three months later. When the author examined the patient there he could find neither prominence nor pulsation. The pulse of the axillary, brachial, and radial arteries, however, was diminished in tension. The reaction to electricity of muscles and nerves was also diminished. Sensation was normal. Patient was extremely anaemic and complained of pains in the neck and right arm and of numbness of the fingers. On stretching the neck the pains were intensified. The power of compression of the right hand was diminished. The Rontgen picture — extreme lateral position of head during exposure (Fig. 40) — shows on the right side the presence of a fair-sized costal stump running from the seventh cervical vertebra, while on the left a small rudiment is seen. The sixth cervical vertebra shows a rudiment on both sides. In view of the vehemence of the symptoms, especially of the pains, the author decided to reopen the field of operation for the purpose of removing the remainder of the rib. Advancing carefully, layer by layer, into the deeper tissues, he neither came in contact with the brachial plexus nor with the artery. It was rather difficult to separate the muscle from the edges of the rib. Most of the separating was done bluntly with the aid of the Cooper scissors, using them as a support. The extirpated fragment of the rib measured 4 cm. As the previous resection had been done subperiosteally, a new formation of bone of more than one cm. in length had attached itself to the stump of the rib. Hence it becomes evident how necessary it is always to remove the periosteum with the rib. The rib, on the whole, was narrow, thickened at its vertebral attach- ment, and presented a small groove on either side. Recovery was uneventful. The symptoms disappeared entirely shortly after the operation. Two months later slight symptoms of pain made themselves felt in the neck on the right side, but these also disappeared after the use of the Supernumerary Mammae. S3 galvanic current. (See "The Journal of the American Medical Association," June 17, 1905.) Fig. 41 shows the complete one-sided type (No. d) in a man thirty- three years of age. The discovery was entirely acci- dental, the patient never having shown any apparent deform- ity or being in any way disturbed. Fig. 41. — Cervical Rib. Supernumerary mammae are not infrequently observed. Their seat varies, some being found in the axilla, on the abdomen, the dorsal region, and even as far down as the anterior surface of the thigh. They have the structures of the normal gland. Small accessory glands are still more frequently present in the same various regions. Sometimes the breasts are pro- vided with two or three nipples. The mammae as well as the nipples are only seldom found to be entirely absent. Enlargement of the mammary gland is frequently but only temporarily observed in new-born boys and also during the period of puberty. Sometimes there is secretion of milk in male adults. 54 Surgery of the Thoracic Wall. In hermaphroditism of the male type the development of the mammary gland is marked. Fig. 42 shows a hermaph- rodite of the preponderant male type (a) who possesses two normal mammary glands (Fig. 42, b). Penis and testicles are well developed, at the same time there are the indications of a vaginal canal. The author is indebted to Dr. J. H. Branth for this rare case. Spina bifida dorsalis is another important malformation . X mm -* 1 W^ 1 Fig. 42. — Man Showing Mammae. (Fig. 43). It is rare, while the lumbar type is very frequent. The dorsal variety differs from the lumbar variety inasmuch as the cord cannot protrude into the hernial sac. As regards treatment, it may be said that in the simple form of meningocele, which is characterized by a cystic distention of the membranes only, the cord itself not partici- pating, aspiration followed by the repeated injection of a 10 per cent, emulsion of iodoform-glycerin generally suffices Dorsal Meningocele. 55 for a cure. In myelocele, where the cord either partially or in its entirety enters the sac, or in myelocystocele, where there is a cystic distention of the membranes besides, extirpation of the sac should be tried. The operation must be of an explor- atory character, the membranes first to be opened from the side, so that the direction and condition of the nerves may be ascer- tained first. After reposition of the cord the cleft may be closed by reverting the surrounding periosteum, and protecting it by a thick layer of muscle and fascia. In the major- ity of these cases the prognosis is unfavorable. Secondary deformities of the thoracic cage may be produced by primary changes of the spinal column. Fig. 43. — Dorsal Meningocele. Kyphosis (Fig. 44), by shortening the vertebral column, naturally shortens the thoracic cavity while its sagittal diam- eter is made longer. It is often combined with the loss of the lumbar concavity, so that the vertebral spine is arched backward. Sometimes this condition is compensated somewhat by lumbar lordosis (Fig. 45). Kyphosis is usually produced by defective growth, rhachitis being a predominant causal factor. Occasionally a continuous habit of stooping may induce it. It may also result from frac- tures, osteo-arthritis, acromegaly, Pott's disease and similar ailments. 56 Surgery of the Thoracic Wall. Fig. 44. — Kyphosis. Kyphosis and Lordosis. 57 Fig. 45. — Kyphosis of Upper Dorsum with Compensating Lumbar Lordosis. 58 Surgery of the Thoracic Wall. Scoliosis (Fig. 46) causes inflection of the thorax by lat- eral curvature of the spine associated with rotation of the ver- tebrae. Sometimes it is congenital, but in the great majority of cases it is of a rhachitic nature and begins at an early period Fig. 46. — Scoliosis. of life. The essential points of treatment are the plaster-of- Paris corset, applied while the patient is suspended in a Sayre's apparatus (Fig. 47); later in restoring the power of the Plaster Jacket for Kyphosis. 59 Fig. 47. — Plaster Jacket Applied in Extension. Note folded towel at the epigastrium, which is to be removed after completion of dressing. 6o Surgery of the Thoracic Wall. dorsal muscles by massage and electricity and by such exercises as produce extension of the back (crawling on the floor). The deformity called pectus carinatum (Fig. 48) is also caused by rhachitis. It is characterized by a keel-like pro- trusion of the sternum while the ribs are collapsed, the lateral thoracic portions being inverted. Thus the sagittal diameter of the thoracic cavity is diminished. The essential part of treatment is that of the rhachitis. At the same time the patients should be kept in the recumbent position as long as possible. Fig. 48. — Pectus Carinatum in a Boy oe Fourteen Years. Protrusion of the lower rib cartilages, as a rule, on the left side, is especially found in the female. Deformities of the ribs often follow curvatures of the vertebral column and may sometimes be corrected by rib- resection. The author has performed this operation once with a fair result, but in two cases there was considerable disappointment. Extreme flatness of the exterior chest-wall is especially observed in girls. Resection of the chest-wall may make it collapse so far that it assumes the shape of a funnel. In rare cases careful physical exercise should be advised at an early period, the same as in chicken-breast. Non-penetrating Injuries of Thoracic Wall. 61 (B) INJURIES OF THE THORACIC WALL (NON- PENETRATING). The wounds of the thoracic wall (also the gunshot wounds) are usually of little significance, except the arteria mammaria interna or one of the intercostals be injured. Contusions of the throat are produced by external violence and may be accompanied by fractures of the ribs, and consequently by the injury of the intrathoracic organs, viz., the heart, the lungs, the large vessels, the trachea, and the diaphragm. Simple contusions not accompanied by injuries of the thoracic viscera are characterized by the presence of ecchymo- sis and slight discomfort during the act of respiration. The possibility of the presence of a fracture should, however, not be lost sight of, even in apparently light cases, the Rontgen rays often having furnished the proof of the presence of a fracture when simple contusion was assumed. Sometimes emphysema of the subcutaneous tissue is observed. Treatment. — The main factor in the treatment of simple contusion is complete rest, which is attained by the application of a moss-board dressing (see page 66) combined with the administration of small doses of morphine. The safest plan of treatment, for at least the first few days after the injury, is to apply the principles of treatment in fracture of the ribs. Haematoma of the thoracic wall is treated by compression first and by massage later on. Wounds of the thoracic wall are treated after common aseptic principles. In order to appreciate these fully, attention is bestowed best upon those factors which may interfere with their thorough execution. They are: the instruments, the dressing and suture material on the one hand, and the skin of the patient and of the surgeon's hands on the other. In reference to the first factors it can safely be maintained that ideal asepsis is now an established fact. All objects which stand boiling- well can indisputably be made sterile. 62 Surgery of the Thoracic Wall. Easy as the maintenance of asepsis is in regard to all objects which stand boiling, so it is difficult in regard to the skin of the patient and the hands of the surgeon, Skin bacteria are the stumbling-block in the way of perfect asepsis. The undeniable fact remains that their total destruction or removal is practically impossible. The surface of the human body is impregnated with many different bacterial species. Some of them adhere to the skin surface, some are embedded in the dried cells of the epidermis. They are all accessible to sterilization. They do not necessarily need destruction, but removal. This can be done by simple mechanical means — viz., scrubbing with soap and water. It is made so much the easier by preliminary procedures — viz., whenever possible, the patient is given a warm bath twenty- four hours before operation, the field of operation being scrubbed with green soap and shaved while the patient is in the bath. Then a poultice of ordinary green soap is applied to the skin until shortly before the operation. Thus, thorough permeation of the epidermis — the dried cells of which are, in fact, macerated by this procedure — is obtained. Before the operation the skin is scrubbed energetically with linen com- presses which are dipped into semi-fluid soap. This soap consists of green soap mixed with soft sand, like sapolio. The scrubbing process consumes about two minutes' time, and goes on while a stream of very warm water constantly flows over the surface to be sterilized. Then thin green soap is used in the same manner and for the same length of time. Particular attention is given to the folds and creases of the skin. Now the skin is dried with an aseptic towel, and rubbed for one minute with a gauze compress which is saturated with 50 per cent, alcohol. The alcohol is not regarded as a disinfectant in the proper sense, but it is mainly used for the purpose of removing the fat of the skin, which is a most con- genial resting-place for bacteria. By destroying their shelter the bacteria are naturally removed. Disinfection. 63 It is self-understood that the means with which asepsis should be attained must be aseptic. This refers particularly to the water used for washing and the soap, which must have been prepared by the boiling process. If brushes are used, special care has to be taken, as they can only with difficulty be rendered aseptic, thorough cleaning impairing their use- fulness . After these vigorous procedures washing with bichlorid of mercury or lysol or similar disinfectants is hardly needed. There are other similar methods of rendering the surface of the skin sterile. If they are thoroughly mastered and carried out minutely, they may be employed just as well. But the trouble is that underneath the skin surface a number of bacteria are sheltered by the glands of the skin, the secretions of which offer a favorable soil for their development; and these are not accessible to any disinfection or removal. Hence, other means have to be chosen to prevent their faculty of infection. And, in fact, they will do little harm if cared for properly. It is evident that in incising the skin the knife bisects a number of glands and thereby exposes the bacteria contained by these glands. This undeniable fact fully explains not only the so-called suppuration of the stitch-canals, many cases of so-called late infection, and the bad reputation of the catgut, but also most of the numerous "incomprehensible infections which develop under the supervision of the extremely careful aseptic surgeon." Here is also the explanation of the suppu- ration occurring "in spite of the most minute aseptic pre- cautions," which not only astonished many an experimenter in his laboratory, but also made him set up new surgical doctrines. Bacteriologic tests of aseptic methods, gained on artificial soil, cannot be applied to biologic processes, the living cell reacting against bacteria differently from gelatin, agar, or serum. That the bacteria thus set free by the skin incision find the most liberal opportunities to come into contact with the 64 Surgery of the Thoracic Wall. deeper regions of the wound need not be emphasized. Still, so far as the author's knowledge goes, there are no systematic precautions taken or advised in this direction. If it is considered that the dissecting knife comes into intimate contact with these deep-skin bacteria, generally represented by the staphylococcus species, it must necessarily be regarded as infected. The hands of the surgeon fall under the same considerations. This indicates two necessities — in the first place the change of the infected knife, and secondly the redisinfection of the surgeon's hands. The latter pro- cedure may become unnecessary if gloves are worn by the surgeon while the skin is being incised. One possibility, however, remains — inoculation of the subcutaneous strata with the knife. This danger cannot be obviated entirely, but it can be reduced to a minimum by slowly and carefully incising the integuments alone as far as possible. Now, as to the exposed skin bacteria which cannot be destroyed or removed : how easy it is to set them hors de combat by simple protection! Sterile napkins are fastened to the sub- cutaneous tissues with miniature forceps, such as devised by the author, so that the skin margins are so well covered by them that they do not come into view during all the subsequent manipulations, which are done then on an absolutely sterile field. After the operation is completed the margins should be united by the subcutaneous method. If there is a necessity for relaxation sutures, they should be applied through the skin, but about three-quarters of an inch distant from the wound margin, so that there is no direct contact with the wound line. For such sutures, however, iodoform silk should be chosen. The same principle of protection should, under proper modifica- tions, be employed in the opening of deep-seated abscesses. (See chapter on Pyo thorax.) Disinfection. 65 The length of time necessary for the scrubbing of the sur- geon's hands may vary according to whether the surgeon had come in contact with septic cases shortly before sterilization or whether he was positive that he had remained clean for at least the last twenty-four hours. Furthermore, the most particular care must be given to the subungual space. Wicked tongues remark of certain physicians that they carry graveyards underneath their finger- nails. To clean the subungual space a proper nail-cleaner is advisable. The nails must be cut short and even with scissors, not trimmed with a file. The space is then scrubbed — first with the rough soap and then with the alcohol. It hardly needs mentioning that the surgeon should wash himself frequently, like other decent people, whether he per- form an operation just at the time or not. In order to protect himself as much as possible he should wear rubber gloves when coming in contact with notorious bacterial shelters, such as the rectum, or when examining septic cases. He should also wash with special care after an operation. Whether a wound is a priori infected or not can hardly be proved. The state of a wound may with some probability be regarded as aseptic if the person who sustained it and the wounding object were both clean, and if but little time had elapsed before it came under the observation of a surgeon. Still, whether aseptic or not, the principles of prophylactic disinfection and the carrying out of the disinfecting process remain the same as described for patients who are prepared for an aseptic operation. If there should be a small wound, the surfaces of which will agglutinate before infection is possible, union by first intention is often secured, provided the premises of secondary infection are removed by the prophylactic disinfection. All wounds, not inflicted by the aseptic surgeon on aseptic skin, are pri- marily painted with tincture of iodine as soon as permissible, in order to reach some of the distant bacteria. 6 66 Surgery of the Thoracic Wall. But if there is extensive injury to the soft tissues, splintering of bones, perforation of the thoracic wall, etc., a large incision is in order. An attempt should always be made to first locate the splinters by the Rontgen rays. The loose splinters must be extracted, while those that still maintain an attachment to the periosteum should be left. Fragments of fat, muscular shreds, fascia or crushed skin and other debris, should also be removed. Projecting points of bone should be trimmed off with bone-forceps. All haemorrhage must be carefully ar- rested; foreign bodies — such as splinters of wood, glass, and bullets — are to be extracted. Pockets underneath the integu- ment are split wide open. These manipulations should be performed only while irrigation with a o.i per cent, sublimate solution is maintained. If necessary counter-openings are to be made, so as to permit introduction of thorough drainage. Great care must be taken that the drains do not come between bone fragments. It is inadvisable to apply sutures to wounds of this kind. After small rubber drains surrounded by iodoform gauze are introduced into the counter-openings, the wound cavity, especially the pockets, is extensively packed with iodoform gauze. The wound is further protected with a large amount of some sterile and absorbent material. The most desirable substance for this purpose is moss-board, made of common German moss, the absorbent power of which is five times as great as that of gauze. It represents a very soft and adaptable material, and it can be very easily sterilized. It is used best by being compressed into a tablet-like shape. After being dipped into cold water it adapts itself to the contour of the body like a plaster-of-Paris splint, over which it possesses the great advantage of being absorbent and much lighter. The bulky species of moss-board makes an ideal splint; for, should the wound discharge exceed the absorbent power of the gauze directly over the wound, it takes up the superfluous Wound Dressings. 67 discharge without impairing the usefulness of the moss as an immobilizing factor. To make a moss-splint adaptable it must be dipped into, and not soaked in, cold water. If warm water is taken, the moss will swell up rapidly and the immo- bilization power is lost. If the secretion becomes abundant, the center of the moss-board, by absorbing it, swells up naturally, but there is so large a portion of the molded moss-splint left that its value as an immobilizing apparatus does not become impaired any more than does a plaster-of-Paris dressing by the cutting of a fenestra. If the arteria thoracica longa or mammaria interna or intercostalis was injured, the wound must be properly enlarged and the vessel tied. This is done after general surgical principles. Although wounds of this kind are to be regarded as virtually infected, many heal without show- ing any reaction, especially if haemostasis is thorough. The modus operandi consists in packing the wound with sublimate gauze and then cleaning the area with green soap and hot water, alcohol, and at last with a 1 : 500 solution of bichloride of mercury. Then the antiseptic tampon is removed from the wound, the vessels tied, and all crushed or necrotic tissue removed. If suturing is resorted to, a gauze drain should be left in an angle of the wound. This precaution is so much more advisable since it is often uncertain whether there is any communication with the pleura or not. Non-complicated gunshot wounds require disinfection of the integumental area followed by simple protection with iodoform gauze (supported by collodion) and immobilization by moss-board. In case the arteria mammaria interna is in- jured, the pleura is usually penetrated. Haemostasis may be ef- fected by tight packing, but the only safe method is tying the artery. This is done best by exposing it freely after the resection of one or two rib-portions. This method should always be tried in doubtful cases in an exploratory sense, since 68 Surgery of the Thoracic Wall. extensive exposure only permits of making a diagnosis of the true condition of the pleura. Thus proper steps may be taken in time and a fatal outcome averted. If the arterial ends cannot be caught in the wound itself, tying may be done at a point above the line of incision, beginning at the sternal margin and continuing parallel to the rib. The intercostal arteries are mostly injured by gunshot or stab wounds. Their importance becomes evident by the fact that during the Civil War, of fifteen patients who sustained in- juries of an intercostal artery eleven succumbed to haemorrhage. Fatal haemorrhage from the intercostal artery after thoracic puncture as well as open incision is repeatedly reported (Billroth). Tying of an intercostal artery should never be attempted before the rib, which covers it, is resected. By lifting the periosteum from the lower surface of the rib the artery is drawn aside and is easily seen after the rib-portion is removed. (For the details of this operation see page 152.) (C) FRACTURE OF STERNUM, RIB, AND COSTAL CARTILAGE. 1. Fracture of the sternum is rare (less than one per cent, of all fractures). It is generally produced by direct violence; either gunshot wounds or a heavy weight falling upon the chest being the causative factors. The line of fracture is nearly always transverse. It is but exceptional that it is caused by indirect violence (muscular contraction, sudden bending of the trunk, the chin being pressed against the sternum). If caused by a gunshot wound, the seat of the fracture may be at any portion of the sternum. Otherwise it is generally at the junction of the manubrium with the corpus. The signs are local circumscribed pain, more or less dis- placement and crepitus, cough, and sometimes haemoptysis and dyspnoea. Fracture of Sternum and Rib. 6 9 The prognosis is favorable except in cases in which there is injury done to the mediastinum. The treatment consists in re- position of the fragments. This is accomplished by putting the patient into a reclined position by placing a large pillow under him, so that the receding fragment pro- trudes. The head should lie bent far backward at the same time. If this procedure does not prove to be efficient, extension with Glis- son's cradle is advisable. 2. Fracture of the rib, while rare in childhood, is frequent in adults and represents 15 per cent. of all fractures. The injury may be caused by direct as well as by indirect violence. In the first event (blow against the thoracic wall, fall at the margin of the sidewalk, staircase, table, etc.) the fragments are generally driven in- ward (Fig. 51, a). If caused by a gunshot, the rib is splintered, the intrathoracic organs being gener- ally also involved. A simple trans- verse fracture may be produced by a bullet fired from so great a distance that its force is consider- ably diminished when it strikes the rib. If the fracture is caused by in- direct violence (as, for instance, by compression of the thorax) it is often associated with Fracture of the Ster- -(Beck's "Fractures.") Fig. 50. — Infraction of Ribs (no Displacement). — (Beck's "Fractures.") 7° Surgery of the Thoracic Wall. fracture or contusion of the humerus. In rare instances the fracture is produced by muscular contraction, in which event the fragments are generally driven outward. According to the age of the patient or to the degree of violence, an infraction (Fig. 50) or a true fracture (Fig. 51) may result. Infractions are much more frequent than frac- tures. In children the thorax is so elastic that fracture is caused only by a considerable degree of violence. The signs consist in intense local pain and in the crepitus that results if the fragment is pressed downward by the palm of the hand. Manual pressure also increases the painful Fig. 51. — A, Fracture op the Inner Costal Table. B, Fracture or the Outer Costal Table. sensation during the act of inspiration. Deep inspiration and stooping toward the opposite side invariably cause great pain. If the rib is fractured only, displacement generally does not take place; but if several ribs are broken, as shown by Fig. 52, considerable displacement may result. It is in these cases that the intercostal artery may become injured, so that an aneurysm may develop. Fractures in the vicinity of the vertebrae impair the func- tion of the costotransversal and costovertebral articulations. In case the lungs are injured, haemoptysis is always, and haemothorax, pneumothorax, and emphysema sometimes, present. The last-named condition may extend to the Treatment of Fracture of Rib. 71 neck and abdomen, and in severe cases it may involve the whole body, the air escaping from the lung into the surrounding connective tissue. The left fourth, fifth, and sixth ribs at their sternal junctions endanger the pericardium and vagus, while the anterior splinter-fractures of the sixth rib may injure the pleural sinus. The right seventh, eighth, and ninth ribs may cause laceration of the liver tissue. The treatment should be mainly directed to immobilization. Fig. 52. — Skiagraph of Fracture of Ribs. Taking into account the relation of the ribs to the pleura and lung, it is evident that immobilization should not be extended upon the thoracic wall alone, but must also affect the intra- thoracic organs. The first requisite will be attained by the fixation of the fragments, which is accomplished by a large and broad strip of rubber adhesive plaster or a large piece of moss-board applied during expiration. The second and more important 72 Surgery of the Thoracic Wall. requisite, immobilization of the lungs, — in other words, re- duction and diminution of the respiratory movements, — is ful- filled by a liberal administration of opiates. Pleuritis sicca, one of the most frequent results of simple infraction as well as of true fracture of a rib, is treated after general principles (rest in bed, fomentations, opiates, etc.). The same views apply in the much rarer event of pneu- monia, which, as a rule, is of moderate extent and significance. Sometimes tuberculosis develops after an injury of the pleura or the lungs. Hemothorax or pneumothorax, if present to a moderate extent, demands aspiration, under the most thorough aseptic precautions. (Compare page 147.) In most cases, however, it is more rational to expose the pleural sac by the resection of three or more ribs. The same holds good in pyo thorax. As to the technic, compare page 151. Pericarditis is not infrequently observed after rib-fracture. If a splinter-fragment has pierced the pericardium, injury to the heart may also result. The true character of the trauma can sometimes be elicited by the Rontgen rays. If, for in- stance, the clinical symptoms are slight and the rays show no displaced splinters in the direction of the pericardium, medical treatment is in order. Even if a bullet, after having fractured a rib, has entered the pericardium, there may be no need of surgical interference provided no severe symptoms are present. An autopsy made by the author on a patient who was shot through the thorax eight years before his death, revealed a bullet embedded in fibrous tissue in the pericardial sac, where it had lodged without ever causing any disturbance. (Compare section on Pericardium.) But the evidence of a sharp bone-splinter pointing toward the pericardium indicates the necessity of exposing the peri- cardial sac after the resection of the left fourth, fifth, and sixth ribs. They do not necessarily need to be resected in their Fracture of 'Costal Cartilages. 73 totality, but may be folded up at their sternal junctions like a bone-flap of the skull. It goes without saying that in such cases the clinical symp- toms are severe according to the anatomical condition. In compound fractures of a rib (Fig. 52) the packing of the wound with iodoform gauze is indicated. If there be much haemorrhage, the packing must be done tightly and extensively, in the form of a tampon bag. If the extent of emphysema is moderate, no interference is required; but if it be extensive, multiple incisions are indicated. To sum up, it can readily be seen that the prognosis of fracture of the ribs depends entirely upon the degree of par- ticipation of the intrathoracic organs. In simple cases union is perfected in from three to four weeks. 3. Fractures of the costal cartilages occur generally at their junction with the ribs, sometimes also in their continuity. The consideration of the etiology, signs, and treatment of this condition is identical with that of fracture of the ribs. It must be considered that in aged people the cartilages become ossified. Dislocations of the ribs are rare. Reposition is easily done. Sometimes severe contusions, not showing any material changes of the thoracic walls, are observed {commotion). In such cases marked symptoms of shock are prevalent, from which the patient is soon resuscitated. (D) BURNS OF CHEST. Burns of the thoracic wall are especially observed in chil- dren who spill boiling liquids on themselves. In adults, burns are sustained sometimes by the explosion of gases or projectiles. By radial heat burns of the first or second degree are produced only. In burns of the 'first degree it is only the epidermis which becomes affected, an erythematous condition being the con- 74 Surgery of the Thoracic Wall. sequence. Acetate of lead with tinctura opii is applied best at the early stage, unguentum zinco-salicylicum being indicated later, when the acute symptoms have passed and desqua- mation begins. Fig. 53. — Formation of Dry Eschars after Burn of the Second Degree. In burns of the second degree where the heat had a pro- longed action the Malpighian layer and the papillae of the skin are destroyed besides the epidermis, the result being the Burn of the Second Degree. 75 formation of blisters filled with thin yellowish serum. The first step in the treatment is the opening of the blisters and the removal of their fragments. Then several layers of 3 per cent, iodoform gauze are applied to the denuded surface and the whole is protected by a large piece of moss-board which is slightly dipped into cold water so that it can be attached to Fig. 54. — Circumscribed Burn of the Third Degree, Caused by Red-hot Iron, Above the Manubrium Sterni. the contours of the thorax. A dressing of this kind immobilizes splendidly and absorbs at the same time, so that there is no need of changing the dressing before the lapse of a few days. When dry eschars have formed (see Fig. 53) unguentum zinco- salicylicum may also be used, just as in the first degree. In the third degree there is a complete destruction of 76 Surgery of the Thoracic Wall. integument and the subcutaneous, sometimes even of the mus- cular tissue, which may be caused by red-hot metal or chemical substances. In the beginning a deep dry eschar is formed (Fig. 54). The slough generally separates in about a week. Where the effect is far-reaching, deep-seated structures being affected or a joint being exposed, it is unwise to wait until de- composition has taken place. As soon as the shock and con- gestive stage (forty-eight hours) are over the patient should be anaesthetized and the necrotic tissues removed. Further treat- ment consists in loose packing with 3 per cent, iodoform gauze and immobilization, preferably by the moss-board mentioned above. The same principles of treatment should be obeyed if there are all degrees found mixed on a burned surface. If the surface is very large, iodoform gauze should be used for the deep sloughs only. It should be considered that in severe burns of the thoracic wall the pleurae and lungs become con- gested (in rare cases serothorax and pyo thorax even being caused). This will favor asphyxia from carbonic acid absorption . It should be appreciated that if intoxication from the partly broken up portions of the burned area takes place besides, the chances of the patient become very poor. We should therefore eliminate at least one of these dangerous factors — i.e., absorption — which we are able to do by following strenuous aseptic principles. The fact should never be lost sight of, that burns are nothing else but wounds and must therefore be treated as such, and that many of those internal alterations like duodenal ulcers, which puzzle us so much, are undoubtedly caused by the indirect influence of septic irritants. The internal treatment consists mainly in the administra- tion of stimulants during the first days, when there were signs of collapse. To promote oxygenation of the blood frequent inhalations of oxygen are in order. Strophanthus, caffeine, or strychnine may be given besides. Various Degrees of Burns. 77 FlG - 55- — Extensive Burn (caused by Flame) Showing All Three Degrees. First degree, at the periphery; second degree, from the right sternal margin to the left mammilla; third degree, over the right mammilla and at the anterior surface of the arms. 7 8 Surgery of the Thoracic Wall. In extreme cases of the third degree skin-grafting is fre- quently indicated (Fig. 56). Sometimes, a portion of a large defect heals under the stimulating influence of the continuous Fig. 56. — Burn of Third Degree, Reaching from Both Mammillae down to the Umbilicus, the Upper Hale being Cicatrized after Three Months, While the Lower Portion is still Ulcerating. (Closure by Skin Grafting. application of a bichloride of mercury solution (1: 5000), while other portions resist all these efforts. Fig. 57. — Contraction by Burns from the Axilla Downwards. Fig. 58. — Axillary Flap Transplanted prom Dorsum. (Compare Fig. 57.) 79 8o Surgery of the Thoracic Wall. In other cases cicatrization of even extensive surfaces takes place sometimes, but at the expense of functional ability (Fig. 57.) Then simple skin-grafting will not suffice. Large flaps must then be borrowed from the vicinity, as in the case illustrated by Fig. 58, where a flap was obtained from the dorsum. This Fig. 59. — Burn of the Third Degree, Extending over the Whole Anterior Surface of the Chest and the Right Side of Neck and of Lower Portions of Face. (Treated by Repeated Skin-grafting.) was turned forward and implanted into the axillary region, a procedure which permitted of lifting the arm. When the whole anterior surface of the thorax is deeply burned, plastic resection should be made before cicatrization is complete. In such cases, as they are illustrated by Figs. 57 and Fig. 60. — Extensive Scar of Side of Dorsum, Caused by the Explosion of an Ammunition Box in the Battle of Gettysburg (Note Epithelioma in the Scar Forty-two Years Later). Fig. 61. — Rontgen Burn, Second Degree (after Removal of Blister). 7 Si 82 Surgery of the Thoracic Wall. 59, transplantation is especially to be made from the abdomen, thick integumental flaps, which are to be resected, giving the best guarantee for the reformation of good skin tissue. Old scars are a source of greater or lesser disturbance even if they do not disturb important functional abilities. In aged people a scar may favor the development of carcinoma, as in the case of the venerable hero, illustrated by Fig. 60. Burns caused by the excessive use of the Rontgen rays fall under the same considerations (see Fig. 61). (E) CONTUSION OF THE THORAX ASSOCIATED WITH INJURIES OF THE INTRATHORACIC ORGANS. Contusions of this severe kind are generally associated with fracture of the ribs. (See page 69.) The clinical symp- toms vary according to the degree and site of the destruc- tion. If the lungs are lacerated the signs are grave, marked shock (cyanosis, anaemia, cold extremities, tremor), dyspnoea, and haemoptysis generally being present. Haemorrhage in the pleural sac causes haemothorax, so that the symptoms of pressure prevail. In most cases a large area of dullness develops quickly, the breathing sounds as well as vocal fremitus disappearing gradually in proportion. (Compare section on haemothorax, page 201.) Tearing of the lung tissue produces pneumothorax, the physical signs of . which vanish in the presence of the high- pitched tympanitic note on percussion and amphoric breath- ing on auscultation. In favorable cases the effused air is slowly absorbed, expansion of the lungs taking place. While the prognosis of these non-penetrating intrathoracic injuries is serious, still it is not as grave as that of the pene- trating type. Treatment. — The therapy instituted immediately after Penetrating Injuries of the Thorax. 83 the injury is placing the patient in the horizontal posi- tion and administering stimulants (injection of camphorated oil, and subcutaneous saline infusions). An ice-bag may be applied to the thorax. If the heart is displaced by the formation of a large bloody effusion, aspiration under the most thorough aseptic precautions is indicated (see pp. 132 and 147, on aspir- ation) . Subsequent effects of intrathoracic contusion, especially pleuropneumonia, are treated after the usual methods. Sero- thorax and haemothorax require aspiration, while purulent effusions demand thorough exposure after rib-resection. (F) PENETRATING INJURIES OF THE THORAX. Injuries to the intrathoracic organs are followed by effects similar to those of the non-penetrating type, the main difference consisting in the possibility of carrying infection into the pleu- ral sac or the lungs. The blood arising from the laceration of lung tissue or from the arteria mammaria interna or intercos- talis can escape freely through the external opening, thus pre- venting the formation of haemothorax. It must be remembered that, in the normal state, the lungs fill the two lateral halves of the thorax completely, an intimate contact existing between the pulmonal and costal pleurae. The pleurae can be compared with two moist glass plates which can be moved under normal conditions but not be lifted off. It is only by the formation of an effusion between these membranes as the result of a pathological process (hydro-, sero-, or pyo-thorax), or by the presence of blood or air as a result of a trauma (haemothorax and pneumothorax), that this air-tight seclu- sion is disturbed. Signs. — While the signs may be so insignificant in those cases in which neither blood nor air escapes in the pleural sac that the injury of the pleura may be overlooked, they are of great severity when the pleura is widely opened. Then, 84 Surgery of the Thoracic Wall. of course, pneumothorax develops rapidly. Physical examina- tion shows a large tympanitic area. There is considerable dyspnoea, the pulse becomes small and irregular, and the patient may succumb to the reflectory paralysis of heart and lungs. Often, however, the patient survives the shock, and the question of his final recovery hinges upon the degree and character of the simultaneous infection. If there was no infection the air will be slowly absorbed. But in case of infection an effusion forms under septic symptoms, the pulse being small and rapid, while the temperature is high at the beginning and becomes low or even subnormal in the further course. The heart, the lungs, and the diaphragm being compressed and displaced by the effusion, it is natural that the dyspnoea assumes a grave character. If the patient tries to assume the recumbent position, he will become cyanotic. The physical signs show dullness on percussion, while aus- cultation is unable to detect any breathing sounds. The tho- racic wall protrudes and the intercostal spaces are filled up. Stab wounds are more prone to infection than gunshot wounds. Whether the pleura alone is injured, or whether the lungs participate, cannot always be elicited. If haemop- tysis, the most characteristic sign of pulmonal injury, is ab- sent, and if the pneumothorax disappears rapidly an isolated injury appears to be present. The prognosis is favorable in such a case. It is obvious that in most instances those means which in- jure the costal pleura are apt to perforate the lungs at the same time. Large bullets generally penetrate the lungs in their en- tirety, making their exit at the opposite thoracic wall, while revolving bullets often are arrested by a rib or a vertebra. If rib, sternum, or vertebra is penetrated, bone splinters may be carried into the pulmonal parenchyma. (For diagnosis see page 68, on Fractures.) As alluded to above, the symptoms of a pulmonal injury Signs of Pulmonal Injury. 85 are not always in proportion to their extent. In cases which terminated fatally after days or weeks, the autopsies showed the most extensive destructions, and still the patients were able to walk a distance or to continue fighting in battle shortly after having sustained their injuries. On the other hand, there may be marked shock, the patient becoming uncon- scious immediately after being wounded, and still recovery takes place rapidly. In a number of patients anaemia and cyanosis, tremor, cold perspiration, and facies hippocratica are observed. There is intense pain, which is sometimes located on the abdomen, and violent cough. The heart beats faintly, the pulse is irregular and hardly perceptible, the respiration shallow, superficial, and frequent. If the patients pass over the shock, the symptoms of haemothorax, sometimes of haemo-pneumothorax, are in the foreground (see above). Haemorrhage from the small blood-vessels stops spontaneously, an occurrence which is favored by the collapse and compres- sion of the tissues involved. Prolapse of lung tissue as well as emphysema are more frequently found in stab than in gunshot wounds, emphysema confining itself, as a rule, to the immediate vicinity of the wound. Prolapse is rare, however. In the Civil War only seven cases were observed. In gunshot wounds produced by the modern small-calibre bullet the smooth canal favors coaptation, which in regard to the openings in the costal and pulmonal pleura is of special im- portance. Projectiles are generally aseptic, but the fragments of cloth, etc., which they often carry with them represent a dan- gerous source of infection. If primary union did not take place, the canal having been infected by the knife or projectile or other wounding instrument, the bloody effusion decomposes rapidly, foci forming in the lung tissue at the same time. Phlegmonous or gangrenous processes may be the consequence. Later on, the pericardium as well as the mediastinum may participate. 86 Surgery of the Thoracic Wall. Statistics show that among twelve injuries there is one of the chest, and that the penetrating type figures with 40 per cent., the mortality rate amounting to about 60 per cent. Treatment. — The therapy of penetrating wounds of the chest consists in the treatment of the wound itself (disinfection and control of haemorrhage) as well as of the primary symptoms described above (page 66). The principles of wound treatment as elicited above must be applied in the first place. If a pro- jectile has caused the injury, the Rontgen method must finally settle the question whether an attempt at extraction should be made. As a rule, the treatment of the wound-canal and of the symptoms is of much greater importance than the removal of the bullet. The treatment par excellence in the majority of cases is the aseptic packing, preferably done by iodoform gauze. The internal treatment is virtually the same as is the non-penetrating kind, particular stress being laid on exterior and interior immobilization (morphine injec- tions). Only if dyspnoea becomes severe, aspiration of the haemorrhagic effusion (in the fifth or sixth intercostal space) must be undertaken. Isolated ligation of the pulmonal wounds must be regarded as a technical impossibility, but ligature en masse may sometimes be tried advantageously. In most cases the aseptic tampon must be resorted to. Pneumothorax and emphysema are not amenable to any special therapy. Secondary symptoms, like purulent effusion, are combated by thoracotomy preceded by rib-resection in about the middle of the axillary line. (As to details of the opera- tion, see page 152.) (G) INFLAMMATORY PROCESSES OF THE CHEST- WALL. Furuncles and carbuncles show a marked predilection for the back, whose integumental sphere, so rich in sebaceous follicles, favors the formation of comedos and of acne. In Carbuncle. 87 America, where the skin receives more careful attention than anywhere else, most people taking a daily bath, this tendency is not pronounced. Most cases of carbuncles are observed among the foreign elements and very little among Americans to the manor born. Formation of an acne pustule, as it may be pro- duced by the friction of the clothing around the scapulae or the lower part of the neck, increases the area of infection, the result being a more or less extensive folliculitis called furuncle. The carbuncle is the same process virtually, the difference being one of degree and not of kind, the subcutaneous connective tissue becomes infiltrated and the integument finally perforated at various places. There is a small amount of liquid pus, as a rule, surrounding necrotic portions of tissue. The usual diameter of a carbuncle amounts to several inches, while the infiltration generally reaches far down in the depths. There is a slight elevation, generally of a circular form, the coloration being dark red or coppery. In all cases of furunculosis or carbunculosis the possibility of the presence of Bright's disease, diabetes, and other de- bilitating affections must be thought of. Treatment. — Small furuncles, if observed at their early stage, may be absorbed by the injection of two to three drops of pure carbolic acid into the center. In the advanced stages of furunculosis and in all cases of carbuncle the most radical steps must be taken. Since the early day of antisepsis, the author learned to treat carbuncle by crucial incision, removal of the softened necrotic parts with forceps, scissors, and curette, and by the application of strong antiseptic fluids. But such procedures were seldom followed by that immediate relief which is so characteristic a sign after the evacuation of a pus-cavity. The following day always revealed new foci, demanding repetition of the painful procedures. And the same manoeuvre had to be repeated day after day for at least a week, sometimes 88 Surgery of the Thoracic Wall. much longer, until the black and grayish sloughs were replaced by a deep, irregular, crater-like ulcer, covered by granulations. Clinical experience having shown that whenever carbuncle was diagnosticated such a course was certain, in a more or less pronounced degree, and that we never succeeded in " aborting " a carbuncle ; also, considering the bacteriological significance of carbuncle, the question was obvious: "Why leave the unavoid- able process of destruction to Nature while it is within our easy reach to destroy the focus at its early stage by excising it in its totality?" 1 From a clinical point of view, carbuncle is nothing but a collection of small furuncles, lying closely together, so that the integument appears perforated like a sieve, by separate in- flamed and necrotic foci. Bacteriologically, we know such foci are caused by infection of pus-producing bacteria. It is in- conceivable, therefore, that by simply dividing a few joci by crucial incision thorough disinfection should be obtained. As soon as infection has spread to the subcutaneous cellular tissue, it extends peripherally. It is true that at its seat of predilection, the upper dorsum, the carbuncle infection is generally arrested at the dense fascia protecting the muscular tissue, while in the face the anatomical relations favor spreading, thrombosis of the facial vein, suppurative phlebitis, participation of the middle meningeal and jugular veins. Thus the fatal course is fre- quently explained on the autopsy- table. Ordinarily, infiltration so increases the density of the integu- ment that it does not yield to the great amount of pressure ex- erted by the pus forming below; it, therefore, cannot find its outlet before some of its portions undergo gangrene. Conse- quently, bacteria and pus must wander from one interspace to another, thus gradually involving the deep structures. The bacteria which merit preeminent consideration in con- 1 See "The Radical Treatment of Carbuncle." The Clinical Recorder, January, Extirpation of Carbuncle. 89 nection with carbuncle are the staphylococcus aureus and albus. Schimmelbusch and Garre rubbed pure cultures of these cocci into the skin of their arms and produced carbuncle, in the puru- lent discharge of which they found staphylococci again.. The cocci invaded the tissues alongside the hairs, between shaft and root. Still, in many cases, the streptococcus, as well as the dif- ferent varieties of proteus, and the anthrax bacillus were found. As is well known, the latter is regarded as the most virulent of all bacteria. It is evident that inoculation with different bacteria means different diseases, no matter how much alike the clinical symptoms may be. In the beginning all carbuncles look very much alike, and it is only in the further course of the disease that clinically a greater or lesser toxic influence becomes marked. Consequently, the greater and lesser virulence of the infecting bacteria, besides the more or less favorably situated locality, may be held responsible for the termination of the case. It would be fair to assume that a staphylomycosis, other circumstances be- ing equal, may not lead to a fatal end as easily as the invasion of the highly virulent bacillus anthracis might. From these con- siderations, it may appear opportune to make bacteriological in- vestigations of each case of carbuncle at its very beginning, and to deduce from the toxic gravity of the case. Unfortunately, such examinations consume too great a length of time to be utilized under ordinary circumstances where prompt action is urgent. Furthermore, the busy practitioner is not always equipped with all the means necessary for such investigations. In view of these facts it seems practicable to look upon the virulent significance of each case of carbuncle as grave, and to act accordingly. As the infiltrated tissue must be eliminated at all hazards, be it infected by whatever bacteria, it is better to sacrifice it at once, and to remove it with its disastrous inhabitants. This common surgical principle is widely adhered to in other surgical diseases, and there is no reason whv it should be abandoned in connection 90 Surgery of the Thoracic Wall. with carbuncle. The results which the author obtained since he made it a rule not to incise, but to excise at once, no matter what bacteria caused the infection, or whether there was any constitutional disease, like diabetes, or not, have been extremely gratifying. The technic of the operation, as it should be performed, either under a local or a general anaesthetic, is as follows: After thorough aseptic precautions, the center of the in- filtrated mass is caught by a strong Muzeux forceps. An incision is then made around the margin of the reddened area and carried down to the deeper tissues (fascia, if in the upper dorsal region). While lifting the infiltrated mass by the forceps, it is rapidly severed from the underlying tissues. The haemorrhage follow- ing the operation is not at all excessive, and can be kept in check by packing tightly with iodoform gauze. A gauze dressing saturated with a strong solution of bichlorid of mercury is then employed until the wound granulates well. The immediate effect of this method is simply surprising. The general dis- turbance, the pain, fever, and the delirious state of the patient disappear at once. Even if performed without an anaesthetic, this operation is less cruel than the method of crucial incision. A circular incision does not cause more pain than the crucial, and after the incision the patient does not require any further operative interference, while after incision he is obliged for weeks to daily suffer the torture of scissors and curette. (H) PHLEGMON OF THE THORACIC WALL; GENUINE AND TUBERCULOUS ABSCESSES; NECROSIS. True phlegmon of the thoracic wall is rare. It generally originates from suppurating glands of the axilla, wherefrom it propagates alongside the anterior chest-wall and on the fascia which is protected by the pectoralis major muscle. Finally the muscular tissues are invaded and an elevation at the sub- Phlegmon of Thoracic Wall. 91 clavicular fossa points to the nature of the process. In ex- ceptional cases the etiological factor is a deep-seated foreign body, like a needle-fragment, which causes an abscess. The symptoms of phlegmon of the thorax are grave. Early and extensive incision followed by liberal packing with 3 per cent, iodoform gauze give the only chance for recovery. Cases Fig. 62. — Osteomyelitic Rib-abscess. which were recognized at a later period generally take a fatal course in spite of the radical interference. Abscess formation caused by a foreign body gives a much more favorable prognosis. The same applies to hematoma produced by an injury, after it started to suppurate, provided a wide opening is made without delay. In extraordinary cases an abscess may be the result of 9 2 Surgery of the Thoracic Wall. osteomyelitis of the sternum or one of the ribs. They are es- pecially observed among the sequelae of typhoid fever. Their treatment consists largely in the resection of the affected bone portiom(Fig. 66). So-called cold abscesses of the thoracic wall mav sometimes Fig. 63. — So-called Cold Abscess Caused by Caries of the Second Rib. be caused by caries (Figs. 62, 63, and 64), but as a rule they are due to tuberculous osteo-periostitis. When the abscess is accessible, it is best treated by aspiration followed by the injection of a 10 per cent, emulsion of iodoform-glycerin. For diagnostic purposes the injection of iodoform-glycerin can also be utilized, since this substance is permeable by the Injection of Iodoform-glycerin. 93 Rontgen rays. It can therefore be recognized on a photogra- phic plate after being injected into the abscess-cavity. The extent of the cavity, as well as of any deep-seated fistula, can thus be elicited. Regarding the peculiar influence of iodoform upon tubercu- lous tissue the findings of the laboratory harmonize entirely with clinical experience. Bruns and Nauwerck, who excised the membranes of tuberculous abscesses, which had been treated with iodoform-glycerin, found neither tubercle bacilli nor tuberculous nodules nor any caseous or necrotic areas. The author could corroborate this statement by his findings in those cases which submitted to operative corrections of deformities, after the tuberculous process was cured by the iodoform treat- ment. The formerly tuberculous areas were replaced by firm, normal, vascular tissue. At first the tuberculous structures underwent fatty degeneration and partial necrosis ; later cicatri- zation took place . The addition of glycerin enhances the effect of the procedure, as the alteration of the tissues caused by it (especially the hyperemia, which in itself is a curative factor, followed by cell infiltration) favors the tissue changes, the slight inflammatory reaction intensifying the influence of the iodoform. The in- nocuous and non-irritating olive oil should, therefore, not be used as a vehicle of iodoform in cases of tuberculosis. That glycerin is an alterative becomes evident from the fact that after the intra-articular injection of pure glycerin a slight elevation of temperature and an acceleration of the pulse is observed. Ex- amination of the urine always reveals the presence of red blood- corpuscles; in severer forms of acute glycerin intoxication hyaline casts are even found. The addition of other drugs or vehicles (mucilage) keeps the iodoform well suspended in the emulsion, but their ad- mixture always impairs the influence of the iodoform more or less. The author has, therefore, used the simple emulsion, con- 94 Surgery of the Thoracic Wall. taining iodoform 10, and glycerin ioo parts. The iodoform settles at the bottom of the glass vessel, therefore the emulsion must be well shaken before use. The emulsion must be sterilized. This is done by filling a glass bottle with it and exposing it to the steam of a sterilizer for about an hour. The bottle should not be closed by a stopper, lest pure iodine be set free. The amount injected is ten cubic centimetres of the emulsion in children and twenty to thirty in adults on an average. It must always be considered that an injection has the dignity of a surgical operation, and that it, therefore, should be viewed from a strictly surgical standpoint. Especially should it be preceded by the same preliminary precautions, viz., sterilization of the puncturing apparatus, of the hands of the surgeon, and of the region to be punctured. Ordinary hypodermic syringes must not be used, because they do not stand boiling without being injured, nor do they .draw thick fluids. Another objection to them is that thin needles break easily if they have to be pushed down into re- sistant tissues. The author uses a strong syringe, the piston of which is so arranged that it can be propelled by a screw (Fig. 80). This arrangement prevents the surgeon from using too much force. At the same time it is provided with two stop-cocks, which permit aspiration of fluid as well as injection, while the needle remains in the joint. The needle itself must be especially strong and of large calibre. In early cases one injection is some- times sufficient. If there is intense reaction, which, if the above precautions are observed, is of rather rare occurrence, the in- jections must be deferred until the signs of reaction are over. As a rule, the injection is repeated every week until there is considerable improvement. Should there be no improvement after the injections have been repeated twice, wide exposure of the joint according to exploratory principles is indicated. This will seldom be neces- sary if suitable cases come under early observation. Mode of Iodoform Treatment. 95 The needle must be introduced slowly. Local anaesthesia is seldom needed. In nervous patients ethyl chloride may be used. All aspirations and injections should be done in the recumbent position. If this modus operandi is adhered to little reaction is to be expected. There is generally a slight rise of temperature. If the patient is kept quiet the pain, which follows occasionally, is insignificant. The reports of iodoform poisoning, so often heard in former years, have become scarce. The author has never been able to observe an undisputed case of general iodoform poisoning, although he used the iodoform since 1878, when he first made its acquaintance at Simon's clinic in Berlin. Then it was applied in a limited way only, but ever since the publication of von Mosetig-Moorhof he has used it moderately, as there is no need for excessive administration. It is true that the iodoform reaction is often found in the urine, as well as in the saliva, a few hours after the injection, but there were no other signs besides, and it is hardly justifiable to call this a poisoning. Abscesses of the thoracic wall may also be produced by peripleuritic abscesses or by a so-called empyema necessitatis (Fig. 92), that is, by the perforation of an empyema pleura. Both processes may show the same clinical signs. Perforating abscess of the lung may also discharge itself be- low the thoracic skin by a slow process, the pleurae becoming fibrous and finally adherent to each other. These conditions are specially considered under their in- dividual headings further below. As to differentiation it must be borne in mind that they may be confounded with aneurysms of the aorta (see Figs. 114- 120), pulmonal hernia, and caver- nous angioma. At its initial stage tuberculosis may attack one rib only, tracking alongside of it and thinning it so that it may in fact fracture it finally. Other ribs may participate, if early inter- ference is omitted. In neglected cases sternum, clavicle, and 9 6 Surgery of the Thoracic Wall. even the vertebrae may be invaded at the same time, so that an attenuation of the whole half of the chest-wall will be the Fig. 64. — So-called Cold Abscess Due to Tuberculosis of Sternum at the Ensdjorm Process. consequence, many "cold" abscesses of smaller and larger size indicating the nature of the disease. Tuberculous Abscess. 97 No matter how slight the first symptoms are, the surgeon should regard any painless swelling, which is forming slowly, with great suspicion, and consider the possibility of abscess originating from a tuberculous focus in rib or sternum. In this stage aspiration, followed by repeated injection of a 10 per cent, iodoform-glycerin emulsion, nearly invariably effects a cure. Of course, constitutional treatment, viz., out- door exercise, cod-liver oil, sea-salt bathing, guaiacol, and sun- baths, must be administered at the same time. If the abscess formation extends far inward, pyothorax may be diagnosticated. When the history does not indicate the nature of the case, the Rontgen method will differentiate, because in pyothorax the outlines of ribs or sternum would appear intact, while in tuberculous caries they would show the signs of arrosion and destruction. The calcareous matter would also be more completely absorbed in caries than in pyothorax; in the latter event there are no visible changes in the bone-shadow at an early stage. There is little tendency to perforation. In old cases the abscess makes an attempt to sink far into the lungs. The pleurae protect themselves against perforation by becoming much thickened, thus forming a resistant wall against invasion. Sometimes the abscess may appear in the loin, the exterior part of the abdomen, or it may wander alongside the sheath of the psoas muscle and emerge from below Poupart's liga- ment (psoas or iliac abscess) (Fig. 65). If the circumscribed character of the abscess has become lost and the rib or sternum become completely destroyed by degrees, the affected bone portions must be removed together with the tuberculous tissue enveloping them. Most of the degenerated tissue can be scraped away. Sometimes there are very thick fibrous masses, which can be extirpated only by use of the scalpel. Thorough removal is just as necessary as if a carcinomatous tumor was to be extirpated. Part of the 9 8 Surgery of the Thoracic Wall. wound may be sewed up, while the remainder should be packed with iodoform gauze. If tuberculosis starts in the sternum it must be realized that the peculiar form and texture of this bone, protected by its tough posterior membrane, gives the disease a chance to spread widely before the abscess breaks through an inter- costal space. This explains why at the initial stage a correct Fig. 65. — Emaciation after Tuberculous Rib-abscess, in a Boy of Twelve Years. Note protrusion under left rib-arch. diagnosis is seldom made, especially when, as it is the rule, the process originates from the posterior surface. Sometimes perforation into the loose areolar tissue of the mediastinum takes place where access is extremely difficult. But in the majority of cases the strong fibrous membrane which invests the posterior sternal surface is strong enough to prevent this fatal occurrence. The technic of the operation in such cases consists in the Resection of Sternum and Ribs. 99 extensive exposure of the foci. The author usually makes a longitudinal incision at the outer margin of the sternum near the swollen area, following the exploratory principle em- phasized in the section on costal resection. If the ribs appear to be diseased a transverse incision is added as illustrated by Fig. 66. — Tuberculosis of Sternum and Ribs (Cured by Extensive Resection). Fig. 66, which shows the result of removal of the left margin of the sternum and of portions of the third, fourth, fifth, and sixth ribs, in a man of fifty-eight years. Sometimes the sternum becomes so much softened by the disease that most of it can be removed by the sharp spoon. tOFC. ioo Surgery of the Thoracic Wall. Hard portions, covering the focus, must be resected by chisel or rongeur forceps. It is astonishing how quickly patients who are often given up as cases of incurable phthisis rally after thorough removal of the diseased area is done. The hectic fever caused by absorption disappears promptly when pus- formation stops, and the patients improve rapidly, provided no further foci have been established in the depths. Tuberculous osteomyelitis of the ribs starts by first forming a small central focus, which gradually extends toward the periphery. The nearest sphere of the periosteum proliferates more and more in that it becomes very much thickened. In the further progress of these changes the other tissues, espe- cially the fascia, participate. Finally an abscess forms, which perforates through the integument, thus establishing a fistulous tract. In some cases various foci form at different parts of the same rib. Tuberculous periostitis of the rib is extremely rare. Its course is slow, the rib usually becoming necrotic and exfoliating itself from the periosteal coat. Tuberculous osteomyelitis falls under the same considera- tions. The prognosis of tuberculous osteomyelitis is favorable if the iodoform- treatment is begun early. When fistulae have formed the iodoform- treatment is generally unsuccessful. Ex- tensive resection and removal of the thickened membranes followed by packing with iodoform gauze is indicated then (see section on rib-resection). Syphilitic inflammation of sternum or rib shows a great similarity to tuberculous processes. It seems that in the majority of cases syphilitic pus is more viscid and homogeneous than the tuberculous, the latter also showing a cheesy character. But these signs are not absolutely reliable. It must also be considered that syphilis and tuberculosis may be present in the same individual. Anatomically it may be emphasized that the syphilitic Actinomycosis of Chest-wall. 101 inflammation originates from the periosteum. A good skia- graph may be able to demonstrate that fact, thus settling the question of differentiation. The best method of differentiation, however, seems to the author to be to administer antisyphilitic treatment. If there is marked improvement, the diagnosis of syphilis is justified. Inunctions as well as the internal use of iodide of potassium (one to two drachms pro die) are recom- mended. The prognosis is unfavorable, the patients generally suc- cumbing to the emaciation. A most radical therapy, however (excision of fistulae and energetic cauterization with Paquelin's cautery), was followed by recovery in a few instances. Actinomycosis of the chest-wall is not infrequently ob- served, dental caries often presenting a predisposing moment for the invasion of the actinomyces into the mouth, pharynx, and the lungs. There an abscess forms rapidly then, from which numerous fistulae establish themselves. The diagnosis can be verified by the microscope only; although the multi- plicity of the abscess is a pathognomonic factor. I. TUMORS OF THE CHEST- WALL. Tumors of the chest-wall are divided best into benign and malignant. They originate from the osseous structures as well as from the soft tissues. i. Benign Growths. — Sebaceous cysts and dermoids are found at the dorsum with moderate frequency. They are sometimes confounded with abscesses and other types of cyst- formation. Their removal under local anaesthesia is easy. Lipoma shows great predilection for the dorsum, where it is observed with considerable frequency. It is always lobulated, which makes its recognition easy. Retromammary lipoma, a rare and peculiar type, is charac- terized by its development at the expense of the mammary 102 Surgery of the Thoracic Wall. gland, which becomes atrophied in proportion to the growth of the lipoma. Lipoma does not annoy the patient except when it becomes very large. The only therapy consists in extirpation, which does not offer any technical difficulties under ordinary circumstances. Fibroma is nearly as frequent as lipoma. In contradis- tinction to the doughy consistency of lipoma it shows a firm and resistant structure and is not as freely movable. Its seat is submuscular, its growth slow, and its usual size that of a walnut. As a rule, extirpation of ordinary fibroma is easy, but when there are any intimate connections with the pleura, as it happens sometimes, thorough removal reaches the dignity of a serious operation. Fibroma molluscum (cutis pendula) is found directly under the skin and originates from the perineurium. Its consistency is extremely soft. This variety extends over the whole body, sometimes as a multiple type, hundreds of nodules of larger and smaller sizes being observed then. The presence of a few nodules does not cause any disturbance, while the multiple variety gives rise to considerable trouble. The removal of the numerous tumors should then be undertaken in several seances. Keloid of the thoracic integument is a fibrous nodular mass of a gray, sometimes of a pinkish color, and is generally multiple. As a rule, the etiology is unknown, but it may well be assumed that a trauma, which remained unnoticed, gives the first impetus in individuals who have a peculiar idiosyn- crasy. As mentioned above, the integument of the dorsum is characterized by the presence of numerous follicles, which ex- plains its predisposition for the development of acne. From pro- liferations around the acne-pustules a real keloid-acne may arise. Sometimes they reach considerable size, in which case they generally produce neuralgic disturbances. Extir- pation should be performed under the most pressing circum- Naevus of Chest-wall. 103 stances only, because the tendency to recurrence is enormous. The removal of the growth should, therefore, always be followed by the transplantation of an unquestionably healthy skin-flap. Some cases showed improvement under careful Rontgen treat- ment following extirpation (Fig. 67). Naevus is especially frequent in children. It is generally * Fig. 67. — Multiple Keloid of Chest, Dorsum, Neck, and Face. of small size, but exceptionally it may reach the extent of the circumference of an orange. Its dark pigmented ap- pearance makes its recognition easy. The therapy consists in the speedy removal by the scalpel. In order to reduce haemorrhage the author's prophylactic suture-method is recom- mended. Cavernous haemangioma is not infrequently found on the 104 Surgery of the Thoracic Wall. thoracic wall. It shows two different types, one of them being characterized by flat formations of a light or dark red color and of various sizes, the other showing a cystic structure with lobulated margins (Fig. 68). As far as treatment is concerned, it may be said that while small haemangiomata may be removed by galvanocautery, or by the Paquelin instrument, extirpation by the scalpel is to be Fig. 68. — Cavernous Hemangioma Extending from the Anterior Axillary Line to the Spine in a Boy oe Six Months. (Recovery after Extirpation.) preferred whenever possible. The prophylactic suture is highly recommended, especially in infants, where even a small amount of haemorrhage may be disastrous. Neuroma is closely related to fibroma, because fibroma, in fact, originates from the perineurium. Virtually it falls under the same considerations therefore. Lymphangioma originates from the axillary lymph- vessels Enchondroma of Chest-wall. 105 and extends alongside the pectoralis major muscle. Some- times it proliferates considerably and may then reach even the mediastinum. Early removal is the best treatment. If on account of large size it cannot be extirpated in one seance, one part may be taken off first and another a few weeks after- ward. Enchondroma of sternum and ribs, while in fact of malignant character, on account of its frequent recurrence and its tendency to metastasis, is usually described among the benign because of its biological structure. It resembles chondrosarcoma, from which it is but difficultly distinguished. The seat of predilection is the body of the sternum, and the point of junc- tion between the bony and cartilaginous portions of the ribs. The size the enchondroma attains is often larger than that of the head of an adult. In such cases the tumor generally extends to the mediastinum. In the advanced stage the prognosis is unfavorable. The only rational therapy is early extirpation. The ribs, included in the tumorous mass, must be exsected. If the pleura participates, it has to be sacrificed, although the danger of pneumothorax should be thoroughly appreciated. In enchondroma sterni the pericardium may be invaded, so that its injury cannot be avoided. Osteoma of the chest-wall is rare. Its treatment consists in thorough extirpation. 2. Malignant Growths. — Most malignant tumors of the sternum and ribs are sarcomatous. The chest- wall may be the seat of fibroma, osteoma, chondroma, myelosarcoma, and osteosarcoma. At the initial stage they may be confounded with tuberculous abscess or gumma. In the first instance aspiration by means of a large needle (because of the thickened pus) will clear the situation. If a gumma is suspected the good old diagnostic maxim, u Ex juvantibus et nocentibus," should be adhered to. The Rontgen method will also be of value in obscure cases, since it may determine how far the pleura 106 Surgery of the Thoracic Wall. and lungs are involved and whether removal still offers any hope or benefit for the patient. The same may apply to far advanced cases of carcinoma mammas, which, thanks to the advances of surgery, are rarely seen at the present time. Tumors of the sternum are more frequently found during middle life. They excel by a predilection for sarcomatous degeneration, while the ribs are more frequently the seat of enchondromatous growths, which favor the infantile age more. The clinical characteristics of these tumors are their slow and painless growth. An injury often precedes their formation. The treatment of these neoplasms is entirely surgical. They must be removed as thoroughly as possible. Access is gained by obeying the principles of exploratory rib-resection (see section on this method, page*i88) after the tumor is exposed by a convex flap-incision. Except the tumor be small, the pleura will always be found adherent. Pneumothorax may consequently be expected, whereupon the operation might be done in the airless chamber. Haemorrhage is generally profuse. It will be treated best by proceeding very slowly and by frequently making use of temporary pressure-haemostasis. Sometimes adhesions to the lungs, the pericardium, or diaphragm must be divided. The Paquelin cautery should be used for division whenever possible. If thorough aseptic precautions were taken, the large wound is to be closed. In spite of the great risks taken, a number of good results are reported. The post-operative treatment of the field of operation by the Rontgen light is an important factor in the prevention of recurrence. Fig. 69 shows a case of myelosarcoma of the chest-wall, which, in spite of its extensive pleural adhesions, was success- fully removed. Primary carcinoma of the chest- wall is always of the type of the ulcus rodens. It is of a circumscribed character there- Carcinoma of Thoracic Wall. 107 fore. At the early stage it generally yields to energetic treat- ment by the Rontgen rays. At later stages the Rontgen treatment should be preceded by extensive extirpation with the scalpel. Whenever possible the defect left by the ex- tirpation should be covered by a healthy skin-flap. Fig. 60. — Myelosaecoma of Thoracic Wall. The large carcinomata found at the chest-wall are always of a secondary nature. The fibrous type of carcinoma mam- mae, characterized by its rapid growth, often surrounds the whole thoracic side like a harness {cancer en cuirasse). In such cases the prognosis is absolutely hopeless, the Rontgen therapy sometimes bringing temporary relief. 108 Surgery of the Thoracic Wall. 3. Hodgkin's disease (pseudoleukemia) shows its most characteristic external symptoms in the neck, the axillae, and the thoracic wall. As is well known, this most interesting disease bears a strong resemblance to sarcoma. Of the etiology and essential pathology of this obscure affection very little is known yet. Its characteristics are an enlargement of the lymphatic glands, lymphatic tissues forming in internal organs like the lungs, the liver, kidneys, spleen, and intestines. As a rule, the swelling begins in the glands* of the neck, one side of which is soon filled up by a mass of glands. Probably the nature of Hodgkin's disease is infectious, the specific effect of the alleged bacterium being caused by its predilection for lymphoid tissues. No permanent therapeutic results have been obtained so far, extirpation as well as administration of arsenic, bone- marrow, and toxine treatment having given only temporary benefit. Rontgen treatment tried recently has given much more satis- factory results. N. Senn 1 reported two cases in which a perfect cure was effected. One of the cases was that of a farmer of forty-five years whose glandular affection dated back a year. It had commenced in the cervical region almost simultaneously on both sides, and involved very extensively the glands of these locali- ties as well as the axillary and inguinal region. As Senn stated, there was a macular eruption of the skin all over the chest, back, and abdomen. The increased respiratory movements and dullness over the anterior mediastinum indicated the extension of the disease to the branchial and mediastinal glands. Spleen considerably enlarged. The patient received thirty-four treat- ments as follows : Right side of neck one minute, left side of neck one minute, neck from before backward one minute, each axilla one minute, neck from behind forward one minute, each groin one minute, spleen one minute. Daily sitting for the first ten days: 60 volts 8 amperes were used each day; distance x "New York Medical Journal," April 18, 1903. Hodgkin's Disease. 109 of tube from surface 12 inches, a medium vacuum tube being used. The treatment was commenced on March 29, 1902. On April 7th, after ten treatments had been given, the glands had undergone a noticeable reduction in size. At this time the patient made complaint of an intense itching all over the chest, and a uniform redness made its appearance over the chest axillary regions. The voltage and amperage were reduced to 42 and 6 respectively. After the next six treatments the voltage was again reduced to 28, amperage remaining the same. April 15th: The itching became so severe that it kept the patient awake all night. The skin of the chest blistered. The skin of the neck, naturally very dark, turned dark brown. A 5 per cent, boric-acid- vaseline ointment, applied twice a day, relieved the itching From April 16th to 23d the exposures were limited to the neck, back, and groins, as the chest and axillae were the seat of quite an extensive burn. April 24th: All of the glands subjected to the Rontgen-ray treatment had nearly disappeared. The face and part of scalp exposed to action of the Rontgen rays are devoid of hair. Axillary and pubic hair has also dis- appeared. Skin of neck dark brown and blistered. The skin of the chest from the neck down to about 4 inches below the nipples exfoliated in several places. The nipples were very sore, discharging pus. The treatment was suspended, and the patient discharged from the hospital with instructions to continue the use of the salve and internal medicine. Two weeks later he returned to the hospital for more medicine, and expressed himself as feeling well. His appetite was good and he was able to attend to his duties. No enlarged glands could be discovered. No elevation of temperature. Breathing much improved. The dermatitis had improved. He re- turned a second time on August 1st, as he had recently noticed a slight enlargement of the cervical and axillary glands. He is feeling well and is able to attend to all of his business. no Surgery of the Thoracic Wall. Dermatitis has disappeared. Return of hair growth. Patient received daily ten treatments, 28 volts 6 amperes; each group of glands was exposed for two minutes at a distance of 12 inches, w f 1 Wf M? 'f^B If: * %. ^ Fig. 70. — Hodgkin's Disease (Neck, Axillae, and Supramammillary Regions). tube the same as before. The glands disappeared promptly. No return has taken place since, the patient being in perfect health, with the exception of a joint affection, which has no connection whatever with the pseudoleukaemic process. Rontgen Method in Hodgkin's Disease. m Senn maintains that there could be but very little doubt that the constitutional disturbances which followed the prolonged use of the Rontgen ray in his second case, and which set in simultaneously with the progressive diminution in the size of Fig. 71. — Hodgkin's Disease (Neck, Axilla, Anterior Surface of the Chest). the glands, were due to a toxaemia caused by the absorption of the products of degeneration of the pseudoleukaemic product. This toxic condition unquestionably was likewise the cause of the increased enlargement of the spleen noted after the second series of applications. This patient has been heard ii2 Surgery of the Thoracic Wall. from very recently, and it is believed that there are no indica- tions of the return of the disease, and he is considered in perfect health. Fig. 70 illustrates the case of a man of fifty-six years whose glandular affections began seven months before the picture was taken. At first the glands of the neck commenced to swell while the axillary glands showed an intumescence about three months later. Six months after the onset nodules alongside the pee- to ralis major muscle were noticed. The respiration was slightly accelerated, temperature normal, pulse-rate increased, and the spleen much enlarged. The general condition was poor, the patient being very anaemic. The patient received six exposures, each one lasting five minutes for each side. There was marked improvement, the patient in fact feeling so much better that he left the hospital. Fig. 71 illustrates the same affection in a man of fifty years, who noticed the first cervical nodules eleven months before the picture was taken. Three months later the axillary glands swelled and six months ago the inguinal region shared the same fate. There was no increase of the respiratory motions, the pulse and temperature being nearly normal. The spleen is enlarged during the last two months ; nodules from the size of a filbert to that of a small apple formed at the anterior surface of the chest. The patient was treated after the same principles, and improved considerably after seven applications. He is still under observation. (4) ECHINOCOCCUS OF THE CHEST-WALL. Echinococcus of the chest-wall generally develops in the muscular strata, as a soft and elastic mass, so that it may be confounded with lipoma at an early stage. Differentiation with abscess and other cystic tumors is sometimes difficult, but can always be obtained by the microscopic examination Echinococcus of Chest-wall. 113 of the aspirated fluid of the cyst, in which the presence of the characteristic hooks settles the question. Sometimes they are detected after considerable search only. The presence of succinic acid also verifies the diagnosis. The therapy consists in extensive exposure and removal of the lining. The prognosis is favorable if these rigorous pro- cedures are resorted to early. Echinococcus of the chest-wall is rare. CHAPTER III. INTRATHORACIC DISEASES. A. PERICARDIUM. (i) ANATOMY OF THE PERICARDIUM. The pericardium (*ep{ rty zapstav, around the heart) is a membranous bag of a conical shape which surrounds the heart and the commencement of the large blood-vessels. It is inserted, so to say, between the two pleural sacs. In general the form of the pericardium is that of the heart, but its base is diverted downwards while its apex is diverted upwards. The base is tightly attached to the centrum tendineum of the dia- phragm. The pericardium consists of an internal layer which is serous and an external one which is fibrous, both membranes being intimately connected with each other. The relations of the serous layer to the heart are the same as those of the pleura to the lung. Consisting of a visceral as well as a parietal portion, it reflects itself on the inner peri- cardial surface. The dense fibrous layer mainly consists of the endothoracic fascia, and is attached to the posterior surface of the sternum by the ligamentum sterno-cardiacum superius and inferius. By this attachment the pressure of the heart upon the diaphragm is materially lessened. Above, the fibrous layer surrounds the large vessels which arise from the cardial basis. The pericardial arteries are derived from the descending thoracic aorta and from the internal mammary artery and its ramus musculo-phrenicus. Pericardium. "5 Fig. 72. — Anterior Mediastinum — Heart Exposed after Dissection of Ante- rior Surface of Pericardium. — (Testut & Jacob.) 1, Sternum; 2, second rib, with second sterno-costal junction; 3 and 4, sixth and seventh ribs; 5, M. triangularis sterni; 6, pericardium incised and unfolded; 7, anterior view of heart; 7', right auricle; 8, aorta; 8', preaortic fold; 9, arteria coronaria dextra; 10, arteria coronaria sinistra; n, arteria pulmonalis; 12, vena cava superior; 13 and 13', right and left venous brachiocephalic trunks; 14, arterial brachiocephalic trunk; 15, veins of thymus; 16 and 16', right and left lungs from without; 17, internal mammary vessels; 18, intercostal vessels; 19, pec- toralis major muscle; 20, subpectoral adipo-cellular tissue. n6 Intrathoracic Diseases. Since the heart does not fill up its bag, the vacant space is occupied by a serous fluid, called liquor pericardii, which amounts to about one-half ounce. (2) INJURIES OF THE PERICARDIUM. Isolated injuries of the pericardium are regarded as rare, Fischer having collected 51 cases in literature. Still it must be remembered that in a number of cases the pericardium is injured, but, the symptoms being insignificant and the course favorable, the diagnosis is not made. Whenever there is an effusion in the pericardium the symptoms be- come so severe that they cannot be misinterpreted, especially when the heart becomes irregular and dyspnoea sets in. The cardiac murmur is hardly perceptible then and is mixed with friction-sounds. The treatment corresponds with that of the penetrating wounds of the chest in the beginning (see page 83). If the symptoms become aggravating, the pres- ence of haemopericardium being assumed, pericardiotomy is indicated. The writer had repeated opportunities to convince himself of the life-saving effect of this unduly neglected opera- tion. (3) ASPIRATION OF THE PERICARDIUM. In cases of haemopericardium aspiration may be tried before pericardiotomy is resorted to. The same should be done in cases of suspected hydropericardium, for diagnostic as well as for curative purposes. A trocar should never be used for this operation, a Dieulafoy aspirator of medium size to which a thin needle is attached being recommended. The principles of asepsis, emphasized on page 61, must be rigidly observed. The needle should be introduced in the fifth intercostal space on the left, close to the sternal margin (Fig. 73). The direction of the needle should, however, not be rectangular to the sternal Aspiration of Pericardium. 117 Fig. 73. — Pericardial Aspiration. Diaphragm Fig. 74. — Large Pericardial Exudate. — (After Curschmann.) n8 Intrathoracic Diseases. surface, but obliquely downward and inward in order to avoid interference with the heart (see Fig. 73). In the presence of a large effusion, as illustrated by Fig. 74, the exudate may still be reached two inches from the sternal margin, but it is always safer to stick to the immediate vicinity of the latter. If decomposed serum or pus is aspirated, a broad opening which exposes the pericardial sac thoroughly should be made at once. (4) PERICARDIOTOMY. In the event just mentioned pericardiotomy is directly life- saving. Pus formation may follow an injury of the pericardium as well as an inflammatory process. The writer observed a large pyopericardium in a boy of fifteen years after the forma- tion of a retrosternal abscess, due to tuberculosis of sternum and ribs, which perforated into the pericardial sac. Recovery took place after extensive resection of a portion of the sternum and of four ribs. In haemopericardium pericardiotomy is usually preferable to aspiration. The conditio sine qua non of this operation is the preliminary resection of two or more ribs. In cases of injury the fifth costal cartilage is selected, while in inflammatory processes a wide area is to be exposed for the beginning of the operation. The fifth cartilage is exposed by making an incision of four inches in length, which begins at the centre of the sternum and extends alongside and over the middle of that cartilage. After its connection with the sternum is severed by a strong scalpel, it is freed from its posterior attachments and lifted by the aid of the rib-embracer. Now it is easy to push it outward and upward, so that it can be divided at its junction with the rib. By this procedure the fourth and fifth intercostal spaces are exposed. In most cases the additional exscction of the fourth and sixth cartilages is indicated. Dividing the Pericardium. 119 By appreciating that the pleural sac is but slightly attached to the pericardium while its connection with the triangular muscle is much more intimate, it will be realized that this muscle demands great attention. First of all, it is carefully dissected and then drawn outward in order to permit of push- ing back the pleura. Thus the anterior aspect of the pericar- dium is freed. The serrated insertions of the triangularis muscle are severed from the posterior surface of the sternum by introducing a Fig. 75. — Pericardiotomy. — (Lejars.) Skin and muscle incised in the shape of an H, the fifth costal cartilage divided and re- tracted outwardly. The anterior pericardial membrane is seized with two Pean forceps and pulled forward and upward. grooved director underneath the sternal margin and freeing the tendinous fibres from the periosteum. Then the index-finger finishes the manoeuvre by pushing the tissues in front of the pericardium aside, where they are held by a blunt retractor. If the pericardial membrane is seized by two forceps, it is pulled forward and upward so that it can be incised from below upward, thus avoiding any possible injury of the heart (Fig. 75). In sticking close to the sternal margin the mammaria interna cannot be interfered with (compare Fig. 27). In returning 120 Intrathoracic Diseases. the pericardium the serous surfaces must be brought into apposi- tion. As a rule, iodoform gauze drainage should be resorted to during after-treatment. B. HEART. (i) ANATOMY OF THE HEART. The heart, a hollow, conical, muscular body, is the central organ of the circulatory system and is situated directly behind the sternum between the two concave surfaces of the lungs. Being placed obliquely in the thoracic cavity, it turns its base to the right in the upward and backward direction, so that it corresponds to the space situated between the fifth and sixth dorsal vertebrae. The direction of the apex is forward and downward to the left and corresponds to the interval between the cartilage of the fifth and sixth ribs, about one and one-half inches below the left nipple. As a whole, the position of the heart is such that its longitudinal diameter forms an angle of 50 degrees with the vertical diameter of the thorax. In the adult it measures five inches in length, three and a half in breadth, and two and one-half inches in thickness. In the male it weighs between ten and twelve ounces, while in the female the weight amounts to from eight to ten only. The anterior surface has a round and convex shape and shows a longitudinal oblique furrow which bends around the apex, slightly deviating to the right to return to the base at the posterior surface. This groove is called the sulcus longitudinalis and is the exterior expression of the longitudinal septum in the cavity of the heart. It is rectangularly crossed by a transverse groove called sulcus circularis or coronalis, which is marked, however, at the poste- rior surface only, while the anterior surface is covered by the arteria aorta and pulmonalis. Thus the heart is divided into halves by a septum which corresponds to the sulcus longitudi- nalis. Each of these halves consists of a smaller and a larger Arteries of the Heart. 121 cavity, called atrium and ventricle respectively. To each atrium an appendage, called the auricle, is attached, which is curved forward and inward. The right half receives in its auricle the venous blood by the superior and inferior vena cava and the coro- nary sinus. From there the blood reaches the lungs through the pulmonary artery, where it is made arterial, to be returned to the left auricle by the route of the vena pulmonalis. Thence it reaches the left ventricle again, to be sent through the body by the aortic route. The arteries of the heart are immense vasa vasorum. They are the right and left coronary arteries and arise from the ascending aorta within the cavum pericardii. The coro- naria dextra or posterior passes forward in the sulcus circu- laris of the anterior surface of the heart to the right cardial border and then turns around to the posterior surface of the heart, in which course it runs alongside the auriculo-ventricular groove. The coronaria sinistra or anterior, which is not as well developed as its fellow, winds around the left cardial border in the sulcus circularis. Then it divides into two branches, of which one passes to the apex in the sulcus longitudinalis anterior. The other branch, called the transverse, passes over to the posterior surface of the heart in the auriculo-ventricular groove. It is important to know that the coronary arteries show a greater tendency to sclerotic degeneration than any other artery in the body. As far as the structure of the heart muscle is concerned, an outer and inner membranous layer, besides a muscular one (myocardium), which is situated between them, are to be distinguished. The outer layer, which belongs to the pericardial cavum, is thin and smooth and contains a large number of elastic fibres. By short connective tissue it is intimately connected with the muscular structure. The inner lining of the heart, called the endocardium, is a thin, smooth, 122 Intrathoracic Diseases. and transparent membrane, which consists merely of elastic fibres lined with pavement epithelium. The special description of the ventricles, etc., is not a sur- gical subject. 0) INJURIES OF THE HEART. Injuries of the heart used to be regarded as fatal, still modern surgery reports a number of recoveries contradicting the old doctrine that wounds of the heart would invariably lead to death. Those patients who do not succumb immediately, as a rule, become unconscious for a while, show great anaemia, the respiration becomes superficial and rapid, the pulse small, fre- quent, and irregular, the apex-beat disappears, and the alae nasi move rapidly, as in severe peritonitis. Others, however, may not show any signs which would point to the severe character of the injury at the moment it is inflicted, and may even be able to walk some distance, so that the grave nature of the wound escapes attention until the further course proves it. The marked feeling of anxiety is one of the most characteristic signs of heart-injury. The continuance of the haemorrhage may terminate life in a few hours then, but sometimes the haemorrhage stops, the weak action of the heart being a favoring moment. After the danger of shock and haemorrhage is over, pericarditis may still threaten the patient's life. Even after recovery pericardial adhesions, dilatation of the right and hypertrophy of the left ventricle may be a source of great disturbance. Sometimes bullets become encysted in the heart, causing little trouble. With the increased knowledge gained by the Rontgen rays, the statistics will doubtless show more cases of this kind. (See author's case, in which the heart was wounded, the bullet being lodged in the pericardial cavum, page 72.) Treatment. — The treatment is symptomatic. As the weak contractions of the heart favor haemostasis, any dis- Treatment of Injury of Heart. 123 turbance should be avoided. If possible, the patient should not be moved for at least a few hours. Transportation must be undertaken with great care. Morphine injections in com- bination with saline infusions are the conditio sine qua non. Nourishment should consist exclusively in milk diet. Later Fig. 76. — Medio-sagittal Section of Anterior Pericardium and Routes of Access. — {Testut &° Jacob.) 1, Pericardium; 2, heart; 3, sternum; 4, pleura; 5, lungs; 6, opening presenting xiphoid process, and on a level with it the subcutaneous and prsepericardiac tis- sue; 7, xiphoid process; 8, diaphragm; 9, parietal peritoneum; 10, subperitoneal cellular tissue; 11, anterior abdominal surface; 12, transverse colon; 13, liver; 14, transverse mesocolon; a, route of access to the anterior thoracic region; b, to the xiphoid process; c, abdominal transdiaphragmatic route. digitalis and hypodermatic saline infusions (Fig. 81) may be administered. If the symptoms of compression prevail, the heart must be exposed. For this purpose an incision is made over 124 Intrathoracic Diseases. the fifth rib extending from the left sternal margin to the anterior axillary line. After the corresponding rib- portion is exsected, the exposed area is carefully ex- plored. If access does not prove to be easy then, parts of the sternum or the fourth rib are removed in addition. The ribs do not necessarily need to be resected in their totality, but may be folded up at their sternal junction like a bone flap of the skull. The apex is secured with a strong silk suture, so that it can be pressed against the thoracic wall, Fortunately most wounds of the heart concern its anterior sur- face, so that they are easily found. The right half of the heart is Fig. 77. — Suture of Wound of Ventricle, the Needle being Conducted through the heart-muscle and the flrst suture ends utilized as a Traction-suture. — (Lejars.) best sutured during diastole and the left during systole, the material being catgut (Fig. 77). According to Fischer, the percentage of recoveries is not higher than 10. It seems to the author that it amounts to about 35. The best chances are offered by the wounds of the anterior surface. The ligature of the arteria coronaria was carried out successfully by Tassi. The wounds of the large thoracic vessels are hardly the object of surgical interference since the injured succumb immediately after the injury. Some sur- vive it for a time. As a warning it may be reported that in the author's practice the innominate of a strong man of Wounds of Diaphragm. 125 thirty-four years was divided by a pocket-knife which had entered the subclavicular space, leaving but a small opening there. The patient being under the influence of liquor and the wound yielding but a few drops of blood, the somnolent condition of the patient was attributed to his intoxication, so that an ambulance surgeon, who saw him an hour afterward, declared his condition to be fairly normal. Two hours after the injury the patient was dead, the family not detecting the true nature of his " stupor" until three hours thereafter. Wounds of the diaphragm are but rarely recognized. Sometimes there are no symptoms at all pointing to this injury, sometimes there is protrusion of the thorax combined with sinking in of the abdomen. The heart is displaced and dyspnoea develops. Percussion reveals tympanitic sounds. In contradistinction to the intrathoracic injuries described above there is distention of the abdomen and symptoms of in- carceration. The treatment is generally without avail except in the case of incarceration, when laparotomy in combination with suture of the diaphragm is indicated. C. PLEURA. (1) ANATOMY OF THE PLEURA. The thoracic cavity harbors three serous sacs, of which two are in pairs. They are called the pleurae and serve the purpose of enclosing both lungs as far as their roots. The other serous sac, called the pericardium, is single and, as de- scribed above, encloses the heart and is situated between the two pleurae. Each pleura is reflected upon the interior thoracic surface, so that, in fact, it represents two membranes. The one investing the visceral surface is termed pulmonal pleura, and the other, investing the interior surface of the chest-wall, is called the parietal pleura. Under normal conditions these two mem- 126 Intrathoracic Diseases. branous layers are in close contact. Only when the cavity is exposed, the lungs by their elasticity collapse and a hollow space forms between the pleurae so that a pleural cavity can be spoken of. The right and left pleurae not meeting in the median line of the thoracic cavity, it is evident that a space is left there. This is called the mediastinum, which is divided into an upper portion which is above the pericardium, and a lower which is below the upper level of the pericardium. The upper portion of the mediastinum is situated above the upper pericardial level, between the sternal manubrium anteriorly and the upper dorsal vertebrae posteriorly. Below it is bounded by a line drawn from the union of manubrium and gladiolus of the sternum to the lower portion of the body of the fourth dorsal vertebra. The anterior portion of the mediastinum is bounded by the sternum in front, the peri- cardium behind, and the pleura on both sides. The posterior mediastinum, a triangular and irregular space, is bounded by the pericardium and the roots of the lungs in front, by the lower border of the fourth vertebra behind and the pleura on both sides. The middle mediastinum is situated between the two latter. Of the parietal pleura three different parts are distinguished, viz., the external (costal), the internal (mediastinal), and the inferior (phrenic). The costal part invests the ribs as well as the costal cartilages, the contents of all the intercostal spaces, the arteria mammaria interna, and the triangularis sterni muscle. It is furthermore in relation to the subcostal muscles, to which it attaches itself by the fascia endothoracica. The phrenic part rests, as its name indicates, on the diaphragm, while the mediastinal portion is in relation to the pericardial sac, the nervus phrenicus, and the vessels which accompany it, on both sides. On the left side it is in relation to the descending and transverse aortic portions, the left ar- teria carotis and subclavia, the ductus thoracicus, the left nervus Mediastinum. 127 Fig. 78. — Mediastinum — Lateral View after Dissection of the Pulmonary Pedicle, the Pleura Remaining in Situ. — (Testut & Jacob.) 1, Integument and subcutaneous tissue; 2, dorsal muscles; 3 and 3', first and ninth ribs; 4, intercostal muscles; 5, intercostal vessels; 6, pectoralis major; 7, clavicle; 8, subclavian muscle; 9, subclavian artery and vein; 10, brachial plexus; 11, costal pleura; 12, mediastinal pleura; 13, pleura dissected from the pedicle; 14, left bronchus; 16, left branch of the pulmonary artery; 17 and 17', left pul- monary veins; 18, pericardium seen in the depth; 19, thoracic aorta. 128 Intrathoracic Diseases. vagus, and the left vena intercostalis superior. On the right side it bears relation to the aorta ascendens, the vena cava superior, the vena azygos major, the arteria innominata, the vena in- nominata dextra, and the right nervus vagus. (2) DISEASES OF THE PLEURA. The diseases of the pleura are with a very few exceptions of a secondary nature, as they represent either a part of a general infection or are transmitted from a disease of a neighboring organ. The primary source may be healed, however, when the secondary affection begins, so, for instance, a pneumonia may have disappeared while a pleural effusion establishes itself. The main affections of the pleura which deserve sur- gical consideration are the effusions and the tumors. The various fluids in the pleural sac are either transudations (hy- drothorax) or serous (serothorax), purulent (pyothorax), bloody (haemothorax), and sero-haemorrhagic (sero-haemo- thorax), or chylous effusions (chylothorax) . All effusions cause dyspnoea. If extensive, cyanosis besides a frequent pulse is marked. The diseased thoracic walls are dis- tended and do not participate in the respiratory excursions. Percussion shows dullness, and marked displacement of the heart. Auscultation proves absence of vocal fremitus and weakened breathing sounds. Any infectious disease of the lungs may be followed by the formation of an effusion. Tumors of the lungs, like carcinoma, carcinoma oesophagi, in- flammation of the mediastinum or of the bronchial glands, pneu- monia, tuberculosis, abscess, gangrene, and influenza may be responsible for the development of pleural effusion. As will be seen on page 257, even subphrenic abscess produced by perfor- ation of the stomach, liver-abscesses, cholangitis, and appendi- citis may lead to secondary pyothorax. Serous Effusions. 129 (3) SEROTHORAX (SEROUS EXUDATIVE PLEURITIS). The contents of a pure serothorax consist of a clear, sterile, aqueous liquid containing a large amount of albumin. There are but a few cellular elements and no bacteria, the latter circumstance explaining why there is no tendency to suppu- ration. The aetiology of simple serothorax is still under dispute. Most cases are of a secondary nature, the idiopathic type being rare. Some investigators believe that tuberculosis of the pleura or of the lungs causes secondary pleural exudation most frequently. Others claim that the inhalation of coal particles and dust would be the exciting moment. If this be true, this kind of pleuritis would be a typical idiopathic form. How much consideration the old theory of a cold deserves is difficult to prove. There can be no doubt that a rapid change of temperature produces vaso- motoric disturbances, which pave the way for bacterial inva- sion, rendering the tissues a favorable soil, so to say, for the development of micro-organisms. Most purulent effusions are preceded by a serous stage ; but even then they contain a large number of leucocytes. When examined microscopically bacteria, especially staphylococci, streptococci, and pneumococci, are found, while a simple serous effusion contains a pure and clear liquid in which no bacteria can be detected. According to Fiedler, idiopathic pleuritis may also be caused by the essential causative factors of articular rheuma- tism. The mechanical changes caused in the thoracic cavity by the formation of an effusion are enormous, the space for the intrathoracic organs being considerably reduced. As indicated by Fig. 79, B, costal and pulmonal pleura are widely kept apart by the presence of a large exudate which compresses the I 3° Intrathoracic Diseases. atelectatic lung to a minimum. The chest- wall is naturally dis- tended so that the diseased thoracic half shows a larger circum- ference than the normal side and the sternum is shifted toward the diseased sphere. Respiratory motions are impossible, the whole side being fixed in extreme inspiration and all air in the lung, which is generally pushed against the spinal column, being evacuated completely. The heart becomes displaced toward the opposite side. (Esophagus and descending aorta Fig. 79. — Normal and Diseased Pleura (Schematic). — {Testut & Jacob.) A, Normal pleural cavity; B, pleural cavity entirely filled by effusion; C, pleural cavity partially compressed by encysted effusions; 1, parietal portion of the pleura; i f , visceral membrane of pleura; 2, interlobular fissure; 3, costo-dia- phragmatic sinus; 4, thoracic wall; 5, lung; 6, diaphragm; 7, liver; 8, total pleuritis; 9, encysted mediastinal pleuritis; 10, encysted interlobar pleuritis; n, adhesions uniting visceral pleura to the lung and the parietal pleura; 12, small encysted effusion; 13, encysted diaphragmatic pleuritis. are also shifted aside. The diaphragm forms a concavity where it showed a convexity under normal circumstances, and conse- quently the kidneys are also pressed downward. On the left side the spleen, on the right the liver, share the same fate. It is evident that the symptoms caused by these conditions as- sume an alarming character, especially the disturbances of cir- culation being extremely grave. In cases of small extent, espe- Aspiratory Puncture. 131 cially where the effusions are encysted (Fig. 79, C), the symp- toms of serothorax are mild pain, which, as a rule, is localized, slight dyspnoea, and moderate fever. Such small effusions disappear under immobilization in bed, diet, Priessnitz applica- tions, and large doses of podium salicylate in combination with small amounts of morphine. Later iodide of potassium in moderate doses is recommendable. But if pressure-symptoms indicate that the size of the effusion becomes considerable, aspiration must be resorted to. In case of re-accumulation the procedure may be repeated, but if this should occur several times, rib-resection and drainage are indicated. If, as it sometimes occurs, bacteriological examination should prove the presence of streptococci in an apparently clear serous exudate, the resection treatment should be undertaken without delay, since it can with certainty be expected that the morphological appearance of an effusion of this kind will soon assume a purulent character. (4) ASPIRATORY PUNCTURE. Aspiration is a surgical procedure and must therefore be preceded by the most rigid aseptic precautions. (As to the principle of asepsis see page 62.) Aside from the general rules regarding asepsis of the skin, the following points should be considered: No matter how well the integument is sterilized, the deep skin bacteria, which are sheltered by the follicles of the integument, cannot be destroyed by ordinary means of disinfection. Still, a great deal can be done to lessen the danger of infection by this source. Fortunately, we possess a permeating disinfectant in the tincture of iodine, which reaches the bacterial shelter — the glands. Bacteriological experiments as well as clinical experience have shown that, if the region to be punctured is first painted with iodine tincture, a sterilized needle in sterilized 132 Intrathoracic Diseases. hands will not carry bacteria which will develop in the cavity. Intracutaneous bacteria are not destroyed by the tincture, but they will be so affected that their power of development is inhibited. Aspiration is one of the most important diagnostic means and should be employed as soon as there is the slightest suspicion of the presence of an effusion. The syringe selected for the purpose should be fairly large and the needle strong, since any unfortunate motion of the patient might break a thin one. One of the best aspiratory instru- ments is the one illustrated by Fig. 80. The author constructed a large aspirator provided with a heavy stand after this principle (Fig. 82). For larger effusions the apparatus of Dieulafoy is recommended. Trocars should never be employed for the evacuation of intrathoracic fluids. Aspiration is best performed in the recumbent position. It is true that the sitting posture is more comfortable for the patient, but is apt to produce sudden anaemia of the brain, which may prove to be fatal sometimes. The needle must be introduced at right angles with the rib selected, -aspiratory syringe, the posterior axillary line in the sixth intercostal space being the most suitable point in the great majority of cases (Fig. 82). The submammary region is the area most favored for subcutaneous infusion of saline solutions in cases of shock and excessive Exploratory Pleurotomy. *33 anaemia. The preparations for this operation- -and an oper- ation it is — should be made according to the principles de- scribed above, thorough asepsis being imperative. As to the modus operandi , see Fig. 81. FlG. 8l. — SUBMAMMILLARY INFUSION. (5) EXPLORATORY PLEUROTOMY. Exploratory pleurotomy was advised and performed first by the author, * and later on recommended by Tuffier . 2 The experi- ence that in spite of the most thorough examination and observa- tion a correct diagnosis could not be made sometimes, and that even repeated exploratory puncture did not reveal the true nature 1 "Exploratory Pleurotomy and Resection of Costal Pleura," New York Medical Journal, Mar. 15, 1895. 2 Turner: " Chirurgie du pneumon," XII International Congress, Moscow, 1S07. 134 Intrathoracic Diseases. of the condition, induced the author to substitute exploratory incision for exploratory puncture in doubtful cases. In the section on pyo thorax (page 147) reference is made to a number of cases of pyothorax in which the presence of fibrous masses or of thickened or cheesy pus prevented their aspiration. The symptoms of effusion (compression, dyspnoea, dullness, weak- ened respiratory sounds) may be present after pleuro-pneumo- nia of long standing, and still aspiration would not yield any fluid. The question arises then whether after absorption of the fluid the pleural walls became thickened, or whether cheesy masses were left. The marked feeling of resistance expe- rienced while pushing the needle into the pleural tissue would indicate the fibrous character of the pleura. Still it must be considered that both conditions might be combined. If cheesy masses were present, their absorption would by no means be desirable, since this would predispose to tuberculosis. It is true that the acute onset of the disease would exclude the possibility of the presence of a neoplasm like carcinoma, sarcoma, or lymphoma, and that differentiation from sub- pleural abscess or echinococcus of the lungs would not be difficult. Still the question of tuberculosis could not be settled with certainty, since the sputa as well as the fragmentary drop gained by the dry aspiration may not show any tubercle bacilli, in spite of the presence of tuberculosis. The fact that from cases of pleuritis, in which the tuberculous character had been diagnosticated by other means, portions of the effusion were aspirated and injected into the peritoneal cavities of rabbits without producing any symptoms of tuberculous infection, proves the uncertainty of the negative result. As to differentiation from lung abscess see the section on that subject. The present status of the Rontgen method does not war- rant any reliable points of differentiation in this connection. Other means of information except the exploratory operation Decortication. 135 can therefore be relied upon but rarely. It is a strange phenom- enon that there is a certain aversion, or rather timidity, in regard to this procedure. While in obscure abdominal conditions no surgeon hesitates to open the peritoneum, why should the pleura be a noli me tangere? All that can be feared in an incision of this kind is the formation of pneumothorax. But this accident would hardly occur in pleuritis of long standing, where the presence of adhesions would prevent unintentional opening of the thorax. Under strict aseptic precautions even this accident, however, would not necessarily be dangerous, since pneumothorax would disappear soon after the wound closed, the lungs then expanding readily. The author has, for instance, met with dangerous symptoms in his cases of subphrenic abscess where, after resection of a rib, the pleural sac was opened before being incised through the diaphragm. In the case of a very much emaciated patient the symptoms of shock became evident as soon as, after opening of the pleura, air rushed into the pleural cavity, so that incision of the sub- phrenic abscess was deferred until the following day, where- after the patient made a good recovery. The modus operandi consists in making an incision which extends over the rib covering the centre of the dull area. A rib-portion, four to five inches in length, is resected subperi- osteally, and the posterior portion of the periosteum divided then, so that the costal pleura comes into view. Careful dis- section reveals the presence of fibrous tissue, which is cut off by using the knife on the flat upon the pleura in the manner in which it is held during the process of shaving off the integ- umental flaps in skin-grafting. Sometimes some of the tissue is found to be cartilaginous or even calcareous, so that the knife produces a grating sound. After the flat incisions are repeated about a dozen times, thus constantly removing pleural tissue, a point of softer consistence is reached. Now a flat probe is introduced in order to ascertain whether 136 Intrathoracic Diseases. the inner surface of the costal and the external surface of the pulmonal pleura are loosely attached to each other by adhe- sions. By pushing the probe farther back it is easy to lift the posterior surface of the costal pleura from the correspond- ing anterior surface of the pulmonal pleura by tearing the adhesions. If the fibrous condition of the costal pleura is found to extend farther, more ribs are removed in propor- tion. Then, by lifting up the costal from the pulmonal pleura, and after having introduced a blunt elevator through the incision in the costal pleura, the degenerated costal pleura is exsected. Cheesy masses are, of course, removed with some tissue. The edges of the wound are united by a continuous silk suture, a few sterilized wicks being left in each corner of the wound. Then, by means of sterile gauze and of a large piece of absorbent moss-board, compression is exerted upon the resected area. Even if only a portion of the thickened pleura is resected, compression is considerably relieved, as is evident from the disappearance of the dyspnoea in the author's cases. If performed under strict aseptic precautions, the risks of exploratory pleurotomy are small. Operations of this nature can be carried out with more safety if the air-chamber constructed by Sauerbruch is used. This ingenious inven- tion eliminates the possibility of pneumothorax in intrathoracic operations by excluding the atmospheric pressure during the operative procedure, thus preventing collapsing of the lungs after being opened to the air. In a lower animal Sauerbruch opened the thorax on both sides, and removed sternum and ribs without seeing the respiration interfered with in the slight- est degree. The Sauerbruch chamber is air-tight. Its size permits of the presence of surgeon, assistant, patient, and operating table. The head of the animal may project outside, while a rubber cuff is tightened around its neck. Regulation of the air-pressure is done by an air-pump, a valve in its wall Pyothorax. 137 permitting the entrance of a sufficient amount of air to keep up continuous negative pressure inside the chamber. Von Mikulicz and his assistant, who did some work inside of the air-chamber for an hour, did not suffer any discomfort. The chamber is composed of boards, which are lined with tin, soldered at the corners. The roof is made of glass. PYOTHORAX (EMPYEMA PLEURA). The treatment of pyothorax dates back to the remotest antiquity, and marks one of the most brilliant eras of pre- Hippocratic surgery. It is reported that Euryphon of Cnidos saved the life of Cinesias by opening the chest-wall with the actual cautery. In the seventh book of the "History of Nature," Pliny describes the case of Pharaeus, who, after having been given up by his physicians, sought death on the battle-field, but when thrust in the chest by a spearman, pus escaped from the wound, and the seeker of death recovered, having been cured by the weapon of his enemy. There can be no doubt that thoracotomy for pyothorax was performed by the great master Hippocrates. A study of his book, "De Morbis Popularibus, " will convince the most skeptical that long before this the opening of the chest- wall was an established operation, the indications for which were well defined. These could be brought to such a degree of precision only as a result of the very frequent and extensive employment of different operative procedures, as free open- ing by the knife, the actual cautery, and the trephining and exsection of a rib. Hippocrates laid great stress upon wash- ing the patients frequently and with very warm water be- fore the operation was performed. Does not this extra- ordinary cleanliness appear like the dawn of aseptic principles ? Is it not an explanation of the operations performed at that early time with such signal success that some are inclined i3 8 Intrathoracic Diseases. to doubt the authenticity of the records ? In this connection, the modern surgeon may recall the frequent washings by the Hebrews — a religio-physiological rite ordained by Moses, who doubtless was one of the greatest judges of human requirements. The diagnosis of pyothorax, as described in Hippocrates's book, "De Morbis Popularibus, " is based upon the auscul- tation of a " splashing sound, while the patient was shaken," and "a noise similar to the one to be heard when vinegar boils. Furthermore the character of the respiration, the position of the patient, the eventual swelling of the diseased side, the fever, the pain, and the hydrops which was pres- ent now and then, were considered." In reference to the technic of the operation, the advice is given "to prepare the patient, fifteen days after the onset of the disease, by washing him first very thoroughly with warm water." Then the patient had to be placed upon a chair. After his hands were tightened, he was shaken by his shoulders, in order to ascertain, by the perception of the splashing sounds, which side was the diseased one. The incision was made far down on the most dependent part of the pleural cavity. After the skin was divided with a sword-like knife {jiayaipiq anqftoeidyq), surrounded by an ad- hesive mass up to three-quarters of an inch from its tip, a long, thin scalpel (hceiza d*upeUi faodijeaq paxei) was thrust into the pus cavity. As soon as a part of the pus was discharged the wound was closed by a piece of raw linen, to which a strong thread was attached. The cavity was evacuated once every day. After the tenth day warm wine and oil were infused every morn- ing and evening. If the pus was of a watery and sticky char- acter and also of considerable quantity, a tube of tin was introduced and shortened gradually according to the prog- ress of the healing process. When the left side was concerned, the prognosis was better than when it was the right one. In Article XLV ("De Morbis," II) the following prognostic hints are given: The Asepsis of Hippocrates. 139 "If the pus is white, clean, and slightly bloody, a cure is effected in the majority of cases. But if it be thick, green- ish-yellow, and malodorous, a fatal outcome is to be expected." There can be no doubt that, based upon such perfected diagnostic means, thoracotomy was performed frequently and successfully during the splendid Hippocratic era, and that most of its admirable knowledge was lost during the twenty- three centuries that have followed. A slight indication of what the medical world has lost of the immense knowledge of the school of Cos, and how advanced the technics of Roman surgery must have been, may be gleaned from a visit to Pompeii. On the repeated visits of the author to this most interesting place it struck him that the peculiar construction of the "house of the surgeon," so well known to the readers of Bulwer's "Last Days of Pompeii," pointed to more or less developed principles of asepsis. ■ The streams of water constantly flowing through the streets of Roman cities were certainly adapted to remove pathogenic bacteria, or at least much of their favorable soil of development, and the large number of small wells in the "house of the surgeon" suggests that the wounded as well as the instruments and dressings were subjected to a very thorough cleaning before and during operation. This would be in harmony with the advice of Hippocrates to frequently wash the patient before performing an operation. From these facts we can fully understand why these old masters with their fine art of diagnosis and with their powerful weapon "cleanliness" have obtained better results than the surgeon of later years, who, after washing his hands superficially in non-sterile water, went directly from an autopsy to the operating-room. There, alas! the masterpiece of anatomical demonstration was repeated on the living patient, who was thus frequently turned into a premature specimen for the autopsy-room. Interesting witnesses of this grand era are the perfect 140 Intrathoracic Diseases. instruments made of steel and bronze which, after being exca- vated at Herculaneum and Pompeii, are exhibited now in the Vatican at Rome and in the Museum at Naples. Celsus and Galen repeated the doctrines of Hippocrates, but later on the whole subject dropped into entire oblivion. During the Middle Ages thoracotomy was mentioned and performed by Ambroise Pare, Fabricius ab Aquapendente, and Jerome Goulu. But this was done only sporadically, Heister, the greatest German surgeon of the eighteenth cen- tury, mentioning the operation as a most unsatisfactory one, and Corvisart, the celebrated surgeon of Napoleon, holding that thoracotomy always accelerated death. Thus, it is not surprising that when Sedillot had the courage to bring the operation to light again, it was not greeted enthusiastically. His results, indeed, were so discouraging that the greatest surgeon of his time, Dupuytren, when himself suffering from pyothorax, declined to be operated on, uttering the classical words that "he would rather die by the hands of God than of the doctors." Bearing in mind that the great Velpeau had lost all his cases of pyothorax, and that, of fifty cases, Dupuytren had only seen four recoveries, his conviction can be well appreciated. Most of these cases, however, be it well under- stood, were treated by aspiration. Later on Sedillot, seconded by Langenbeck, recommended an opening by the trephining of a rib. It was reserved for the great discovery, antisepsis, to elevate thoracotomy to the high pedestal which it at present occupies. Especial credit is due to the surgeons Roser, Simon, Volkmann, Schede, Kiister, and Konig; but it should not be forgotten that the great internists, Kussmaul, Bartels, Lichtheim, and Gerhardt, were the pioneers in establishing the proper indica- tions for the operation. Full recognition is also due to our great countryman, Bowditch, for having first recommended exploratory aspiration, a procedure of high practical value. Multiple Resection of Ribs. 141 It now became customary, particularly through the efforts of Konig, to combine the resection of a piece of a rib with tho- racotomy in suitable cases. Schede, Bardeleben, Runeberg, Billroth, Rydygier, Volkmann, Ziemssen, Glaesser, Raczynski, Turner, Subbotin, Quenie, and Weir, Bull, and McBurney in this country, recommended the method. It was, however, understood that resection should be performed especially in adults and in cases of long standing, while aspiration and simple incision should be preferred in children. The author may be permitted to state that in 1882 he advised resection of a piece of a rib in all cases of pyothorax without exception, as this method offers the best means, not only for sufficient drainage, but also for thorough palpation and inspection of the cavity. As early as 1869 the genius of Gustav Simon found a way to heal old pyothoracic cavities by resecting from three to seven long pieces of ribs, thus mobilizing the thoracic wall and enabling it to adapt itself to the contracted lung. The author takes this opportunity to give due credit to this emi- nent surgeon, who also performed the first nephrectomy, for his ingenious method — an operation which, strange to say, is attributed to Estlander of Helsingfors. Simon presented cases successfully treated by him by the method described above before the Society of Mittelrheinische Aerzte, at Mannheim, in 1870, but his untimely death prevented him from claiming his priority. An excellent American surgeon, Warren Stone, of New Orleans, also performed the so-called Estlander operation long before Estlander, and so did both Kiister (1873) and Schede. Estlander deserves credit, how- ever, for having developed the method further. Schede has, as is well known, obtained admirable results in old pyothoracic cavities by practically removing the whole wall, including the ribs and the pleura. Etiology and Bacteriological Examination. — Pyothorax 142 Intrathoracic Diseases. is caused by the invasion of pus-producing bacteria into the pleura. Unless from a traumatic cause, it is but seldom of an idiopathic character. The large pleural surface, being lined with epithelium, is not a favorable soil for the development of bacteria under ordi- nary circumstances on account of its ability to absorb them and carry them off by its numerous lymphatic roads as well as by the alternating form of pressure exerted during the process of respiration. There is no other organ in the body which has such strong means of self-defense, which can only be overcome by an extreme virulence of the invading elements or a great change of the normal tissue. The latter may be induced by pathological processes encroaching upon them from this vicinity, by trauma (especially rib-fracture), by anomalies of the blood, or by disturbances of the circulation. Among these the somewhat antiquated "cold" may be mentioned. 1 There can no be doubt that immediately after camping on cold, moist ground, or after being wet through by rain, the symptoms of such diseases as rheumatism and other acute complaints may suddenly appear. Such facts happen so frequently that they deserve our attention. It seems that on such occasions micro-organisms which had previously settled in temporary innocence in the organs of apparently healthy individuals are set free by vasomotor dis- turbances. While proof of such theory cannot, of course, be furnished, this much is certain: that even among the most hygienic surroundings the surface of the body is covered with pathogenic bacteria. Virulent species are found even in the mouths of healthy persons. From this well-proved fact we must necessarily conclude that it is not bacteria alone which produce the disease, but that, besides the 1 It seems that the rapid variations of climate so characteristic of the State of New York predispose more to pleuritis and pleuro-pneumonia than the more equable climates of other parts of the country. Winter and early spring show the largest statistics. Precursors of Pyothorax. 143 bacterium and the favorable soil necessary for its further development, certain other conditions are required, the true nature of which we are still unable to determine. The com- bination of these conditions represents the favorable soil in which the bacterium develops. They may act upon the eco- nomy of the body by reducing its vital resistance. Predis- position, the term so often praised and so often ridiculed, is also an important factor here, just as in tuberculosis and other infectious diseases. Pyothorax generally develops from a preceding disease, as croupous pneumonia, pleuro-pneumonia, gangrene of the lungs, hemorrhagic infarction, tuberculosis, pericarditis, peri- tonitis, nephritis, osteomyelitis, oesophageal and tracheal ulcers, spondylitis, and appendicitis. The infectious diseases, par- ticularly measles, scarlet fever, influenza, sometimes diphtheria and smallpox, are also important precursors. During the extraordinary " grippe" epidemic in 1889-90 pyothorax was extremely frequent. Pyothorax may also be caused by the perforation of a subphrenic abscess into the pleural sac. Abscesses of this type may be of stomachic, intestinal, appendicular, hepatic, cholangioitic, and of perinephritic origin. Septic infection, the various types of tonsillitic and peritonsillitic processes, and retropharyngeal abscess may also be causative factors. Several times the author has seen pyothorax follow grave forms of gastro-enteritis. According to Koplik, a streptococcus-pyothorax may be caused even from a slight infected wound. In the vast majority of cases the precursor of pleuritic effusion is pneumonia. Why in one case pneumonia takes its well-known regular course, and in another is followed by a serous effusion, which is absorbed, and why in still another case it gives rise to pyothorax, is also unexplained. It would exceed the limits of this work to amplify these 144 Intrathoracic Diseases. theories further. We may, however, learn from them that the causal nexus of the aetiological factors of pleuritis, as well as of pyothorax, is not yet sufficiently elucidated. Whether in some cases of pyothorax the pleuritic effusion was of a serous character first and became purulent later on is not yet proved. It seems that even the so-called serous effusions, which later on " turned into pyothorax," contained the pus-producing ele- ments from the beginning of the process, which can, of course, not be recognized macroscopically. It was expected that bacteriology would bring more light that would be utilized in practice, but the most of its achievements thus far are of a problematic character. The investigations of eminent workers in this branch (A. Frankel, E. Levy, Prudden, Koplik, Netter, Weichsel- baum, and Prince Ludwig Ferdinand of Bavaria) have shown that the pyogenous bacterium most frequently found in pyo- thorax is the streptococcus. This coccus could be especially cultivated in cases of pyothorax due to trauma, caries of the ribs, pneumonia, and tuberculosis of the lungs, and also after pyaemia and septicaemia. Many pyothorax cases, particularly the so-called meta- pneumonic empyemas, are caused by the pneumococcus. A considerable number, especially the benign types, show the staphylococcus albus and aureus. The pneumococcus is more prevalent in children, while the streptococcus is much more frequently found in adults. Sometimes the pneumococci and the streptococci are present at the same time, and it often happens that even more varieties of bacteria are found together. During the influenza epidemic the influenza bacillus has been frequently found in the protoplasm of the pyothoracic pus-cells by R. Pfeiffer. The typhus bacillus, the bacillus call communis, and the micrococcus tetragenus and proteus are also found in pyothorax. It is to be regretted that the most ingenious bacteriological Bacteria in Pyothorax. 145 investigations treat only the pus, but not the diseased tissues. In tuberculous effusions, be they of a serous or of a purulent character, the tubercle bacillus is rarely found. If there is any suspicion in this direction it is advisable to rely upon the inoculation experiment, viz., to inject some of the aspi- rated fluid into the peritoneal cavities of rabbits, mice, or preferably of guinea-pigs. Thus, the tubercle bacillus is often demonstrated by the development of tuberculosis in the animal. Two to three months will elapse, however, before such infor- mation can be obtained. When the animal is killed, tuber- culous nodules from the size of a pin to that of a bean are found, particularly in the large omentum and in other abdom- inal organs. As to the significance of various pus-producing bacteria, it may be stated that the streptococcus is found in at least half of all cases of pyothorax. As this coccus is most commonly met with in suppurative processes, and has its constant domicile in and on perfectly healthy persons, it is self-evident that it will frequently be present in pyothorax. It seems that this micro- coccus especially tends to the formation of solid masses. Its predilection is, as we have seen, for adults, and particularly for infectious diseases. Frankel' s pneumococcus is more prevalent in the primary pyothorax of children, about 25 per cent, occurring in adults and 75 per cent, in children. The cases in which this coccus is detected show the most benign character of all, so that there is some inclination to attribute this to the coccus; but it seems to the author that the vitality of the organs and the compliance of the thoracic walls are the main factors ex- plaining the more benign character of pyothorax in children. In tuberculous pyothorax the tubercle bacillus is, in the majority of cases, absent. A negative examination, therefore, does not disprove the presence of tuberculosis. There are 146 Intrathoracic Diseases. cases where the tubercle bacillus is found, and in others only streptococci, staphylococci, and several mixed forms are detected. But inoculation experiments show the presence of tuberculosis beyond doubt. In 109 cases of pyothorax Netter found the streptococcus 51 times; the pneumococcus, 32 times; the bacillus tuberculosis, 12 times, and saprogenous organisms, 15 times. Among the latter, proteus and sarcinae may be mentioned. Of 274 cases of pyothorax coming under the author's obser- vation within the last fifteen years, 144 were examined bacterio- logically. There were found: streptococci, 56 times; pneu- mococci, 37 times; staphylococci, 28 times; saprogenous micro-organisms, 8; tubercle bacilli, none; in the remain- ing 21 cases no micro-organisms were found. It must be assumed, however, that these effusions were of bacterial origin just the same. In three cases, in which no micro-organisms could be cultivated, the injection into the peritoneal cavity of a guinea-pig produced tuberculous infection. As to the technic of bacteriological examination of thoracic effusions, it should be borne in mind that the skin of the patient, the hands of the surgeon, and the aspiratory apparatus, par- ticularly the needle, must be thoroughly aseptic. Rigorous scrubbing of the skin with soap and hot water, rubbing with alcohol, and afterward washing with bichloride must always precede the aspiration, which (see page 131) must be regarded as a surgical operation. As an additional precaution, the skin must be dislodged before introducing the needle, so that the stitch-canal in the skin and the one in the underlying tissues shall not be in line (Fig. 82). The left index-finger is pressed into the in- tercostal space to steady the skin, then the needle is pushed forward slowly. If a purulent effusion consists mostly of a very thick cheesy mass, the aspiration will naturally be nega- tive. The same result may be expected when the needle is Microscopical Examination in Pyothorax. 147 thrust into thick adhesions or into a massive fibrous pleural sward, or if the lumen of the needle be blocked by a fibrinous coagulum. Therefore, when pyothorax is suspected, the needle must be introduced several times at different portions, and when this also fails, a very large needle should be tried, in order to ascertain whether some thick pus could not be drawn through it. Sometimes it is preferable to push the needle far forward, pull out the piston, and then withdraw the instrument slowly. Fig. 82. — Pleural Aspiration, Piston Drawn Up. After each negative result it is also advisable to push a wire through the needle, thus removing any thick pus which may remain adherent to the inner surface of the needle. Occa- sionally it will be useful, after the operation, to fill the syringe with sterile water, and force the water through the needle into a Petri dish. In case cheesy masses are present, small particles are sometimes drawn into the interior of the needle, where they cannot be seen by the unaided eye, but when mixed with the sterile water, they can be recognized under 148 Intrathoracic Diseases. the microscope. In case the microscope does not give sufficient information, resort can be had to cultures of the fluid. Staphylococci are easily recognized on agar- cultures; while it is not easy to distinguish between strepto- cocci and pneumococci, as the cultures on agar appear very much alike. But the difference between these two cocci can be elicited after inoculation upon rabbits or white mice. From the foregoing it is evident that bacteriological means are not sufficiently far developed to be practically utilized by the physician in this special field. When the benign char- acter of the pyothorax is demonstrated by the presence of the pneumococcus, it has been advised to aspirate the pus instead of opening the chest-wall. But in the section on criticisms we shall see that this recommendation is of academic inter- est only. Diagnosis. — The diagnosis of pyothorax is easy in the great majority of cases, the symptoms being caused by the mechanical consequences of the abscess which compresses the intrathoracic organs — that is, more or less fever (chills), emacia- tion, and respiratory disturbances. They may be summarized as follows: History of preceding diseases, such as pneumonia, etc. (see foregoing remarks), suppurative processes in the neigh- borhood, pyaemia, etc. Furthermore, high and continuous fever at the beginning, later on intermittent and interrrupted by cold chills, great exhaustion, headache, dry tongue. In cases of long standing, oedema of the thoracic wall is observed. Percussion reveals perfect dullness. It should be borne in mind that in pneumonia the feeling of resistance is much more pronounced than in pyothorax, and that between the dull areas tympanitic sounds are found. Percussion shows that the neighboring organs are more or less displaced if there is an effusion. Auscultation reveals absence of the respiratory sounds, or at least weakened respiration. With the phonendo- Pyothorax and Subphrenic Abscess. 149 scope fine distinctions are somewhat more easily perceived than with the common stethoscope. The vocal fremitus is also either weakened or absent. In pneumonia the vocal fremitus is increased. To these rules, however, there are many exceptions. The main differential points in regard to pneumonia have just been noted. Other sources of error occur in growths of the pleura and of the lungs (sarcoma, carcinoma, lymphoma), which also at times produce effusion. In such cases the slow course and the entire absence of fever are pathognomonic (see above). If, in such cases, an aspiratory needle is care- fully introduced, hard masses are felt. Microscopic examina- tion of the cells, which are generally contained in the aspirated blood, furnishes information in nearly all such cases. Abscess of the vertebrae, echinococcus of the lungs, and actinomy- cosis may also be suspected. Pyothorax is also often confounded with subphrenic abscess. Here it should be borne in mind that in subphrenic abscess there is generally a history of previous abdominal dis- turbance and none of cough and expectoration, as in pyo- thorax. The heart is little if at all displaced, and there is no excessive action of the thorax or of the intercostal spaces. In the lungs, vesicular breathing is found below the clavicle, and pectoral fremitus is also clearly perceptible. There is a well-marked limit to the region of vesicular breathing, below which the expiration murmur is replaced by amphoric sounds. Deep, inspiration pushes the boundary-line of the region of vesicular breathing much farther down, into areas in which formerly no respiratory murmur could be perceived. This would indicate a well-marked separation between the lungs and the abscess cavity, the boundary-line of the lungs pro- truding toward the abscess cavity during deep inspiration. It is sometimes impossible to distinguish an encysted pyothorax from a subphrenic abscess. The pathognomonic 150 Intrathoracic Diseases. signs of such accumulations are absence of cough and rapid change of note if the patient is rapidly turned. Still the author's observations show that pleuritic effusions, particularly pyothorax, sometimes occur without showing these symptoms. 1 An error in this direction, however, will be of little practical importance, inasmuch as the treatment of subphrenic abscess is the same in principle as is that of pyothorax. It has been hoped that the Rontgen rays would give some more elucidation in these points. But effusions, be they serous or purulent, cannot be diagnosticated directly by the rays; still, by finding a translucent space, as, for instance, between diaphragm and liver, the presence of a subphrenic abscess ap- pears to be probable. (See section on subphrenic abscess.) The pus-cavity may either be of small extent or contain a cheesy accumulation, or it may be divided by adhesions into several minor cavities (Fig. 79, C), Or the needle may reach a pleural band of great thickness; the author has seen them up to the diameter of one and a half inches. Sometimes one may be surprised by the result of the ex- ploratory puncture, which may be negative although all the symptoms pointed to the process of pyothorax at first. And, on the other hand, it may happen that all the classical symptoms as described above may be absent, and still pyothorax be detected at last. The author has repeatedly found pus only after many aspirations were made; as in a case where the cavity was almost filled up with a cheesy mass, the liquid pus present amounting only to a trifle. Under such circumstances it is natural that the needle, after being introduced into these solid masses, cannot draw any pus. The same negative result may be obtained where there are large fibrinous masses in serous effusions. It has furthermore to be considered that there are exceptional cases of pyothorax, where the pus-cells have settled down to the 1 See: "Pyothorax and its Treatment," "Medical Record," May 13, 1894. Mode of Operation in Pyothorax. 151 bottom of the abscess cavity like a sediment, while above a collection of a clear serous fluid is found which, if aspirated, would necessarily leave the surgeon under the impression that no pyothorax existed. Such misapprehension may come all the easier if the exploratory puncture is made high up. This fact teaches that punctures should be made below as well. It should, however, not be forgotten that it is just in the most dependent part that clots are likely to settle which are apt to clog the exploratory needle. If in such a case absorption of the fluid should take place, and the sediment-like pus should undergo thickening at the same time, the negative result of the aspiration would give no correct information as to the true state of the pleural sac. In regard to the technic of the aspiration, the author refers to page 131. Operative Treatment. — The treatment of pyothorax can only be surgical. Its principles are governed by the same that apply to any case of large abscess, — that is, thorough evacuation and drainage, which can only be achieved by making a wide opening in the chest- wall. This demand is so simple that it is hard to understand the still antagonistic attitude of some physicians to this fundamental surgical maxim. A wide opening can only be attained by combining the in- cision with the resection of a piece of a rib, the latter being such a simple and easy operation that any physician may perform it. The technic is as follows: Thorough asepsis is just as necessary as in any other operation. Particular attention must be given to the skin of the patient and to the hands of the surgeon (see above). All the paraphernalia needed at the operation must, of course, be sterilized: the instruments, ligatures, etc., in boil- ing soda solution, and the towels, sponges, etc., in steam. If no sterilizer be at hand, the towels, sponges, etc., can also be sterilized in a boiling pot. 152 Intrathoracic Diseases. As a rule, the seventh rib is selected. The median axillary line is preferred as the centre of the incision, as thence the abscess walls can be reached equally well in front and behind ; the muscular strata also being thin there. It also enables the patient to be brought to the edge of the table during the operation, so that he might assume the dorsal decubitus; whereas, if the incision were made farther back, he would be obliged to lie on the healthy side, thus rendering evacuation more difficult. If, how- ever, the dull area, as sometimes occurs in abscesses of small ex- tent, is far from the median axil- lary line, the resection must take place at the point where the aspira- tory needle revealed the pus. It would, of course, answer sim- ple surgical rules to make the open- ing at the most dependent part of the cavity. But it must be borne in mind that by following this maxim in this special instance the diaphragm and even the peritoneum might be incised. This is apt to happen in cases of recent origin, when the diaphragm rises imme- diately after the evacuation of the cavity. The author even noticed that a few minutes after resection 1890.; , .. . . ot the seventh rib the openmg m the thoracic wall became obstructed by the rapidly uprising diaphragm. The incision, about four inches in length, should be made Fig. 83. — Exposure of Rib in the Median Axillary Line. — {Beck, in "Medical Record" Use of the Periosteotome. i53 down to the periosteum of the rib selected. Its direction must, of course, be parallel to the margin of the rib alongside its Fig. 84. — Incision-line in Resection of Rib (the Knife Dividing the Peri- osteum). — (Lejars.) centre (Fig. 84). The periosteum, both in front and behind, is raised by means of a periosteal elevator. Having freed the periosteum, the elevator is pushed beneath the rib, between it Fig. 85. — Dividing Rib with Rib-shears, while Annular Part of Periosteo- tome Retracts the Soft Tissues. — (Beck, "Annals of Surgery ," /aw., 1904.) and its posterior^periosteum, and allowed to rest on both edges of the wound. With a blunt hook or the annular part of the periosteotome (Fig. 86) the tissues are retracted along the rib 154 Intrathoracic Diseases. toward the axilla, while with a bone scissors the rib is cut be- tween hook and elevatorium. Next, the elevatorium is pushed toward the sternum, forcing the rib from the last fragment of adhering periosteum. A simpler way is to free the periosteum by introducing the author's annular periosteotome (Fig. 86) and carrying it Fig. 86. — Annular Periosteotome. Fig. 87. — Author's Rib-shears. around the denuded rib. By pushing it to and fro the last periosteal fragments are separated from the rib. At the same time it may be utilized as a retractor (Fig. 85.) If the author's elevatorium shears are used, nothing is required but to tear away the connection between the perios- Incision of Pleura. 155 teum and the rib and divide the rib, the instrument being of such a shape as to keep the tissues properly retracted. One blade, if taken apart, can be used as an elevatorium, so that the whole operation could practically be finished with those two instruments alone. A piece a little over an inch in length is resected. It is under extraordinary circumstances (see above), or in cases of old standing, that two or three ribs must be sacrificed. During these manipulations it is impossible to strike the intercostal artery on account of its anatomical situation (see Fig. 88. — Incising the Costal Pleura after Removal oe a Piece of a Rib. — (Lejars.) anatomical part), while in performing simple incision this ac- cident has frequently occurred. A few drops of tincture of iodine are then applied to the wound surface to form a protection against the escaping pus; aseptic tampons may also be pressed against the wound for the same purpose. The very thin thoracic fascia and the costal pleura are now incised, the opening being just wide enough to permit the introduction of a grooved director. As soon as pus appears in the groove of the director a small Pean forceps is introduced, and the opening gently dilated. Evacuation of the pus must take place slowly, as rapid evacuation might produce 156 Intrathoracic Diseases. fatal anaemia of the brain, on account of congestion of the lungs. The time for evacuation may be from twenty to thirty minutes. A sponge should be pressed against the opening from time to time to interrupt the stream of pus, thus avoiding too rapid expansion of the lungs. The pulse, the respiration, and the color of the face should be watched very thoroughly during these manipulations. If the condition of the patient permit, the finger is now introduced, and any solid masses, such as fibri- nous lumps or necrosed tissues adher- ing to the abscess wall, are wiped with the index-finger or with sponges fastened to a sponge-holder, or even with a blunt spoon, which the author advised for that purpose. By now introducing the pleural speculum (Figs. 89 and 90), the whole cavity can be inspected. Further cleaning is then an easy matter. The solid masses are best brought out by an ir- rigation with sterile normal salt solu- tion. When malodorous pus is found, an antiseptic wash, preferably bi- chloride of mercury (1 : 5000), is used for this instead. If haemorrhage should have occurred, or if signs of shock are present, such procedures may be deferred for a day or two. The costal pleura is now stitched to the skin with four silk sutures (on suppurating wounds iodoform silk is always preferable), one at each end of the wound and one on each side, with strong curved needles, sharpened on both edges from tip to eye, for ordinary needles break easily when forced Fig ). — Author's Pleural Speculum. Pleurostomy. i57 through the thickened pleura. Thus the wound surface is entirely covered, and the adjacent tissues are protected against infection. At the same time secondary haemorrhage is pre- vented and the wound kept wide open. This procedure may be termed " pleurostomy. " Fig. 90. — Pleural Speculum in Situ. If more than one rib is to be resected, the periosteum of the rib below is divided and the rib resected in the same man- ner as the first one (Fig. 91). The costal pleura underneath is also incised, a large aneurysm-needle is afterward intro- duced through one of the pleural incisions, and conducted i58 Intrathoracic Diseases. underneath the costal pleura to the other. With strong silk sutures the tissues, containing fascia, muscles, periosteum, costal pleura, and intercostal arteries, are ligated en masse close to the cut surface of the rib. Then a vertical incision is Fig. 91. — Simultaneous Resection oe Two Neighboring Ribs.- national Medical Magazine" January, 1897.) -(Beck, " Inter - made through the tissues between the two ligatures, thus creating a wide opening. If the skin is forcibly retracted, the integumental incision can be utilized for the resection of the rib above. The whole side is then protected with a large piece of moss-board, which, after being slightly dipped in Anaesthesia in Pyothorax. 159 water, adapts itself to the contour of the body like a plaster- of -Paris dressing. The dressing should, however, be applied while the patient assumes the dorsal decubitus, as sudden anaemia of the brain might be caused by the erect position. The whole pus cavity is packed with 3 per cent, iodoform gauze, a narrow strip, several yards long, being preferable for that purpose. The packing is done tightly for the first day in order to prevent haemorrhage, later on loosely. It is only after the rigorous procedures described that the cavity can be regarded as entirely evacuated. No necessity for subsequent irrigation arises, as all decomposable elements were removed. Anaesthesia. — Full anaesthesia should be administered only if the pulse is strong. This is an exceptional circum- stance in all cases of abscesses that have existed for a long time. It is well known to what immense dangers a general anaesthetic exposes the thoracic organs when their functions are so much impaired by compression. Ether being con- traindicated in every respiratory disturbance, only chloro- form is recommended, as a rule ; and there is no need to call attention to the danger to which the use of this paralyzing drug subjects the heart. Since the operation takes but a few minutes for a well-trained surgeon, it would be better to use local anaes- thesia (Schleich's infiltration or ethyl-chloride) when an anaes- thetic is required. Even cocaine is by no means void of danger. If chloroform is employed, only a few drops should be poured into the mask at a time, and the pulse, the respiration, and the color of the face should be very carefully watched. A hypo- dermatic syringe for the use of stimulants (strophanthus, cam- phorated oil), tongue-forceps, and mouth-opener (if available, an oxygen apparatus also) must be close at hand. After-treatment.— Packing with iodoform gauze renders after-treatment simple, since it offers the great advantage that no subsequent irrigations are required. This is an important 160 Intrathoracic Diseases. factor considering the unavoidable irritation caused by them, which has sometimes led to sudden death, but also because it pre- vents the formation of those very adhesions which are so much needed for the gradual obliteration of the cavity by the agglut- ination of the pleurae. No frequent change of the position of the patient is needed, as is required when drainage-tubes are used. All the pus is absorbed by the iodoform gauze in the cavity as soon as it forms, stagnation thus being prevented best, while a rubber drain carries off only part of the secretion. Consequently there can be no decomposition, and, naturally, no fever. The first dressing must be renewed after twenty-four hours, the discharge during the first few days generally being ab- undant. Except in the presence of malodorous pus it does not need to be changed then more frequently than every second or third day. The patient, if at all able, should get up after one week. During the first few days of the after-treatment small doses of morphine are administered for the purpose of immo- bilization, especially when cough is present. If the pulse be weak, strophanthus and caffeine may be added. Nourish- ment is given frequently and in small quantities to avoid distention of the stomach. If the pyothorax be of short standing the cavity may become obliterated in two or three weeks. In one of the author's cases, that of a child six months of age, obliteration was perfect six days after the resection, but this, of course, must be con- sidered an exceptional occurrence. In older cases it may take months. The average time for cases of short standing is four weeks. Thoracic fistula remained in none of the author's early cases. The gauze-moss-board dressing (see page 66) acts like an aspiratory valve, which yields to the internal expiratory pressure, the latter often being intensified by cough, etc., while, at the same time, it resists the inspiratory external pressure. In cases of short duration percussion is generally Prognosis of Pyothorax. 161 found normal, and auscultation reveals vesicular breathing above the formerly dull area, as early as twenty-four hours after operation, the lungs having expanded then. This shows that the atmospheric pressure, which is erro- neously regarded as hindering the early inflation of the lungs, can be of but little importance in this connection. The healing process does not take place by granulation, but by the distention of the lungs. Where the pulmonic pleura approaches the costal, where, in other words, the lungs touch the thoracic walls, a portion of the distending lung tissue adapts itself to the costal pleura, where it gradually becomes agglu- tinated by fibrinous adhesions. Prognosis. — If septic and tuberculous cases are ex- cluded the prognosis of pyothorax rests entirely upon early diagnosis. In other words, it is the family physician who is responsible for the final outcome. Among the author's cases of this type there is not one, in fact, which ended fatally. The operation itself is entirely void of danger if done under the precautions described above. The results can only be attrib- uted to the thorough evacuation made, and particularly to the removal of the solid masses found in the great majority of cases. In 62 per cent, of his own cases, especially in children, the author found them present to a greater or lesser extent. No method except resection enables the surgeon to introduce his finger, which procedure renders examination of the cavity possible and permits of thorough evacuation at the same time. So far there is no method which shows with any possible degree of probability before operation whether such fibrinous or cheesy masses are present or not. All we know is that the streptococcus favors the formation of solid masses. A large opening, which can be guaranteed by the performance of a resection only, allows inspection and palpation of the cavity and represents the means to diagnosticate the presence of the solid masses. So long as no information about this most 162 Intrathoracic Diseases. important point can be obtained by any other method, resection should always be preferred. If performed late in an emaciated patient whose strength has failed under expectant treatment, resection will seldom avert the fatal result, the lungs having lost their contractility after that long period of compression, while the functions of the neighboring organs are impaired by the continuation of their displacement. There are, in fact, no contraindications for the radical operation. In the inexcusable cases of long standing, where the cyanotic and emaciated patient shows a small and frequent pulse, a preliminary aspiration may be done to relieve the patient temporarily, resection to be performed on the following day then. As stated above, the author always insisted upon the resec- tion of a piece of a rib in all cases of pyothorax, irrespective of the peculiarity of the case, because he has seen cures even in cases to the operation of which he had proceeded without a gleam of hope, this showing how easily errors of prognosis occur. Even in such desperate cases where the tarrying policy had caused amyloid degeneration of the liver, ascites, etc., entire restor- ation to health has sometimes followed resection treatment. Amyloid degeneration on this basis must not always be re- garded as a hopeless condition, especially not in children. In tuberculous cases repeated cures have been effected, and the author's early statements about the advisability of the resection treatment in such cases were corroborated by Schede and Guterbock, and later by Kiister, Rydygier, Hofmokl, Th. Weber, and Koranyi, who reported a number of cures. Re- garding the absolute hopelessness of this type of the disease if let alone or treated medically, even a smaller percentage of cures would indicate the resection treatment. It would also be of incalculable benefit if such patients were operated upon much earlier. The chances being then much more favorable, the number of cures would be considerably augmented. Tuberculous Pyothorax. 163 While primary miliary tuberculosis as well as pyothorax, caused by the perforation of a tuberculous cavity into the pleura, gives a very poor prognosis, those cases in which the pleura has been infected from tuberculous lungs show a consid- erable percentage of cures. Mixed infection is generally present in cases of this variety, the pneumococcus, staphylo- coccus, and streptococcus being also found. As mentioned in the section on aetiology and bacteriological examination, the tubercle bacillus was not found in the pyo- thoracic effusion of a number of these cases, in which, never- theless, the presence of tuberculosis could be proved by other than bacteriological means of investigation. In other words, the absence of the tubercle bacillus does not at all prove the absence of tuberculous disease. As long as our diagnostic means in this direction are not more reliable, the surgeon will always be correct by operating upon every pus-accumulation in the pleural sac, whether it is tuberculous or not. That exposure to atmosphere and light are also healing factors in this connection, as they prove to be in peritoneal tuberculosis, appears to be probable. Those of the author's cases in which malodorous pus was found at the time of the operation invariably died. In all of them other grave processes were present, — either tuberculosis or multiple pyaemic foci. Some of them were observed after grave gastro-enteritis in children. In others tuberculosis pulmonum was present, and perforation of a cavity into the pleural sac could be suspected. This would mean a futile attempt of the vis medicatrix naturce. If infectious diseases are the precursors the prognosis is much more favorable, especially so after measles and influenza. The same view applies to trauma. The prognosis after the per- foration of a subphrenic abscess is somewhat less favorable. As stated in the section on aetiology and bacteriological examination, the cases of pyothorax in which the pneumo- 1 64 Intrathoracic Diseases. coccus is found show the most benign character of all. They are prevalent in children. Whether this is due to the particular character of the coccus itself is doubtful. It seems, as mentioned before, that the vitality of the organs and the pliancy of the thoracic walls in childhood are the main factors in this more benign tendency. Accidents. — There are many reports on accidents which have occurred during anaesthesia. By obeying the principles emphasized in the section on operative treatment, accidents from anaesthesia hardly occur during the operation itself. The responsible post of an anaesthetizer should never be left to the beginner, whose ignorance of the danger makes him so self-confident, his ambition being that the patient should be under the influence of the anaesthetic as long as possible. Thus he does not resist the temptation to give the drug too freely. But, while it is certainly most agreeable for the surgeon not to be disturbed by the insufficient anaesthesia of the patient, it is nothing less than a crime to subject the patient to any greater risk of life than is absolutely necessary. The author knows of several cases in New York where the patient died under the anaesthesia before the surgeon in charge had an opportunity to perform his operation for pyothorax. What the legal aspect of such accidents is every surgeon knows. Still it is surprising that they do not occur more frequently in patients who suffer from large effusions which compress one lung totally and the other at least partially, and where the heart is displaced and the circulation in the large blood- vessels impaired besides. The fact should not be lost sight of, that it is less cruel to trouble the patient and to save his life than to give him the so-called benefit of a full anaesthe- sia and to risk his life under the pretext of humanity. A limited anaesthesia frequently leaves an impression only and not a clear perception of all the surgical procedures; and frequently it is the nervous dread of these procedures, and Disadvantage of Drainage-tubes. 165 not the physical pain itself, which terrifies the most courageous patient. The odor alone of an anaesthetic will sometimes give the patient the agreeable impression of being insensible to pain. Nor is irrigation by any means void of danger, even if simple sterile water be employed. It is, therefore, a decided advantage of the resection-treatment that it does not require this dangerous and annoying manipulation. Alarming con- ditions are especially provoked if the irrigating fluid be driven into a bronchus, when a communication exists. Violent cough paroxysms of long duration are generally observed under such circumstances, the patient sometimes succumbing during such a paroxysm. Sudden collapse has repeatedly followed a too rapid and too forcible infusion, or a too rapid evacuation of the pyo- thoracic contents. This is safely avoided by slow evacuation, as mentioned above. Rubber drainage-tubes have often been a source of trouble. The mode of after-treatment advised dispenses altogether with this crux medicorum. The author was called eleven times to extract drain- age-tubes which were imperfectly secured (as by one safety- pin only), or where the rubber was of an inferior quality, so that breakage occurred. Twice he removed drainage- tubes, one being nine and the other eleven inches long, more than one year after operations performed by Buelau's method. Among some physicians a strong predilection exists for very long drainage-tubes on the assumption that the longer they are, the better they drain the cavity. This is an error. Long tubes are nothing less than an obstacle to the expansion of the lungs, and do not drain off any more than short ones which reach only the internal opening of the cavity. As said above, a strong needle should be used in stitching the costal pleura to the skin, preferably a Hagedorn needle. It has occurred that in uniting the pleura with the skin thin 1 66 Intrathoracic Diseases. needles broke and dropped into the pleural cavity, wherefrom they could be extracted only with great difficulty and danger. In exceptional cases a large rubber tube may be used in con- nection with the gauze-treatment. Then the tube must be secured by two large safety-pins, which are attached to the wall of the tube in the shape of a cross. Criticisms of the Different Methods. — The methods used in the treatment of pyothorax are simple aspiration, permanent aspiration (Buelau's method), incision, and resection. A discussion of the value of the so-called " expectant treat- ment" will hardly be expected in a surgical book. Still there is no doubt that the vis medicatrix natures is sometimes triumphant where either diagnostic ignorance or obstinate aversion to surgical procedures dictates therapeutic nihilism. There are cases of pyothorax which heal by perforation into a bronchus or by absorption, the latter process especially having been observed in pneumococcus pyothorax. As such occur- rences are extremely rare in comparison with the enor- mously large number of the victims of delay, and as we do not at all know the conditions under which these marvellous cures are effected, such hazardous expectations may well be called criminal. It is true that cases sometimes recover not be- cause of but in spite of the treatment. But can a rule be deduced therefrom? And does not the exception confirm the rule rather? Furthermore, if absorption takes place, the question arises whether this be really a fortunate event for the patient, as clinical experience shows that whenever absorption of pus takes place during a considerable length of time, a favorable soil for the development of tuberculosis and inflammatory processes is created. And besides it should not be forgotten that perforation into a bronchus might just as well kill directly by causing suf- focation. Another mode of the vis medicatrix natures deserves men- Empyema Necessitatis. 167 tioning, — namely, the so-called empyema necessitatis, — that is, a pus-collection in the pleural cavity which perforates through the chest- wall. But of this it may be said that in general it would represent nothing but an attempt of nature to heal, and, as a rule, not a successful one, inasmuch as the amount of drainage it can procure is entirely insufficient. Consequently most patients in whom this " fortunate accident" happens Fig. 92. — Empyema Necessitatis, following Pleuro-pneumonia, in a Child of Three Years Finally Cured by Extensive Resection. succumb later to the consequences of pus-retention, unless a free opening be finally made. R. K. Pel 1 says that the principle ubi pus, ibi evacua has justifiable exceptions, and that if empyemata be of small size, if the general condition of the patient be excellent, the pulse slow and full, fever absent, and the appetite good, absorp- 1 " Zeitschrift fur klinische Medicin," p. 211, Berlin, 1890. 1 68 Intrathoracic Diseases. tion through thickening can be expected. Such dangerous maxims cannot be condemned too much. And as to the true dignity of the cases it must be doubted whether the diagnosis was correct in the cases of recoveries, no exploratory puncture having been tried in any of them. If such nihilism is based upon an exclusive consideration of pathology, it deserves more attention than if it be simply the outcome of ignorance. Nevertheless it does the patient the same amount of harm. Medicine is not only a science, but first of all it should be a practical art, of which pathology is certainly the basis, but still only a part of the entity. Only when the two factors, science and art, go hand in hand, does the patient obtain that amount of benefit to which he is entitled. Regarding aspiration reference is made to the section on this subject (page 147). There is a great variety of apparatus devised, some of them, like that of Dieulafoy, being very com- plicated and expensive. Whether the entering of air into the pleural cavity, however, is really such a dangerous occurrence as is generally supposed, is not sufficiently proved, still it is cer- tainly preferable to always use an aspirator. On the other hand, it seems to the author that most of the accidents following sim- ple aspiration are rather due to non-observance of aseptic pre- cautions, to which careless operators are still inclined. As to the therapeutic value of simple aspiration in pyo- thorax, the author is satisfied that perfect cures have been effected by this method, especially in children, in whom the benign pneumococcus is so frequent. (See page 145.) Such cures are repeatedly reported. But these few cures amount to nothing in comparison to the immense number of those who have died under the aspiration-treatment. The author simply refers to Dupuytren's experience in aspiration (see page 140). Of the author's uncomplicated cases which submitted to early resection, not one was lost, but in a large number of his patients, who were repeatedly aspirated, and in whom resection Fibrinous Clots in Pyothorax. 169 was practised as a last resort, the radical procedure came too late. As before stated, in 62 per cent, of the author's cases solid masses were found in the pus-cavity. These could certainly not be aspirated. Now, if any of our diagnostic means could enable us to know whether such masses were or were not pres- ent, it might appear pardonable to recommend free opening only when solid masses are present, and to try aspiration when they were absent. But as long as we possess neither physical, mechanical, nor speculative means to make this differentiation otherwise than just by making a free opening, that method must be chosen which guarantees removal of the solid masses; and suppose a case which would have recovered by simple aspiration should undergo the more radical procedure of free opening, it will certainly not succumb, but will get well just the same. This kindergarten-surgery is analogous to the well-known modus operandi of emancipated mid wives, which culminates in the idea that aspiration is evidently a very easy pro- cedure; that it is, in fact, "no operation," and the most unskilful surgeon can do it. Therefore it finds its most enthusiastic advocates among the large contingent of the amateurs who are so self-confident that they "never require the advice of a surgeon." They are generally the same who see all their cases of appendicitis recover without being "fooled by the surgeon." When they aspirate, they draw as much pus as they can; the patient is then greatly relieved, and so enthu- siastic in praising this most agreeable way of being operated upon that it would be simply impossible for the surgeon to persuade him to such a "mutilating operation" as free opening. If the pus accumulates again, the patient gladly submits to a second and also to a third or fourth aspiration, because "a stab with a needle is hardly felt." But the solid masses in the pleural cavity cannot be driven through the calibre of the 170 Intrathoracic Diseases. aspirating needle, nor will they be absorbed. So the aspiration is repeated until much precious time is wasted, the patient becoming emaciated and the lungs contracted. Then, as a last resort, a free opening is made, which at this late stage seldom averts the fatal outcome, wherefrom the aspiratory enthusiast deduces that free opening, particularly the resec- tion-treatment, yields a bad prognosis, and that he, at least, "never saw a good result from it," of course. No doubt if these surgical caricatures could once see the solid masses in the pleural cavity they would condemn their own procedures at once. But unfortunately they never see an opened thoracic cavity, at least not at the early stage of pyothorax, and so they naturally conclude that such masses do not exist. Aspiration, however, is by no means always an innocent manipulation. The irrigation in the pleural cavity may pro- duce epileptic spells, vertigo, nausea, fainting, and even fatal collapse. At the same time a nervous surgeon may interfere with the intercostal artery. According to reports, death has repeatedly occurred from this source through extensive haem- orrhage. In summing up, it may be emphasized that aspiration should be reserved exclusively for exploratory purposes, for the cure of so-called serous effusions, and for temporary relief in exceptional cases, as described above. In the latter event, however, when patients are so exhausted that they would not stand resection, resort should preferably be taken to aspiration combined with drainage (Buelau's method, page 171). As to the definition of serous effusion it may be said that those effusions should be called serous which, although they may contain a small amount of pus-cocci, still show the light color and the characteristic consistency; while pus represents a yellow, thick, homogeneous fluid. In practice the differen- tiation should only be made from the macroscopical point of Suction Method. 171 In 1879 Baelz advised the combination of aspiration with irrigation. The wish was father of the thought, and it was certainly a splendid idea to try to wash out the pleural cavity. But the solid particles there are unfortunately of too large size to be forced through the canula of a trocar, so that this method, which was received with great enthusiasm at first, dropped into deserved disuse. Permanent Drainage. — The so-called Buelau's or suc- tion method (Fig. 93) deserves attention. It is far superior Fig. 93. — Buelau's Suction Method. to simple aspiration in that it aims to prevent refilling of the pus after aspiration. The technic of this method consists in introducing through the intercostal space a large trocar, from which the stylet is withdrawn, the canula remaining. After a rubber drainage-tube is pushed through the canula into the pleural sac the canula is removed. The tube itself, which remains in situ, is then fastened to the skin with adhesive plaster and connected with a long rubber tube by a glass canula. The tube ends in a glass vessel rilled with bichloride of mercury, 172 Intrathoracic Diseases. where it is kept by attaching a piece of lead to its end. The glass vessel may be represented by a bottle, which the patient can carry around in his waistcoat pocket. The advocates of this method claim that a permanent evacuation proportional to the expansion of the lungs is thus achieved. Brilliant, however, as this method appears on a superficial contemplation, it has many and great disadvantages. First of all, the same objection as against simple aspiration must be raised, — namely, that the solid masses cannot be removed by suction any better than by simple aspiration. Even the enthusiasts of this method admit that the drain is oftentimes obstructed by fibrinous coagula. Fever is nearly always present, on account of retention of pus. It is but a small consolation that, by the introduction of instruments and fre- quent irrigations, this perpetual obstruction can be removed, and that in the course of time the solid masses become liquefied. Another deplorable feature of this method is that the drainage-tube comes loose in the wound canal, which will finally suppurate, then, of course, the seclusion from the air no longer being hermetic. Even as strong an advocate of this method as Aust 1 complains that pus which was free of odor at the time of the operation repeatedly became septic in the later course of the treatment. When the adhesive plaster becomes loose the drainage-tube is apt to drop into the cavity, and the only way to remove it thence is by free opening. The author has seen six cases in which such accidents happened after Buelau's method was used; but, as they necessitated resection, it seems, after all, that the accident was a fortunate event for the patient. It is furthermore to be remembered that all such patients require much more careful watching than those under radical treatment. In fact, the control must be so close that the method can be well carried out in a hospital only, wherefore it is not apt to become popular in private practice. 1 "Miinchener medicinische Wochenschrift," 1892, No. 45. Simple Incision in Pyothorax. 173 In cases where the intercostal space is narrower than usual, a small drainage-tube can sometimes be introduced only with difficulty and after much annoyance to the patient; therefore Buelau's method should be reserved for very emaciated patients, and then as a temporary resort only. It is a characteristic sign that the advocates of this method are all internists. Simple incision through the intercostal space has still many advocates who claim that a small incision which permits of the introduction of a thin drainage-tube fully answers the pur- pose of evacuation and drainage. It is also emphasized that any general practitioner could make the incision; while resection is regarded as a difficult operation, which would require the well-trained hands of a surgical specialist. Re- section should be reserved, therefore, as a last resort in cases where, after several months of unsuccessful treatment after the incision method, the ribs had approached each other to such a degree as to render drainage imaginary. As regards the advice to make a small opening into an abscess, it must be considered that, according to commonly accepted surgical principles, it is not expected that a small opening in an abscess would secure thorough drainage and evacuation. Modern surgery dictates that the opening should be made as broad as possible. The intention is to expose the abscess cavity so much, indeed, that it can be inspected in its whole extent, that its walls are palpable, and that its lining membrane as well as any necrotic tissue, the latter often being present in abscess cavities, can be removed. It is only after such rigorous procedures that evacuation could be considered to be thorough. The wound discharge will be scant and is found in the gauze introduced into the cavity. Retention will not occur and, as a natural sequence, perfect and quick recovery can be looked for. Nobody expects nowadays that a surgeon should " lance" an abscess at any other part of the body or introduce a small drainage-tube, the 174 Intrathoracic Diseases. use of which would also imply the necessity of daily irrigations. But why should a pyo thoracic cavity be treated on different principles ? After simple incision the field of operation cannot be inspected at all. Only if the intercostal space be very wide, which is never the case in children and seldom in adults, the surgeon's finger can be introduced; and if the opening permits of this, the finger is greatly restricted in its exploratory motions, and only small solid masses can be removed. Large masses will remain. Adherent clots cannot be detached from the pleura, nor can the size of very large masses be reduced inside of the cavity, a manoeuvre which would permit of their washing out by a subsequent irrigation. Consequently these masses have to undergo decomposition, and are dissolved or lique- fied under constant febrile elevations, retention of pus, of course, always being present. Finally they may be washed out, piecemeal, so to say, provided the patient holds out so long. As regards the alleged difficulty of resection, the author is confident that the physician performs many a more difficult operation than that of rib-resection. If he desires earnestly to learn its technic, operating once on a lower animal will give him the routine that enables him to do it properly. Interfer- ence with the intercostal artery happens much more frequently in simple incision than in resection on account of the situation of the artery below the inner surface of the rib. (See Figs. 31 and 32.) In resection the incision is made only as far as the peri- osteum. So far there are no vessels of any importance. Then the further procedures can be carried out with blunt instru- ments. The tissues in which the artery is embedded are pushed aside so that it can be easily seen and avoided (Fig. 94). If such an accident occurs after incision, resection has to be made at once, but if the operator is very nervous the patient may bleed to death before the operation is completed. On the other hand, if this accident should happen after the resection of the rib, Importance of Intercostal Space. i75 the artery can be caught directly. Fatal hemorrhage from the intercostal artery after incision is reported from several clinics (Billroth). Should the ribs move together after simple incision, fur- ther introduction of a drainage-tube, even if it be of smallest size, becomes impossible. This condition, which prevails in Integument and sub- cutaneous cellular tissue Externe intercostal Lungs as they are seen through a small fen- estra cut into the costal pleura Third rib Third costal cartilage . Interne intercostal Superficial aponeuro- Integument and sub- cutaneous cellular tissue iDterne mammary ganglia Chondro-sternal ar- ticulation Pectoralis major, dis- sected and reverted Superficial aponeu- rosis Fig. 94. — Two Intercostal Spaces on the Right. — (Testut and Jacob.) the majority of cases, in fact represents a type of the almighty vis medicatrix natures, the effort of nature to diminish the extent of the cavity. But, unfortunately, the intended remedy in this case is nothing but a prevention of the cure, because it obstructs the opening. As mentioned before, the author has with a few excep- tions dispensed with the drainage-tube. Formerlv he used 176 Intrathoracic Diseases. to introduce a rubber drainage-tube of the size of a man's index-finger three days after resection. The tube was secured by two large safety-pins adjusted through the wall of the tube in the shape of a cross. The reason why he did not introduce the rubber drain immediately after operation was that he had not only witnessed considerable haemorrhage after it sometimes, but also observed irritation by friction, this being caused by the constant respiratory movements of the pleurae. It seemed that as soon as granulations appeared, the pleurae also becoming accustomed to the contact with the atmosphere, the irritation was well borne. Two weeks after operation, on an average, a smaller drain was introduced and gradually shortened. When the discharges became scant, the drainage-tube was left out and a small strip of iodoform gauze substituted. For the fol- lowing few days the patient was watched carefully. Frequently the cavity was entirely obliterated on the following day, but often union was only superficial, retention of pus occurring which was generally heralded by an elevation of temperature. Then, of course, the drainage-tube had to be reintroduced. After a week the same manoeuvre was repeated until, several days after the obliteration, no discharge showed, while the temperature remained normal. Sometimes the presence of pus was revealed after a grooved director was forced through the scar tissue. The position of the patient had also to be changed every few hours, so as to make the pus flow into the dressing, thus trying to avoid its stagnation. The danger of stagnation induced Kiister to recommend counter-openings on the oppo- site side of the original opening. But all these annoying manipulations are rendered unnecessary if the cavity is packed with gauze. The disadvantages of the drainage-tube in general are, in the first place, that no antiseptic influence will be exercised upon the wound or the cavity itself; antiseptic gauze cover- Advantages of Gauze-drainage. 177 ing the outer ends of the drainage-tubes preventing decom- position of the wound products only after they have left the tubes and entered the gauze, so that the absorbent qualities of the gauze are not at all utilized. But if a cavity is packed with gauze every particle of discharge must be absorbed, and, however large the cavity, the pus will be in the gauze only and the wound surface must be dry. At the same time the antiseptic, with which the gauze is impregnated, exerts its influence continuously. A drainage-tube does not withdraw or absorb pus, for it has no power to aspirate the pus, which merely traverses the tube, its lumen being the point of least resistance. In other words, the flow through the tube occurs only when pus is abundant, which is the first step to its retention. In conclusion, the author feels justified in claiming that the resection method in connection with subsequent gauze treatment is, in contradistinction from all the other methods described, a clean, easy, safe, and nearly bloodless operation. It guarantees a large opening for a sufficient length of time, and makes subsequent operations unnecessary. Thoracic fistula in particular is impossible if the method be carried out in time. The resected piece, if the periosteum has been pre- served, is always restored, as may be demonstrated by palpa- tion as well as by the Rontgen rays. The author's own statistics embrace 529 cases, observed during a period of twenty-five years in the city of New York. Among them were 131 below three years; 151 were between three and five years; 37 were between five and ten years; 36 were between ten and sixteen years, and 51 above this age. Among them, 40 died. Nineteen of them were children below five years ; of the others, 5 were between five and sixteen years, and 16 above that age. Of the non-complicated cases, where inflammatory pro- cesses in the lungs or pleurae had been the precursors, 13 178 Intrathoracic Diseases. 261 were diagnosticated at an early stage. All of them recov- ered. In 115 cases the operation was done at a late stage, 14 of them showing the typical vaulting of the thorax. In 11 a fistula remained. Seven of these cases ended fatally from amyloid degeneration. In one of these cases the fatal end occurred sixteen months, in another twenty-one months and three years after the operation; in all of them Simon's (the so- called Estlander's) operation had been tried. In the latter case seven ribs were resected. As already noted, if only the non-complicated cases, in which resection was performed early, were considered, the mortality-rate would be practically nil. But as the author has made it a rule to perform the radical operation even under the most desperate circumstances the mortality-rate is in- fluenced accordingly. Nevertheless, among 86 such cases 54 recovered in spite of their poor chances. Among the fatal cases 15 may be enumerated in which malodorous pus was present (so-called stinking empyema). Eleven of them were infants; in seven of them grave gastro- enteritis was the precursor. In one case, a child of eighteen months, gastro-enteritis had been present two weeks before the signs of pyo thorax developed. The high fever present in the beginning had nearly subsided, but there was always a rapid pulse and great weakness, conditions which usually point to the constant absorption of toxic elements. In one case, where diphtheria was the precursor, pyasmic foci were present. No antitoxin had been given in this case. In four other fatal cases (one was a mixed infection) the presence of tuberculosis was proved by bacteriological exami- nation. In three cases of well-developed tuberculosis the result was also fatal, in all of them the exitus occurring from three to eight weeks after resection. In three cases of tuberculosis, where the diagnosis was cor- roborated by inoculation experiments, perfect recovery took place. Statistics in Pyothorax. 179 Statistics may easily mislead. If, as in some clinics, only the favorable cases are operated upon, the statistics will of course be more favorable. Schede reported seven deaths among eighty-six cases. In five of the latter grave septicaemia, pyaemia, and progressing gangrene of the lungs had been present. Of the other two, one was due to sudden collapse after operation, and this acci- dent could, according to Schede's own statement, have been avoided under different circumstances, mainly dependent upon the surgeon. In the other case, a child of seven months, broncho-pneumonia was present on the opposite side when resection was performed. This properly reduces the number of deaths to two, or perhaps to one only, — in other words, to a mortality of not more than 2.4 per cent., or a percentage of 97.6 of perfect and definite cures. Glaeser 1 reports twenty-one perfect cures in cases which were highly complicated. In all of them he had first tried Buelau's method unsuccessfully, performing resection only after the suction drainage had been kept up for seven weeks. Konig, among seventy-six cases, lost ten after resection, the latter all being complications of the gravest character. 2 Among forty-four cases of pyothorax J. Raczynski saw all those of metapneumonic origin recover after resection. Among eleven cases of tuberculous pyothorax resected by Kronlein, four recovered perfectly, four died, and three were improved. Perfect recovery took place in eight of the author's cases of amyloid degeneration. These were old cases. Some of the advocates of Buelau's method admit, however, the occurrence of many failures. Pel, 3 for instance, and Quincke report many failures besides their successful cases. ^'Resectio costarum contra Heberdrainage bei Behandlung der Pleuraempyeme," Hamburg, 1890. 2 F. Konig: "Die Erfolgeder Behandlung eitriger Ergiisse der Brusthohle," " Ber- liner klinische Wochenschrift," 1891, No. 10. 3 P. K. Pel: "Bemerkungen liber die Behandlung der Pleuraempyeme," "Zeit- schrift fur klinische Medicin," 17, Bd. 199. 180 Intrathoracic Diseases. Even Leyden, 1 the celebrated clinician of ultraconservative tendencies, reports four cases, of which only one was cured by Buelau's method, while another one recovered after resection which was performed later. The third case died from tuber- culosis without being resected ; and the fourth succumbed, after having been resected at a very late stage, to exhaustion. Thoracic Resection in Old Cases of Pyothorax. — At the Ninth German Congress of Internal Medicine, Ziemssen and Ewald, the internists, said: "Old cases of pyothorax should not exist; and when they did, the attending physician should be held responsible for their existence." This may be a rather severe verdict; still, in a way, it expresses the truth. The histories of old pyothorax observed by the author inva- riably reveal the fact that thorough evacuation of the pleural effusion was omitted at an early stage, that is, until after the expansion power of the lungs was materially impaired or totally lost. In the great majority of these cases aspiration therapy was continued for weeks before radical steps were taken. In some of them a simple incision had been made, in a smaller num- ber procrastination went so far as to look for healing by the development of a so-called empyema necessitatis, and in a few cases surgical therapy was not considered at all because the pyothorax was supposed to be of a tuberculous nature. It may safely be assumed that in all these patients, except those affected with tuberculosis, recovery could have been expected after timely and thorough evacuation, i. e., by pri- mary rib-resection. And yet even in tuberculous pyothorax recovery took place in a number of cases after they were treated by extensive thorax resection. Similar principles apply to the treatment of pyothorax in which other pathological conditions prevailed, like emphysema. Complications of this kind naturally 1 Leyden: "Ueber einen Fall von retroperitonealem Abscess nebst Bemerkungen zur Therapie der Pleuraempyeme," "Berliner klinische Wochenschrift," 1889, No. 29. Prognosis in Tuberculous Pyothorax. 181 delay the healing process, even after early resection. When- ever the diagnosis of such extraordinary condition was made early, the writer performed resection of the thorax wall with- out delay. As a rule, the expansion power of the lungs can be esti- mated at the time of the primary rib-resection. If the case is of long duration, the history points to the presence of com- plications, and the diaphragm fails to rise, the pulmonal pleura approaching the thoracic wall to a limited extent only. Then the resection of a small piece of rib is insufficient, as practised under ordinary conditions. And if the costal pleura appears to be fibrous, thoracic resection should also be substituted for simple costal resection . Whenever the condition of the patient should not permit of so extensive a procedure, the typical primary rib-resection should be performed at the time with a view to undertake thoracic resection a week later, when the patient has become more resistant. As mentioned above, cures in tuberculous cases were reported by Schede, Gueterbock, Kuster, Rydygier, Hofmokl, Th. Weber, Koranyi, and the author, after free rib-resection. In view of the absolute hopelessness of tuberculous pyothorax, if let alone or treated medically, even a smaller percentage of cures, as reported, would imperatively indicate the resection treatment. Patients of this kind should also be operated upon much earlier, the chances being much more favorable then. While primary miliary tuberculosis as well as pyothorax, caused by the perforation of a tuberculous cavity into the pleurae, gives a very poor prognosis, those cases in which the pleura has been inf ected . f rom tuberculous lungs show a con- siderable percentage of cures. Mixed infection is generally present in cases of this variety, the pneumococcus, staphy- lococcus, and streptococcus being generally found besides. Although the tubercle bacillus was not found in the pyotho- racic effusion of most of these cases, the presence of tuber- 1 82 Intrathoracic Diseases. culosis could be proved by other than bacteriological means of investigation. It should, in other words, be appreciated, therefore, that the absence of the tubercle bacillus does not prove the absence of tuberculous disease. Thus the surgeon, as long as our diagnostic means in this direction are not abso- lutely reliable, will always be correct by operating upon any kind of pus accumulation in the pleural sac, be it tubercu- lous or not. In bilateral tuberculous pyothorax, of course, radical steps promise little. The persistence of a pyothoracic cavity, whether it be simple, complicated, or tuberculous, must necessarily lead to a fatal end. It is true that the better the patient is situated, the longer the inevitable outcome may be postponed, but in the end he will succumb just the same. It is difficult to understand, therefore, why expectant treatment is still pre- ferred to timely resection. As described above, the inevitable consequences are that the pulmonal tissues as well as the thoracic parietes lose their elasticity. By the long continuance of the inflammatory irri- tation, the pleuras will be thickened and infiltrated, so that the costal pleura finally becomes so hard that it appears like an osseous coat-of-mail. At the same time the persistent and abundant suppuration leads to amyloid degeneration (Fig. 95). In those exceptional cases where the lungs have not com- pletely lost their elasticity, efforts were made with the appa- ratus of Perthes, which permits of continuous aspiration (like Buelau's). But, as a rule, the pulmonal pleura had become immovable then, the lungs are fixed and inexpansible ; while at the same time the chest-wall fails to show any tendency to sink in. To enforce collapse of the chest-wall has been the aim of the various operative procedures advised ever since Gustav Simon made the first suggestion of multiple rib-resection. Ingenious, however, as Simon's method is, its practical ad- vantages are small, because their indications are limited for Expansion of Lungs. 183 the reason that the pleurae are left untouched. Even Kiister and Estlander, who deserve credit for extending the operation, Fig. 95. — Resections in Old Pyothorax. — {Testut and Jacob.) A. Old pyothoracic cavity before radical operation, the compressed lung being lined by a fibrous membrane. B. The cavity filled up after the collapse of the thoracic wall is attained by multiple resection, the pulmonal pleura being attached to the thorax. C. Ideal expansion of the lung, as it is intended by Delorme after decor- tication. Fig. 96. — Flap-formation in Total Resection of Chest- wall. failed to recognize the main obstacle for the healing process in the thickening of the pleura. They maintained that the 184 Intrathoracic Diseases. pleura should be a noli me tangere, and that the pleural wheals were useful and necessary for the formation of adhesions be- tween the pleurae. It was the genius of Schede which recog- nized this fact, on which the principle of resection of the thorax is based; in other words, that since the pleurae represent a coat-of-mail as firm as osseous tissue, they must share the fate of the ribs, i. e., removal. Simon's original idea thus formed Fig. 97. — Flap Replaced and Gauze Drain Led through Fenestra in it. the stepping-stone to the more perfected method of Schede (Figs. 96, 97, and 98). Schede' s principle is carried out in practice by the exposure of the cavity through an incision reaching from the fourth rib, running in a curve downward to the posterior axillary line on a level with the tenth rib, and then up again in a curved direc- tion on the medial side of the scapula. In this way access is expected to be gained to the largest cavities (Fig. 98). Principle of Schede Operation. 185 While the principle of Schede, as far as the removal of the pleural tissue is concerned, must be held as irreproachable, there are some objections to the details of his technic. First of Fig. 98. — Outlines of Horseshoe Flap in Schede's Operation, which was Performed Two Years after Permanent Drainage was Tried. (Cured.) all, the fact must be considered that most of the cases of old pyo- thorax do not need so severe a procedure; in other words, that Schede's method reaches beyond the mark. It is, in fact, in its general execution one of the severest of operations; and it 186 Intrathoracic Diseases. offers no little danger to the patient, who is generally much weakened through prolonged suppuration. It is also to be ap- preciated that the method is not only performed by the skilful hands of its inventor, but also by the average surgeon, and si duo jaciunt idem, non est idem. As a matter of fact, the tendencies of modern surgery are toward the development of atypical operations. Even the fundamental principles of incision for amputation, sacred for thousands of years, and formerly the piece de resistance of the old masters, have become shaky, the surgeon nowadays adapting himself to the individuality of the case. And if we consider that old pyothoracic cavities show a many-sided picture which even the all-penetrating Rontgen rays cannot faithfully portray, it becomes evident that a typical method of resection is applicable in a minor number of cases only. Of course, we can measure the extent of the cavity by pouring in fluids, and the Rontgen rays give us an inlook after the infusion of iodoform-glycerin, which marks the shadows. Skiagraphy also proves uniform opacity in necrosed conditions of the pleurae, while fluoroscopy shows how far the mobility of the ribs is interfered with. But none of these points, while they are of great academic interest, furnishes the detailed factors of a plan of resection. Probing is extremely uncertain, because the cavity is always more or less irregular; the fistulous tracts are generally twisted and often of a meandering nature. The probe, by being arrested by projecting pseudo-membranes, is an altogether un- reliable indicator of the topography of the cavity. The con- sideration of this deficiency of our examining methods has led the author to employ procedures which would fit each indi- vidual case ; in other words, which would permit of forming a detailed plan of operation while operating. In other words, a large exploratory incision should precede the operation, the details of which will then be dictated by inspection and palpa- tion. Principle of Exploratory Resection. 187 As described above, exploratory incision in diseases of the pleura was performed by the author with good results. In his first case, for which he is indebted to Dr. I. M. Rottenberg, of New York city, fibrous degeneration of the pleura as a con- Fig. 99. — Exploratory Incision Line Above Old Fistula, in a Boy of Five Years, Treated by Simple Incision Eighteen Months Before Exploratory Resection of Chest-wall and of Lower Portion of Scapula. Note scar of fistulous opening below incision line. (Cured.) sequence of a long-standing inflammatory process had taken place. Considerable respiratory disturbances were caused, which could not be explained satisfactorily. Exploratory re- section of a rib in the region of dullness not only enabled the author to recognize this condition, but also gave the chance to 188 Intrathoracic Diseases. remedy it by removing the enormously thickened layers of the pulmonal pleura. The experience gained in this case induced the author to try the principle of gradually and methodically proceeding in cases of old pyothorax, and with gratifying results, as described in an essay on Pyothorax, in the " International Medical Magazine," January, 1897. The modus operandi of this exploratory method consists in resecting the rib which lies approximately in the middle of the roof of the cavity, regardless of the pleural fistula, as illus- trated by Fig. 99. The fistula is utilized for the passage of a sound, but during the operation itself it is avoided, because in old cases osseous projections are formed around the fistulous tract which make the direct method difficult (see Figs. 106 and 108), most of them being more easily reached from the side. The pleura underlying the resected rib is now incised. By means of a lateral incision enough room is gained to inspect a large part of the cavity and to palpate the cavity walls. The use of the pleural speculum (Fig. 89) originally advised for primary resec- tion is not necessary in such cases. If the cavity is small and the patient in a fairly good con- dition, which is exceptional, then the next two or three ribs are resected in proportion to the extent of the cavity beneath, while the soft parts are held back with sharp retractors. The cos- tal pleura is then excised by means of a blunt-pointed knife. If the fibrous tissue is very hard, then the lumen of the in- tercostal arteries is so much diminished by compression that the haemorrhage can be regulated by temporary pressure. Then soft parts and ribs may be divided at the same time. Although this formation of wheals is to be expected especially in very advanced cases, one should not rely too much upon such helps of nature, but make sure by means of a temporary pro- phylactic ligature en masse. This is carried out best by the aid of a large aneurysm needle (Fig. 91). In more extensive cases Technic of Exploratory Resection. 189 the ribs are divided successively in the same manner; the pre- Fig. 100. — Skiagraph of Case Illustrated by Fig. 99, Six Weeks after Resection of Three Ribs and Lower Portion of Scapula. Note reformation of osseous tissue from the periosteum. sumptive length of each piece being ascertained by palpation as it is incised. Palpation also tells whether the pleura below 190 Intrathoracic Diseases. the ribs is still elastic or must also be sacrificed. The incision of the soft parts proceeds likewise, which results in the forma- tion of an irregular flap. But no particular attention needs to be paid to the shaping of the latter, as it must depend more or less upon that of the cavity. Accordingly, cross-incisions may also be made. If a portion of the scapula is found to be in the way it is excised. The muscular flap set free by the resection of the scapula can be utilized for the purpose of partially filling up the under- lying cavity (Figs. 99 and 100). A mentionable point, to the author's knowledge not yet presented in literature and not of rare occurrence, is the con- cave arrangement of the lung surface which overbridges a certain amount of the cavity. The lateral parts of the pul- monary pleura succeed here in attaching themselves to the costal, fibrous adhesions holding them there. But the mid- dle portion does not follow, and now it represents the floor of the cavity over which the approximated sides form the roof. The picture of this remarkable condition can be com- pared with that which results when one presses in the lung surface with the thumb so far that the sides of that segment of the lungs collapse in a funnel-like ring around it. This resembles the longitudinal fold formed of the gastric wall when united in Witzel's method of gastrostomy over a tube, so that a canal is made of it. (Compare Fig. 79, C.) Special caution is necessary at the beginning of the opera- tion in this instance. Suppose in a case of this kind the incision were to be made directly, without first exploring the cavity thoroughly, then the lungs would be injured. By locating the area of the thin portion, that is, where the pulmonary pleurae join, access is easily gained to the cavity by first carefully dividing the fibrous tissues. Blunt dissection is preferable during this procedure. The lateral portions then gape apart and the circular cavity is transformed into a flat one. Partial decorti- Resection of Scapula. 191 cation is also advisable then. It appears that the right half of the lung is particularly prone to this sort of adher- ence, that is due perhaps to the presence of the middle segment, which seems to have a tendency to be drawn toward this direc- tion during the healing process. The fact that the scapular region is the predominant seat of old cavities explains some of the technical difficulties in- curred in the attempt to produce an artificial collapse of the chest-wall. While in 21 per cent, of the author's cases the anterior, and in 8 per cent, the lateral, thoracic region was affected, the posterior area figures with 71 per cent. If it is considered that the posterior chest-wall excels in firmness and rigidity, it will be understood that its collapse is produced with more difficulty than in front. Consequently, cavities show a much greater tendency to establish themselves there. It is evident that the artificial collapse can only be effected if all obstacles are removed; in other words, if the portion of the scapula which may prevent access to the underlying cavity is also eliminated. (See Fig. 99.) Similar principles apply to the apex of the pleural cavity, which is not at all touched by Schede's procedure. Just as in the scapular region, it is only the removal of the respective cavity roof which makes its collapse possible. The vicinity of the subclavian vessels seems to have prevented surgeons from invading this field for that purpose. Still, there is no other choice than to remove the costal dome. The risks of this operation are greatly lessened by the author's method, which is simple and comparatively safe and can be performed to a limited as well as to a large extent, just as the individuality of the case demands it. With the arm at right angles, the incision is led close to the lower border of the pectoralis major muscle in a horizon- tal direction till it ends at the lower part of the anterior margin of the deltoid muscle. The muscles are then dissected back 192 Intrathoracic Diseases. superiorly until the axillary region is free. The -vessels and muscles are grasped by strong blunt retractors and pulled upward. Sometimes separation is possible only by the aid of lateral incisions into both pectorales. Thus the vessels are tempo- rarily placed hors de combat, and the ribs can be removed according to the principles emphasized. If it should be dim- cult to reach the first rib by means of this pectoro-axillary incision, then the clavicle must be resected temporarily. The decorticated flap is then trimmed and placed on the pulmonary surface of the pleura. If pieces of the pulmonary pleura have been removed, agglutination is much easier. It is difficult to remove callous areas in debilitated patients, their weak pulse sometimes preventing the surgeon from finishing the operation in one seance. But whenever possible, a second procedure should be avoided, for a supplementary operation always destroys some of the fruits of the first. Of course, in a case of doubt, we rather sacrifice them for the patient's safety. This kind of decortication is obtained by flat, saw-cutting incisions similar to those employed in preparing microscopic sections. The principle is akin to that of the temporary resec- tion, followed by decortication of the pulmonal pleura, as advised by Fowler and Delorme. But it is practised only as the ne- cessity arises during exploratory section, and then as a sup- plement to the resection of the costal pleura. Ingenious as the idea of methodical decortication is, how- ever, clinical experience shows that it is only in a small series of cases that the lungs expand fully after the pulmonal pleura is mobilized. Therefore nearly always a resection of the chest- wall must be added to decortication of the pulmonal pleura. Garre 1 tried decortication repeatedly, but always with an unsatisfactory result. He also believes that the results of the procedures are entirely due to the interference on the chest-wall. 1 XXVII Kongress der Deutschen Gesellschaft fur Chirurgie, 1898. Exploratory Pneumotomy. i93 Jordan 1 and Krause 2 report similar results from this com- bination. The same principle was obviously applicable to the treat- ment of lung abscess, and therefore the author recommended the exploratory pleurotomy and pneumotomy in cases in which Fig. ioi. — Thoracic Fistula Continuing after Schede's Operation. other methods, especially aspiration, failed. 3 Later, Turner reached the same conclusion. During the after-treatment stress is to be laid upon early 1 "Beitrage zurklin. Chir.," Bd. xxxiv. 2 Ibid., Bd. xxiv, v. 1. 3 See, on the diagnosis and treatment of abscess of the lung, "New York Medical journal," August 28, 1897. 14 194 Intrathoracic Diseases. gymnastics which favor expansion of the lungs. To this end the author recommends dumb-bells and practice on a bugle. If these procedures are not neglected, deformities of [the thoracic side or the spinal column are not observed. As an example the case illustrated by Figs. 101, 102, and 103 may serve. Fig. 102.— Collapse of Chest-wall after Pectoro-axillary Resection. It represents a man of forty years, who was seized with pleuropneumonia four years before the closure of the cavity. Aspiration was tried first; later, the purulent effusion was dis- charged by the incision method. The thickened pleura de- manded repeated rib resections, altogether four thoracotomies being undertaken. Schede's operation was finally performed Failure of Schede's Method. 195 two years later (Fig. 10 1). But, although this was done in the most skilful manner, the cavity did not become obliterated, for the reason that only its lower portion was situated within the extent of the horseshoe flap, while the upper part was not at all touched. And this area represented a large cavity in itself. Fig. 103. — Considerable Shrinking of Left Side after Multiple Rib-resection (Note Straight Attitude). When the author saw the emaciated patient for the first time operative exploration in the upper thoracic region revealed the presence of a large and irregular cavity which extended as far as the first rib anteriorlv and 196 Intrathoracic Diseases. to the second in the dorsal region. The anterior area was exposed first, the fibrous tissue being extensively and atypically removed in order to get better access to the cavity, so that the wound treatment could be done more effectively. The patient improved soon afterward, so that his condition permitted of i 1 Fig. 104. — Late Resui er Anterior Resection of Right Thoracic Wall. a more severe interference. The upper four ribs were then exsected after access was obtained by the pectoro-axillary incision described above. This resulted in considerable col- lapse of the anterior chest-wall, which was gradually followed by the obliteration of that portion of the cavity (Fig. 102). Six months later the removal of the posterior rib portion, together Rib-stumps After Resection. 197 198 Intrathoracic Diseases. with the lower part of the scapula, was undertaken. The cavity then gradually filled up. There is, of course, deformity in proportion to the enormous collapse of the chest- wall. But the patient's attitude is straight, nevertheless (Fig. 103), which is to be attributed to his continuous exercise. A skia- graph taken then showed the anterior aspect of the cavity after the first exploratory operation, and another the rib defect at the posterior aspect. The signs of inflammatory atrophy of Fig. 106. — Synostosis around a Rubber Drainage-tube, Forming a Bony Canal; the Small Osseous Fragments Represent Stalactite-shaped Projections as the Result of Osseous Proliferations. the bones due to the absorption of calcareous matter are recognized as an expression of which the poor contrast between bony and soft tissues must be regarded. Fig. 104 represents a man of thirty-eight years, who suffered from a pyothoracic cavity, treated by simple incision for three years until the masterly hand of Billroth exsected part of the anterior thoracic wall, which was followed by prompt recovery. Although five ribs were sacrificed there is no indication of Osseous Projections an Obstacle. 199 any deformity, the patient having been under the author's ob- servation for fifteen years. The regenerating tendency of the resected ribs is illustrated by the Rontgen rays (Figs. 100, 105, and 108). As illustrated in previous essays, 1 the Rontgen rays also offer splendid means of studying the various stages of bone proliferation after resection. The photographs (Figs. 106 and 107) represent the results of such processes, Fig. 106 showing synostosis around the Fig. 107. — Bony Union between Two Ribs without Channel Formation; after Incision Method. drainage-tube so that a complete bony canal was formed ; and Fig. 107 showing synostosis without channel formation. The small bone fragments of Fig. 106 illustrate the stalactite- shaped formations obtained from old fragments. The skia- graph (Fig. 108) illustrates similar formations two months after resection. The development of these irregular masses deserves close con- sideration. Their shape is apt to injure the pleura, a fact which teaches the necessity of methodical exercise at an early period, 1 See "International Medical Magazine," January, 1897. 200 Intrathoracic Diseases. that is, of forcible inspiration as long as the area in question is soft and yielding; in other words, as long as there is no de- position of calcareous matter in the regenerating bone tissue. Sometimes these irregular bone formations may cause disturbances to such an extent that their removal becomes From Beck's " Rontgen-Ray Diagnosis, 11 copyright, 1904, by D. Appleton and Company. Fig. 108. — Regeneration Process aeter Resection of the Fifth, Sixth, Seventh, and Eighth Ribs, and of a Portion of the Scapula. Two Months after Resection for Old Pyothorax. necessary. Where extensive proliferation is to be anticipated, the periosteum should be removed, therefore, together with the ribs. As to the inflammatory irritation as an inducing factor in this Hydrothorax and Hemothorax. 201 abundant osseous formation, as well as to the inflammatory atrophy causing absorption of calcareous matter and conse- quently translucency of the ribs by the Rontgen rays, the author refers to "The pathologic and therapeutic aspects of the effects of the Rontgen rays," "Medical Record," January 18, 1902. Schede's advice as to the outlining of the skin-flap has been modified by Helferich, Sudeck, and Tietze. In suitable cases these modifications yield good results. But none of them can be utilized as a general method, like the exploratory. HYDROTHORAX. Hydrothorax is always a consequence of a disturbance in the circulatory system, especially in nephritis and cardial insuf- ficiency. In contrast to the effusion produced by an inflam- matory process, this transudate is generally bilateral. The fluid is more opaque than that of the common serothorax, con- tains less albumin, wherefore its specific gravity is smaller than that of an ordinary effusion. In view of its aetiology hydro- thorax cannot be the object of radical surgical interference. If the disturbance caused by mechanical pressure is great, palliative aspiration-treatment is indicated according to the principles described in the section on aspiration. HEMOTHORAX. Haemo thorax is produced by a penetrating trauma injur- ing one of the large blood-vessels or by the pathologic corrosion of a vessel in the pleural cavity ; or it may take place in a tuber- culous cavity, in rib-caries, or in aortic aneurysm. The signs of haemothorax are well marked : extreme anaemia of the skin-surface, collapse, fainting-attacks, frequent pulse, and great weakness being present. The treatment is, as long 202 Intrathoracic Diseases. as the original cause cannot be remedied, only of a palliative character; hypodermatic saline infusions (Fig. 81) or intrave- nous injections being the most potent means. The coagulation of the blood in the chest cavity, however, in exerting pres- sure upon the bleeding surface, is sometimes an efficient factor in arresting the haemorrhage. The respiration, on the other hand, is an irritating moment, wherefore an immobilizing ten- dency should prevail, which is best supported by the adminis- tration of narcotics, like morphine or codeine. Even a slight cough may keep up the haemorrhage, wherefore its prompt suppression by narcotics is most important. After the patient has survived the haemorrhagic shock he is still in great danger on account of the presence of the bloody effusion, which is apt to decompose. This necessitates thorough observation and readiness to interfere as soon as aspiratory puncture proves the presence of pus. Under such circum- stances an irregular fever curve will point to suppuration. CHYLOTHORAX. Chylothorax is produced by an injury of the thoracic duct inside of its course in the thoracic cavity. Such injury takes place in vertebral fractures, an osseous fragment being pushed into the duct, or on account of violent compression of the thorax by heavy machinery. Some of the cases are due to malignant growths in the thoracic cavity, especially to carcinoma of the pleura or the lymph-glands which are situated in the region of the junction of the duct with the left subclavian vein. The diagnosis is made by proving the presence of chyle by explora- tory puncture. Pure chyle has a serum-like appearance and its analysis reveals the presence of sugar. The prognosis hinges on the question whether the natural pressure exerted by the exudate itself is strong enough to stop further leakage. Literature reports a small number of cases Anatomy of the Lungs. 203 which have thus recovered. Immediately after the injury there is no indication for surgical interference, while later aspira- tion of the exudate is in order. THE LUNGS. Anatomical Part. The lungs (pulmones) occupy both sides of the chest as two elastic sponge-like organs of a conical shape. They are sepa- rated by the heart as well as the other mediastinal contents. The concave base of each lung rests on the convexity of the dia- phragm, while its tapering apex is situated in the upper thoracic aperture. The exterior concave surface adapts itself to the lateral thoracic concavity, while the inner depressed surface forms a niche for the heart. Besides there are two borders, the anterior being sharp and thin. It overlaps the anterior surface of the pericardium. The posterior border is round- shaped and broad. It is larger than the former and extends between the diaphragm and the ribs. Another long and deep fissure, which penetrates nearly to the root, divides the lung into two lobes. The right lung, however, is also divided by an additional fissure, which is considerably shorter than the main fissure, by which a small triangular lobe is created (middle lobe). The root of each lung {radix or pedunculus pulmonis) is a pedicle, composed of the undivided portion of the bronchus, the pulmonal artery, and the two pulmonal veins, and in addi- tion the bronchial vessels, which nourish the pulmonal paren- chyma, the bronchus of the anterior and posterior pulmonary plexuses, and a few bronchial lymph-glands. The whole is held together by connective tissue and covered by the pulmonal pleura. As mentioned in connection with the anatomy of the pleura, the pulmonal pleura forms the coat of the lung, which on account 204 Intrathoracic Diseases. of being tightly attached to it, makes its detaching difficult. The whole smooth and shining surface of the normal lung is divided by numerous dark lines into small angular spaces (insulae pulmo- nales) which are the expression of the borders of the pyramidal Pectoralis major muscle Pectoralis minor muscle Superior lobe ^ Serratus magnus muscle Diaphragm Sternun > Ensiform cartilage Fig. 109. — Anterior View oe the Thorax with Chest Wall Removed, Show- ing the Lungs. — (Morris, Modified from Bourgery.) lobes of the lung tissue (pulmonal lobules), each of which repre- sents a separate lung en miniature. It is estimated that the lungs contain about 1800 millions of lobules. The function of this most important viscus is to change the venous blood into arterial during the act of respiration. If Respiratory Motions. 205 filled with blood, the weight of the lungs amounts to about two and one-half pounds in the adult — in women somewhat less. If they do not contain any blood, the specific weight is less than that of water, which explains the transparency of normal lung tissue on the Rontgen plate. Inflamed lung tissue, especially in a state of hepatization, becomes solid and therefore imperme- able by the rays. Lungs, or parts of them, which did breathe, swim on an aqueous surface, a phenomenon which differentiates dead-born children from those which died after birth. During inspiration the lungs become enlarged in proportion to the distention of the thorax, which is produced by the action of the respiratory muscles. The friction produced by the in- haled air at the angles of the bronchial ramifications as well as by the distention of the lobules at their terminus, finds its marked expression in a noise which is perceived during auscul- tation as vesicular breathing. It is an important pathogno- monic factor that this noise is absent in all diseases of the chest which are characterized by the presence of exudates. During expiration the lungs become diminished in size. This is automatically caused by the elasticity of the lungs and the thoracic wall as soon as the inspiratory muscles cease to functionate. The average number of inspirations in a normal adult is sixteen. The anterior margins of the lungs change their posi- tion during the process of inspiration, so that they draw nearer to the pericardium. Thus the heart is somewhat more em- braced, so to say, the consequence of which is a weakening of the heart-sound during that period. The lateral surfaces of the lungs glide along the thoracic wall, the apices somewhat pro- jecting beyond the margin of the first rib, behind the scalenus anticus muscle. The friction caused there may explain the predisposition of this sphere for the development of tuberculosis. 2o6 Intrathoracic Diseases. SURGICAL DISEASES OF THE LUNGS. Abscess op the Lungs. While the propriety of the surgical principle " Ubi pus, ibi evacua!" is nowadays recognized in all parts of the human body that are accessible to the scalpel, there is a feeling of hesitation in regard to pus accumulations in the lungs, although they are by no means of rare occurrence. This timidity in attacking lung abscesses with the surgical knife is apparently caused by the widespread prejudice that they are all of a tuberculous character and could consequently not be cured by simple evacuation. But while there is no doubt that the presence of one tuberculous abscess presupposes the affection of a more or less extensive area of lung tissue, which would certainly be but little influenced through the opening of a single abscess, still there are numerous abscesses of an entirely different character, that is, such as are caused by preceding inflammatory proc- esses, by suppurative bronchitis, bronchiectasis, etc. These being of a non-tuberculous character, they are curable, if treated after true surgical principles. If this fact were fully realized, the medicamentous armamentarium of euthanasia would be given up in many cases of alleged phthisis. As to the pathology of lung-abscesses, it is recommend- able to divide them into acute or chronic or such as are caused by a foreign body. The acute abscesses may be either simple, or of a putrid or gangrenous nature, while the chronic abscesses and bronchiectases may also be either simple or putrid. The diagnosis of lung-abscess is made by the presence of copious purulent expectoration, its admixture of elastic fibres and blood-pigment, the history of a preceding inflammatory process, particularly of pneumonia, which has run no typical course, the physical signs of the presence of a cavity, and the absence of tuberculous manifestations, etc. As to localization, it must be borne in mind that while cavi- Abscess of the Lungs. 207 ties of the apex contain more or less air, those situated farther below show purulent secretion only. If in the latter variety ex- pectoration is copious, so that the cavity becomes evacuated, the respiratory sounds become tympanitic on percussion, and are clearly perceptible on auscultation. If, on the contrary, the cavity is rilled up, there is complete dullness, and the respira- tory sounds are hardly, if at all, audible, pectoral fremitus also being absent. Cavities of recent origin are more easily localized than old cases, not only because the course of the precursory disease furnishes clearer information, but also because the physical symptoms are much more pronounced. Old cavities are, with few exceptions, deeply situated, and can generally be reached below the lower angle of the scapula. Exploratory puncture, while quite reliable in pyothorax, often fails to disclose lung abscess, and has therefore to be replaced by exploratory pleurotomy or pneumotomy. In favor- able cases the abscess is located by the Rontgen method (Fig. no). As to the technic, see section on Rontgen examination of chest, page 249. The treatment is governed by the same principles as those applying to any case of abscess — that is, thorough evacuation and drainage. This can be done only by making a wide open- ing in the chest-wall. To accomplish this, the resection of at least two ribs is required. The technic is as follows: Thorough asepsis is just as necessary as in any other operation and is practised after the principles emphasized in the section on asepsis, page 62. As a rule, the eighth rib is selected first. The skin incision, about rive inches in length, should be made in the centre of the selected area and carried directly down to the periosteum of the rib. The further steps are carried out in accordance with the rules laid down in the description of the performance of rib-resection (see section on pyothorax, page 151). After the costal pleura is incised a large aneurysm needle is introduced 208 Intrathoracic Diseases. through one of the pleural incisions and conducted underneath the costal pleura to the other. With strong silk sutures the tissues, containing fascia, muscles, periosteum, costal pleura, and intercostal arteries, are ligated close to the surface of the Fig. iio. — Skiagraph of Area or Lung-abscess. rib. Then a vertical incision is made through the tissues between the two ligatures, thus creating a wide opening (Fig. 91). By retracting the wound-margins forcibly the skin in- cision can be utilized for the resection of the rib above. If, as it rarely occurs in these cases, adhesions should be absent, the Opening of Abscess by Cautery. 209 lung may collapse, so that it is found impossible to draw it forward, in which event the final incision has to be deferred for a day or more. When the lung moves freely beneath, it is essential to shut off the pleura by packing gauze tampons around the margins in order to prevent infection from the escaping pus. As a rule, this procedure renders suturing of the pleura to the lung unnecessary, as well as the artificial formation of adhesions by the use of caustics. If the abscess is located superficially, infection of the pleural cavity might also be caused by the stitch canals. The further steps must be taken with great care and patience. Should palpation of the pulmonary area have failed to give information, an exploratory needle of moderate size may be slowly pushed into the lung (see Figs. 80 and 82). If neces- sary, this must be repeated at different points. Should the focus not be reached by the needle, the pulmonary pleura must be carefully divided and the thin, slightly red-heated point of a Paquelin cautery thrust into the suspected portion. The author found it advisable to construct a thin director, made of platinum, which fits round the heated platinum tip of the Paquelin cautery, just as a stylet fits to a trocar. After the tip and encircling director have perforated the lung tissue, the tip is withdrawn and the director left in situ to ascertain whether any pus appears at the groove of the director. If so, a small artery forceps is introduced and the opening gently dilated. The great advantage of the Paquelin cautery is its preventing infection, while the exploratory needle is apt to cause it. In those cases where, after exploratory resection, the costal pleura appears to be especially thin, and where at the same time no adhesions are present, the membranes not being immobilized by adhesion-formation, pneumothorax may form as soon as the pleural sac is opened. Then the opening must either be packed quickly or the pleurae sewed together. As to the value of the Sauerbruch cabinet in such cases see above. 210 Intrathoracic Diseases. In one of the author's cases the lung collapsed as soon as the pleura was incised, the patient becoming cyanotic, the res- piration shallow, and the pulse imperceptible. He was virtually given up, but after thorough packing with sterile gauze and the administration of stimulants he rallied. Although it seemed desirable to defer pneumotomy for a few days the condition of the patient was so bad that the opening of a large gangrenous focus was undertaken on the following day. But the patient succumbed to sepsis. The pleural suture should be rather extensive, the under- lying pulmonal tissue to be seized as well as the soft tissues in the wound of the chest-wall. Sometimes the pulmonal tissues are brittle, so that the stitches may tear. To stop up the punc- ture holes Tiegel 1 saturated the silk sutures with iron chlorid, thus utilizing the coagulation of the blood. The same author recommended to place two " scaffold threads" deep in the lung, one on each side of the incision and parallel to the surfaces which were expected to be approximated. These sutures were then passed around these and knotted. Tiegel claims that tearing of the pulmonal tissue, even when brittle, was obviated. After the cavity is exposed, no irrigation or exploration with the finger is advisable, since procedures of this kind might provoke haemorrhage. A narrow strip of iodoform gauze is carefully introduced into the cavity. The whole is then once more thoroughly cleaned, examined, and packed with iodoform gauze, and finally protected by a large piece of moss- board. The dressing need not be changed more frequently than every second or third day, unless there should be signs of retention of pus. It is advisable to tell the patient to blow at intervals with his mouth and nostrils closed, which helps to evacuate the purulent discharge. The patient should get up after a few days if possible. During the early period of the after-treatment small doses of 1 "Zur Technik der Lungennaht," "Munich Medical Weekly," No. 46, 1905. ^Etiology of Gangrene of Lungs. 211 morphine are administered for the purpose of immobilization, especially when cough is present. If the pulse be weak, stro- phantus and caffeine may be added. Nourishment must be given frequently and in small quantities at a time. Anaesthetics should be used only if the pulse be strong enough, which in most cases of lung abscess must be regarded as an exceptional circumstance. Ether being contraindicated in respiratory disturbance, only chloroform can be employed ; and attention needs not be called to the danger to which the use of this paralyzing drug subjects the heart. Since, for a well-trained surgeon, the operation does not take very long, it would be better to use ethyl chloride, or Schleich's infiltration method, and also to administer a morphine in j ection before the operation . If chloro- form is employed, only a few drops should be poured into the mask at a time, and the pulse, the respiration, and the color of the face be carefully watched. If a general anaesthetic be employed at all, which facilitates matters, the author prefers ether in spite of its disadvantages. GANGRENE OF THE LUNGS. Gangrene of the lungs is primarily due to invasion of sapro- phytic bacteria into the lungs. They gain access either by being suspended in foreign bodies of an organic nature, like food particles directly, or by entering later, after the foreign body has settled there. It is self -understood that patients afflicted with inflammatory or ulcerating processes in the mouth, pharynx, or larynx are especially inclined to the aspiration of decomposing elements. The same applies to carcinoma of the tongue, pharynx, larynx, oesophagus, and stomach. Frac- tures of the mandible which are not well immobilized, and where the oral cavity is not kept clean in a most scrupulous manner, may also give the impetus to such a fatal complication. The fact that patients emaciated by one of the precursory 212 Intrathoracic Diseases. affections mentioned, also aged persons and alcoholics, are particularly liable to acquire pulmonal gangrene is one of its most important features. The direct type is the most frequent. The secondary type of pulmonal gangrene is caused by pre-existing affections of the lungs, like fetid bronchitis. If in pneumonia, bronchiectasis, or pulmonal tuberculosis a new putrid infection takes place, gangrene may be caused in an indirect way. To necrotic decubitus, suppurating caries, puerperal processes, and similar conditions gangrene of the lungs may also be due. Pulmonal gangrene is most frequently found in the lower lobe, and especially on the right. Here it may be circum- scribed as well as diffuse. There the pulmonal tissue has changed to a grayish-green mass the odor of which is characteris- tically penetrating. (The author has seen some of his best nurses faint on account of this odor.) It is especially the expectoration of the fetid secretion from such necrotic foci which points to the presence of pulmonal gangrene. The sputum is profuse, the daily amount being from 150 to 500 ex. It contains various types of bacteria. The pathognomonic proof is furnished by the presence of fragments of pulmonal parenchyma. The prognosis of gangrene of the lungs, which was regarded as most unfavorable before the aseptic era, has materially changed for the better. It depends upon the aetiology of the various types, the embolic as well as the bronchiectatic form of gangrene being inauspicious. As long as the process is of a circumscribed nature the chances are naturally more favorable. The mortality of the present time shows 31 per cent, only in cases where radical pneumotomy was performed. This result would be still more favorable would not, in the cases mentioned, a number of aggravating circumstances have coexisted, viz., multiple foci, bilateral gangrene, and association with embolic processes, inflammation, or abscess of the brain. Bronchiectasis. 213 In order to be able to approach the cavity as directly as pos- sible, extensive exploratory resection of the chest-wall should pre- cede its exposure. This is so much more necessary as there are often small cavities grouped around a large one, which are more or less connected with the latter. It is self-understood that they must also be made accessible to direct surgical interference. The best guide for localization is the Rontgen method, see page 225. All necrotic tissue must, of course, be completely removed and the cavity packed with iodoform gauze. Irriga- tion must not be used during the after-treatment, which is vir- tually the same as that of lung-abscess (see page 210). BRONCHIECTASIS. Bronchiectasis is, as a rule, not a disease per se, but a conse- quence of various affections of the lungs or bronchi. From an anatomical point of view a cylindrical and a sacculate form is to be distinguished. (Compare anatomy of the bronchi, page 238) . The cylindrical bronchiectases represent regular dilatations of the bronchial tubes, due to bronchial catarrhs of long dura- tion, as they are found in emphysema, whooping-cough, and sometimes in pulmonal tuberculosis. Atrophy and ulceration of the bronchial walls, caused by the cough attacks, probably give the first impetus. The diagnosis of this form is uncer- tain, copious (500 to 900 c.c. during one cough-attack) and thick muco-purulent sputa, which show a stratified character when standing stagnating in a glass, being the main factors pointing to its existence. In the sacculated type, which confines itself to a limited part of the bronchial area, the dilatation assumes a globular or oval form. The glandular mucous membrane, the muscu- lar fibres, and the elastic elements undergoing complete atrophy, the bronchial wall loses its character entirely, so that the cavity is lined with a thin membrane only. 214 Intrathoracic Diseases. in emphysema cavities of this nature may be surrounded by normal lung-tissue, but in the great majority of cases they are situated in the midst of indurated shrinking pulmonal tissue, which often is due to a preceding pleuritis. The sacculated type is unilateral, as a rule, and its seat of predilection is the lower lobe. In differentiating bronchiectasis from tuberculosis it should be considered that the bronchiectatic patient appears pale and more or less cyanotic, but never cachectic, his panniculus adiposus being abundant, as a rule. As in fetid bronchitis, the ends of the patients' phalanges are club-shaped. As long as there are no complications fever remains absent. Auscultation and percussion do not reveal any essential diagnostic points out- side of proving the presence of a cavity. But the Rontgen method differentiates and localizes the cavity under favorable circumstances (see section on the Rontgen method, page 250). The prognosis of bronchiectasis is less favorable than that of pulmonal gangrene, the percentage of complete recoveries being only thirty, while that of the partial recoveries amounts to the same rate. It is, of course, the type and the extent of the cavity which determines the prognosis. Thus, it can be well appreciated that the large ectasies of the lower lobes give a good prognosis, since they can be easily reached, a resection of one piece of a rib generally giving sufficient access. In the greater majority, however, mobilization of the thoracic wall by multiple rib-resection is preferable. The mortality 7 rate in such cases amounts to 6 per cent. only. This result is un- doubtedly due to early and radical interference. The after-treatment is the same as in lung -abscess (see page 210). ECHINOCOCCUS OF THE LUNGS. As is generally known, echinococcus-disease is produced by the taenia echinococcus, a parasite whose domicile is in the Echinococcus of the Lungs. 215 intestines of the dog, sometimes perhaps also of the cat. Its length is four millimetres. It has four joints, the posterior of which is larger than the remaining three together. The implantation of this parasite causes the formation of hydatids, which grow into cysts and secondary proliferative cysts in various organs of the human body, particularly the liver. The knowledge of the echinococcus disease dates as far back as to the time of Hippocrates, who described a "jecur aqua repletum" which would open into the abdominal cavity. The same author speaks of an operation on an echinococcus cyst, before which operation he advised to produce adhe- sions between abdominal wall and cyst by the use of artificial moxae. The true parasitic origin of the disease, however, was not demonstrated until Goze, in 1782, recognized the characteristic heads and hooklets of the taenia. The echinococcus disease is found in all parts of the world ; yet with the exception of Iceland, some parts of Australia (Victoria and Tasmania), and the vicinity of Irkutsk (Russia), where it is endemic, it is but rarely observed. Especially rare is the echinococcus disease in this country, which explains fully why the American literature on this most interesting subject is so very scant. The predilection of the echinococcus for the liver is quite natural. The vena portae leads it by the shortest and broadest route, just as it carries a pyogenic embolus from an infected focus. The echinococcus is found much less frequently in other organs, as, for instance, in the medulla of bones, the pleurae, the spleen, the intestine, the heart, and still more rarely in the lungs. The literature of echinococcus of the lung is meagre, therefore. The author has observed three cases, two of these being described in "The Journal of the American Medical Association," November 19, 1898. Whether the parasite in the author's cases was originally implanted in the lungs (primary echinococcus of the lung), 216 Intrathoracic Diseases. or invaded indirectly from the pleura or liver by slow perfor- ation, is not fully evident from the previous histories. While in one case the localization of the abscess, which had been incised two years ago, might point to its origination in the liver, the symptoms of an affection of the lungs were predominant from the early beginning of the disease. That well-pro- nounced symptoms were absent for a long period could be explained by the slow growth. In the initial stage frequent cough and bloody expectoration are found, as a rule, while the physical signs are not yet marked. Exploratory aspiration is contraindicated in pulmonal echinococcus, pneumotomy being the proper procedure for diagnostic as well as thera- peutic purposes. The resume of the diagnostic points may be condensed as follows: (i) Whenever the symptoms of a chronic affection of the lungs become apparent, and pneumonia, circumscribed effusions, pyothorax, and infectious diseases (particularly tuber- culosis) are to be excluded, the possible presence of echinococcus should be thought of, especially so when at a later stage there is violent cough and expectoration of blood and pus of a most offensive odor. (2) In those rare cases where the examination of the sputa fails to show the characteristic elements of the parasite, it should be considered that at the early stage of pri- mary echinococcus the lines of dullness are irregular according to the shape of the cysts, and sharply pronounced, while later, when it comes to the formation of an abscess cavity, they are replaced by tympanitic sounds. • Accordingly there is also no abnormal temperature at the beginning, while later the characteristic irregular temperature-curve points to pus reten- tion. (3) Sometimes there is an expansion of the thoracic wall and a dilatation of its veins. If the abscess wall ap- proaches the chest-wall, bulging of the intercostal spaces becomes noticeable. From the author's cases it appears that the diagnosis of Actinomycosis of the Lungs. 217 echinococcus of the lung is usually difficult. Its rarity pre- vents its general and thorough study, but it can fairly be assumed that it is more frequent than is supposed, because on account of its difficult recognition it is often mis- taken for an altogether different disease. With our better means of investigation and our greater zeal, this disease will in the future be more frequently detected, and pneumotomy, the only proper therapy, more often resorted to. As to Rontgen examination, see the section on that method (page 250). As to the technic of the operation, see section on rib resection and on lung abscess (pages 151 and 210). ACTINOMYCOSIS OF THE LUNGS. The ray fungus, actinomyces bo vis s. hominis, was discov- ered by the author's immortal teacher, Bernhard von Langen- beck, in the vertebral abscess of a man, in 1845. The favorite domicile of this peculiar fungus is the maxillae of cattle, in which it causes indurated tumor-like masses, which undergo softening and suppuration. In man the lower jaw is most frequently also the primary focus of the disease, which extends continually into the adjacent tissue and internal organs, like the lungs, the pleurae, the heart, the liver, the kidneys, the intestines, and the brain. The actinomyces can be cultivated on agar by cutting off oxygen, in which event yellowish- white colonies are formed. But if the air has free access, an ochre-colored appearance is obtained. Pure cultures injected into the cavum peritonei of rabbits produce typical actinomycosis. The fungus stains well with the aniline dyes and by the method of Gram. It gains access to the lungs by direct aspiration or by using wheat or fragments of carious teeth as a vehicle. Sometimes it reaches the lungs or the pleura indirectly by transmigrating from an inflamed oesophageal area alongside 218 Intrathoracic Diseases. the spinal column and the thoracic wall and causes destruc- tion and cavity formation. After having invaded the lungs, the actinomyces strives to reach the pulmonal surface and finally infects the pleura. In making its way to the pleura the fungus causes the for- mation of fibrous adhesions. At the same time effusions are found which may be of a serous or a purulent character. Then it will resemble serothorax or pyothorax so much that it is mistaken for any of these conditions in the majority of cases. The diaphragm, pericardium, and mediastinum are generally left free. The infiltration of the thoracic wall may finally soften, thus producing fistulous tracts, from which grayish or yellowish sero-pus, mixed with the characteristic actinomycotic granula, is discharged. Primary actinomycosis of the lungs represents 20 per cent, of all cases. The diagnosis is based upon the presence of the granula. Hodenpyl found that in 18 of 34 cases the microscope made the diagnosis at an early stage. At the incipient stage tuber- culosis may be thought of, which is justified by the presence of dyspnoea, continuous fever, night-sweats, haemoptoe, and the emaciation. But the continuous absence of tubercle bacilli, while the destruction process is extending, shows that there must be an entirely different aetiology. If there be much fibrous infiltration, osteosarcoma of the ribs, the sternum, or scapula may be thought of, temporarily, until the formation of fistulas clears the situation. Even when the granula are absent, the fact that the thorax appears to be swelled on one area and re- tracted on another, the induration of the soft tissues, the physical signs of pleural effusion while the aspiratory needle proves the absence of such, the slow process, the absence of electric fibres and of tubercle bacilli, should point to the peculiar nature of the disease. The prognosis is doubtful. Surgical interference is suc- cessful in the incipient stage only. Literature up to date Pulmonal Tuberculosis. 219 knows only of five complete recoveries. Schlange 1 reports three recoveries. The operation consists in free opening by extensive rib- resection (see section on the technic of rib-resection) and the extirpation of the degenerated tissue, especially the thickened fibrous swards. Lung cavities must be drained (see section on lung abscess). Prevertebral and perioesophageal foci can be reached by the surgical knife under extraordinary circum- stances only. At the lower portions of the oesophagus Ender- len's method for the opening of the mediastinum can be utilized. 2 TUBERCULOSIS OF THE LUNGS. The results of operations performed for this most frequent of all diseases are not very encouraging. Still there is a num- ber of cases in which cures were effected. Surgical interfer- ence should therefore not be condemned, as is frequently done. Of course, it should only be undertaken if there are circum- scribed foci. If there is as large a number of foci as is illus- trated by Fig. in, no chances for an operation are to be thought of. Sonnenburg demonstrated a patient, before the German Surgical Society, who had recovered completely after the extirpation of a tuberculous focus in the lungs. Mur- phy reported 26 temporary cures among 47 patients operated upon in the same manner. Tufher and Lawson published the most encouraging results, but other surgeons were less fortunate. There are three drawbacks regarding the indications for the operation: 1. Its danger. 2. The uncertainty of a detailed diagnosis, although the Rontgen rays give us good chances for localizing the foci. 1 " Zur Prognose der Actinomycose," "Archiv fur klin. Chirurgie," 1892, Bd. xliv, p. 870. 2 Enderlen: "Contribution to the Surgery of the Mediastinum," "Deutsche Zeit- schrift f. Chir.," Bd. lxi. Intrathoracic Diseases. j Operation in Tuberculous Foci. 221 3. The possibility of recovery by non-operative means. In its incipient stage the disease is often cured by medical, that is, by climatic, dietetic, and mechano-therapeutic, means, while in late stages it has generally passed beyond the hope of benefit from operation. The best results are obtained in cases of mixed infection where continuous septic absorption is produced. There the stagnating contents of the cavity are promptly removed by drainage, and if the fever -was due to the absorption it dis- appears after further decomposition is thus prevented. Natur- ally the general condition improves accordingly. A fair result may also be obtained in those types of pulmonal tuberculosis where tissue-necrosis has not yet taken place, or where no such tendency exists. The operation may also be indicated in case of excessive and repeated haemorrhage. The more radical extirpation of a tuberculous focus, as performed by Turner, is extremely dan- gerous; still, once in a while such risky steps are followed by a cure. In one of his cases Turner incised the pleura below the second rib and freed it from the ribs as far as he could, thus virtually establishing a pneumothorax outside of it. After having palpated the indurated focus in the apex, he opened the pleura and pulled the lung tissue forward with a large grasping forceps. Then he resected the whole portion. Drainage was omitted. The patient was shown in excellent condition at the Societe de Chirurgie twelve days after the operation and was reported cured four years afterward. Mobilization of the thoracic wall above the cavity and par- tial decortication of the pleurae is a most important adjunct in the healing process, as it favors diminishing the extent of the cavity by the collapse of its indurated roof, thus also causing relaxation of the overextended tissues, and thereby being re- lieved from the continuous straining due to the respiratory motions. 222 Intrathoracic Diseases. Even the infiltrated tissues situated below the cavity are favorably influenced by extensive resection of the thoracic wall as soon as they become thus immobilized. On an average five to six ribs should be resected, each one of them to the extent of five inches at least. The fric- tion as a predisposing moment for tuberculosis of the apex -Relapse after Extirpation or Larynx and Upper Portion of Trachea for Tuberculosis. (see page 205, final sentence) suggests mobilization of the first rib if there be a focus. This can be done by simple division of the cartilage, the scaleni and subclavian muscle preventing reunion of the fragments. The technic of the operation is practically the same as described in the section on lung abscess (page 210) (see on pyothorax also, page 151), and should always be preceded by Intrathoracic Tumors. 223 the resection of a few ribs. The lung tissue should be invaded by Paquelin's cautery while using the trocar-director advised by the author. Injections of iodoform-glycerin into the cavities have also been tried by the author with an encouraging result in two cases. Where no stagnation of the secretion exists, this mode of treatment should be given a trial. (See section on aspira- tion, page 93.) If tuberculous cavities form secondarily, the chances for operation are very unfavorable. Fig. 112, for instance, illus- trates a case of primary tuberculosis of the larynx treated by extirpation. The patient, a man of thirty-eight years, did well for nine months, during which time he carried a canula, when tuberculous granulations showed in the tracheal canal. At the same time the signs of abscess formation in the lungs appeared, to which the patient finally succumbed. INTRATHORACIC TUMORS. A correct diagnosis of tumors of the lungs is still very difficult, pleural effusions often being mistaken for malignant growths, and vice versa. There are benign growths in the lungs as well as malignant. The benign growths are osteoma, enchondroma, fibroma, and lipoma. They need no consideration from a clinical point of view, since they are not only rare but of such small size, as a rule, that they give rise to no disturbances. Most of them were accidentally detected during autopsy. Dermoid cysts, which should properly be called tera- tomata, generally originate from the mediastinum and invade the lungs. They contain hair, as a rule, are found especially in young individuals, and are characterized by their slow growth. They gradually cause symptoms of compression of the lungs and displacement of the heart. Finally they may cause 224 Intrathoracic Diseases. a protuberance of the ribs. In some cases they perforate into the bronchi, suppuration taking place then. Sometimes a fistulous tract forms at the outer surface of the chest-wall. Under favorable conditions enucleation must be attempted. In most instances the cyst could be removed only partially. Von Eiselsberg 1 succeeded in enucleating large dermoid cysts in their entirety. The malignant growths are either sarcomatous or can- cerous, the latter being found more frequently than the former. Carcinoma of the lungs is generally found in aged persons. It is far more frequent in men than in women. Sometimes' numerous carcinomatous nodules of the size of a walnut are found ; at other times a whole lobe is taken up by the neoplasm. The diagnosis is very rarely possible in the initial stage, the symptoms being vague. There is more or less pain, cough, expectoration, and slight dyspnoea. Later bloody serum may be aspirated from the pleural cavity. Then the symptoms of compression (atelectasis of some pulmonary areas and bronchial stenosis) become predominant, and in the further course of the disease inflammatory symptoms (pneu- monia) may supervene. The physical signs consist in more or less marked dullness. With this a skiagraphic shadow in the plates of the translucent area of the normal lungs must correspond. (See Rontgen method, page 249.) If there is an effusion in the pleura, as- piration in connection with a trocar, which terminates in a flexible hook, sometimes reveals tumorous fragments, the nature of which is recognized by microscopic examination. The sputa contain polymorphous epithelium, which is free from pigment. Its size is different and shows marked contours and a well-defined nucleolus. Lenhartz regards the admixture of large and numerous fatty globules as path- ognomonic. 1 " Zur Therapie der Dermoidcysten des vorderen Mediastinum," " Wiener klinische Wochenschrift," xix, 1903. Sarcoma of the Lungs. 225 The prospects of a surgical operation are unfavorable, even if the diagnosis is exceptionally made at an early stage. Ront- gen treatment should be tried as a palliative measure, hard tubes to be selected for that purpose. (See Rontgen treatment in the final chapter.) Secondary carcinoma caused by metastasis or by continua- tion of a mammary growth is considered in connection with the primary seat (see section on mammary carcinoma). Sarcoma of the lungs is less frequent than carcinoma. The predominating type is that of lymphosarcoma, which is especially found in miners who inhale dust containing arsenic. When the lymphosarcoma originates from the bronchial glands and the peribronchial tissue it forms large nodules. Primary sarcoma of the lung tissues is extremely rare. The clinical symptoms consist especially in the signs of compression of the nerves and dilatation of the veins at the chest-wall. In lymphosarcoma there is very marked stridor caused by the swelling of the bronchial glands. In sarcoma association with pleurisy is more frequently found than is carcinoma. An effusion generally consists of hemorrhagic serum, but may also be purely hemorrhagic. E. Frankel maintains that the presence of very large vacuole- cells, ten to twenty times the size of leucocytes, is pathogno- monic for sarcoma. Metastasis is more frequent in sarcoma. Rapid cachexia and anaemia also point to sarcoma. As far as treatment is concerned, the principles emphasized above on carcinoma also apply. Partial removal of such sarcomatous or chondromatous growths, which originated from the thoracic wall and extended into the lung tissue, proved to be successful in some instances, while no successful removal of primary sarcoma of the lungs is reported as yet. The tumors of the mediastinum resemble those of the 226 Intrathoracic Diseases. lungs. They are either benign (fibroma, cyst, dermoid cyst, and endothoracic struma) or malignant (carcinoma or sar- coma). Their treatment is practically identical with that of the tumors of the lungs. Syphilis of the mediastinum is rare and must be treated after general antiluetic principles. Mediastinals is usually of secondary origin, the inflam- mation of adjacent organs continuing alongside the sheaths of the carotid or jugularis. Sometimes the pre visceral space in front of larynx and trachea, in which abscesses of the thyroid gland, the larynx, and the trachea form, is its source. The same may be said of the retrovisceral space behind pharynx and oesophagus. In favorable cases opening of the abscess cavity is indicated. Galen exposed the mediastinum after trephining the sternum. The mediastinum posticum is best made accessible by removing a transverse process together with that portion of rib which is situated below it. DIAPHRAGM. Surgical diseases of the diaphragm are rare, while con- genital anomalies are fairly frequent, diaphragmatic hernia being observed in many instances. In these cases an open communication between the abdomen and the thoracic cavity exists. The symptoms of this malformation are abdominal in character. If the diaphragm is absent or if the defect be large, the infants are unable to live. Perforation of the diaphragm, due to injury and inflamma- tory processes, will be dealt with in the section on subphrenic abscesses. ANEURYSM OF THE THORACIC AORTA. The symptomatology of thoracic aneurysm belongs to a text-book on internal medicine. As far as differentiation is con- cerned, it should be appreciated that aneurysms may be mistaken Iodide of Potassium in Aneurysm. 227 for tumors and vice versa. The Rontgen method has done much to elucidate diagnostic points which were obscure before its discovery. (See section on thoracic skiagraphy, page 246.) The surgical treatment of thoracic aneurysm has so far confined itself to the ligation of the two branches of the bi- furcation after Brasdor-Wardrop, which of course is a very risky procedure, Winslow, however, and Guinard having reported favorably on it (Fig. 113). As to the route of access, compare Figs. 31, 72, and 78. From a theoretical standpoint it does not appear im- possible to undertake the removal of a small aneurysmatic Fig. 113. — A, Ligature after Brasdor-Wardrop. B, Ligature after Anel. sac, if detected early, and to sew up the wound of the ves- sel. So far, however, nobody has attempted it. A much more reliable method is the injection of gelatine after Lancereaux. The administration of drugs (mercury and iodide of potassium) has also given good results once in a while. The admirable influence of iodide of potassium is illustrated in the following case: An Italian laborer showed a pulsating tumor at the left intraclavicular fossa (Fig. 114). The diagnosis aneurysm of the subclavian artery had been made and ligation advised. In the meanwhile several skiagraphs were taken that showed 228 Intrathoracic Diseases. the presence of aortic aneurysm, the supraclavicular tumor being only a portion of it. Shortly after iodide of potassium was_ administered the supraclavicular tumor disappeared entirely (Fig. 115). The size of the aneurysm had considerably *m- Fig. 114. — Supraclavicular -Projection of Aortic Aneurysm. decreased, as was shown by the skiagraph (Fig. 116). In har- mony with the anatomic diagnosis is the excellent condition of the patient, who has now been under observation for six years. It should be borne in mind that the fluoroscope shows the normal aorta in the left mediastinum at the first intercostal Rontgen Method in Aneurysma Aortae. 229 space. A sac-like bulging of the arch, showing considerable pulsation above this space, points to the presence of aortic aneurysm. Vehement pulsation, if there is no sac-like bulging, indicates aortic insufficiency. Fig. 115. — Supraclavicular Region After Disappearance of Aneurysmatic Tumor Illustrated in Fig. 114. In a most extraordinary case of aortic aneurysm, illus- trated by Fig. 117, it was possible to demonstrate not only com- plete atrophy of the sternum down to the xiphoid process, and of the sternal portions of the clavicle, but also the over- lapping of the heart over the parasternal line and downward 230 Intrathoracic Diseases. From Beck's " R5ntgen-Ray Diagnosis, 1 ' copyright, 1904, by D. Appleton and Company. Fig. 116. — Aortic Aneurysm, Illustrated by Figs. 114 and 115, Showing Im- provement AFTER THE ADMINISTRATION OF IODIDE OF POTASSIUM. Early Signs of Aortic Aneurysm. 231 displacement of its apex. The patient, an architect, aged thirty-nine years, German by birth, single, gave the fol- lowing family history: Father died suddenly when sixty- five years of age; mother also died suddenly when sixty. His only brother died of typhoid fever at twelve. There were no sisters. 2 3 2 Intrathoracic Diseases. The patient denied lues, and the examination did not contra- dict his statement. Gout and chronic nephritis, as well as any erotic excesses, were to be excluded. He was always well until five years ago ; then, after lifting an excessively heavy weight, he noticed a small protuberance on the left side of his neck; Fig. 118. — Aortic Aneurysm Causing Disappearance or the Sternum and oe the Sternal Portions of the Clavicle. (Compare Fig. 117.) this grew constantly, invading at last the whole anterior surface of the neck and the upper portion of the chest. It is highly probable that the exertion in lifting caused an enormous increase in the circulatory pressure, followed by an over- extension, and probably a laceration of the tunica intima and media. Late Signs in Aortic Aneurysm. 233 Shortly after this he was admitted to a hospital, where he was treated for torticollis, as he states, for five weeks. During that period slight dysphagia and hoarseness had been present. He recovered again so far as to regard himself as well for an entire year. Then a " severe attack of malaria " induced him to seek hospital treatment again. At that time the tumor had not exceeded the size of a large apple. The hoarseness was considerable then. After having improved again he left the hospital, and for eighteen months after had been under medical treatment with great temporary success. Then he began to suffer from slight dizziness, with constric- tion of the throat and chest, slight dysphagia and hoarseness also recurring. On October 31, 1898, when the patient entered St. Mark's Hospital, the author saw him for the first time. The tumor had reached an enormous size then, extending over the sternum, the sternal portions of the clavicles, and the whole anterior surface of the neck, the diameter of the latter portion being 7! inches. The constant pressure of the tumor had caused complete atrophy of the adjoining osseous structures, so that no visible trace was left of the sternum or of the ster- nal portions of the clavicles. The examination of the heart both by percussion and by the Rontgen method revealed hypertrophy of the left ven- tricle. The apex-beat was felt in the sixth intercostal space an inch beyond the mammillary line. Above the jugulum and in the right parasternal line a diastolic as well as a systolic murmur were noticed, the latter being more distinct at the systole. On placing the hand gently on the tumor vibration could be felt. The lungs were normal. No cough was present. Some- times, especially after any muscular exertion, there was dyspnoea. The respiration was 20 to the minute, the pulse 78, the temperature oscillated between 97 and 98 F. The 234 Intrathoracic Diseases. pulse of the right radial artery was weaker than that of the left, and lagged behind it appreciably. There were no signs of arteriosclerosis. The voice was clear and its resonance simply remarkable, the previously existing hoarseness un- doubtedly having been due to pressure paralysis of the recur- Fig. -Incipient Stage oe Sternal Atrophy due to Aortic Aneurysm. rent nerve. The dysphagia, caused by pressure upon the oesophagus, was very moderate on admission. The subjective disturbances of the patient were then insignificant. He had a fine appetite and attended to his business for the preceding four weeks. Surprising Euphoria in Aortic Aneurysm. 235 The pulsation was unusually moderate in comparison to the large size and hardness of the tumor, a circumstance which pointed to the presence of abundant coagulation. It must also be assumed that the aortic wall formed by adven- titia and the abundant proliferation of connective tissue had Fig. 120.- -Advanced Stage of Pressure-atrophy of Sternum and Third to Fifth Ribs due to Aortic Aneurysm. become so much fortified that the blood could discharge again from the subadventitial sac in the peripheral portion to the proper vascular channel. To these fortunate circumstances, the coagulation as well as the patency of the vascular channel, the surprising euphoria was attributed. 236 Intrathoracic Diseases. As mentioned above, the skiagraph (Fig. 117) showed com- plete atrophy of the sternum down to the xiphoid process, and of the sternal portions of the clavicles. The heart overlaps the parasternal line, and its apex shows a slight displacement downward. Its oval shape is distinctly recognizable, and is well demarcated from the aneurysm, the intrathoracic extent of which is enormous. Thus it can be seen that often more reliable information as to type, shape, and size of intrathoracic tumors can be obtained by skiagraphy than by percussion. There can be no doubt that the Rontgen rays enable us to recognize aneu- rysms at their earlier stages, so that frequently a series of prophylactic measures can be taken which may counteract any further aneurysm formation. The therapy being under perfect control, it can be ascertained whether under treat- ment either improvement, arrest, or still further expansion may take place. The patient was subjected to Barwell's diet and to gelatine injections after the manner of Lancereaux for two months. The injections were well borne, except on one occasion, when a slight rise of temperature followed and persisted for three days. During that period the patient's general condition was considerably affected. There could be no doubt, however, that the tumor decreased in size; the hoarseness disappearing entirely, and the subjective condition of the patient being much improved. In July, 1899, the patient died after three days of an acute attack of pneumonia. The autopsy showed no rupture of the enormous sac, but suppuration of the bronchial glands, prob- ably caused by the gelatine injections. The specimen ob- tained at the autopsy proved the correctness of skiagraphic representation. The gelatine is prepared by dissolving 2 grammes of white gelatine in 100 grammes of hot water, to which \ gramme of com- Texture of Trachea. 237 mon salt is added. This solution is sterilized in a kettle by ex- posing it to full steam for fifteen minutes. Before use it is to be warmed in water which has a temperature of ioo° F. Under thorough aseptic precautions the whole amount is injected below the integument near the aneurysm. The injections are repeated every second day; at least 12 are required. The patient must remain in bed while under treatment. Fig. 119 shows the incipient stage of atrophy of the sternum due to aortic aneurysm in a man of sixty-two years. Temporary relief was caused in his case by gelatine injections. Fig. 120 illustrates a more advanced condition, the third, fourth, and fifth rib becoming atrophied by the pressure exerted through a large aortic aneurysm. The sternum had almost entirely disappeared. This patient refused to submit to the injection treatment, because his subjective condition was surprisingly good. ANATOMY OF TRACHEA AND BRONCHI. The trachea (aspera arteria, rpa^u aprrjpia, " rough wind- pipe") (Fig. 121) is virtually the cartilaginous and cylin- drical continuation of the larynx, as the oesophagus is the con- tinuation of the pharynx. It is a stiff and resistant tube, whose posterior surface is soft and flattened, and has the oesophagus behind it. The softness and resistance of the posterior aspect of the trachea are dictated by the fact that during the act of swallowing the oesophagus is distended by the bolus, which necessitates the yielding of the wall in front of it. The trachea measures from ten to twelve centimetres in length and tw r o and a half centimetres in width. It extends from the lower border of the fifth vertebra. In descending vertically down to the thorax it is covered by the deep fascia colli, the thyroid gland, and below this by the lower thyroid veins. Behind the incisura semilunaris sterni it descends to the third thoracic vertebra, where 2 3 8 Intrathoracic Diseases. it is divided (bifurcation) into two divergent branches, called the bronchi, each one entering one lung. The right bronchus is shorter and wider than the left and also more transverse. Each bronchus is divided into as many branches as there are lobes, viz., two on the left and three on the right side. In order to be protected against any compression from without First ring of trachea Right pulmonary artery \pl// Position of thyroid isthmus Level of sternum Last ring of trachea Left pulmonary artery Left bronchus Fig. 121. — Anterior View of the Larynx, with the Trachea and Bronchi.- (Morris, after Bourgery.) the trachea is stiffened by a series of imperfect cartilaginous rings of the hyaline type. They are sixteen to twenty in number, are embedded in a fibro-elastic membrane, and connected by unstriped muscular fibres only at their posterior surface. In other words, there is a defect behind, the rings being open there and having the appearance of a c, the open part of this letter Foreign Bodies. 239 corresponding to the posterior wall of the ring. The shape and width of the trachea and bronchi are dependent upon those of the cartilages, which are connected in a continuous series by a fibrous membrane, that permits of extension and shorten- ing of the tracheal tube. The interior of the trachea is lined with columnar ciliated epithelium and elastic fibres. Where the cartilaginous substance is absent lymphoid tissue is found. The bronchi show the same structure, the left bronchus con- taining nine to twelve cartilaginous rings, while the right has only six to eight. FOREIGN BODIES IN THE RESPIRATORY PASSAGES. Literature on this subject has increased considerably and the statistics of operations show much improvement. The greatest impetus was given by the Rontgen method, which brought new light into this formerly unpromising field. As to general symptoms and treatment of foreign bodies, which enter the thoracic cavity through the chest- wall, the author refers to the section on penetrating wounds of the chest, page 83. The foreign bodies, which enter the bronchi, especially the right bronchus, by the natural passages, are bullets, coins, bodies of irregular shape (fragments of glass or bone), beans, grains of corn, melon-seeds, coffee-beans, etc. The greater width of the right bronchus causes a stronger current of air to the right lung, which explains the fact that in the far greater majority of cases the right bronchus becomes the seat of a foreign body. The symptoms depend upon the size and shape of the foreign body to a large extent. Irregular bodies will soon be anchored, while globular ones obstruct the bronchus, so that there is no access of air to it. Whether the body moves or not will also have an influence upon the character of the symp- toms. 240 Intrathoracic Diseases. The early symptoms of a foreign body in the bronchi are : More or less local pain and diminution or even disappearance of the breathing sounds at the area concerned. Dullness on percussion may not appear at first, but will manifest itself as soon as there is infiltration and atelectasis. Vocal fremitus is nearly absent. The sputa show bloody streaks. Sometimes when erosion of a vessel has taken place there may be hae- moptysis. More or less dyspnoea is always present. If the foreign body moves, violent attacks of cough are observed. There is a sensation of suffocation then, which is accompanied by nausea or vomiting and sometimes even by temporary un- consciousness. In many instances these symptoms may not become marked in the beginning, so that if the anamnesis is not reliable, doubts as to the correctness of the diagnosis may arise. These doubts can at once be removed by resorting to the aid of the Rontgen method, and it is in fact a crime to endeavor to ascer- tain the fact by further expectant procrastination, which means nothing less than death for the unfortunate patient. Foreign bodies always cause grave symptoms sooner or later, and they should therefore be extracted at the earliest possible moment. So far there is only one case known in literature, in which the aspirated fragment of a broken tracheal canula became encysted, after having caused severe symptoms for two months (Blumenthal). According to Hoffmann, 1 a foreign body should be thought of, when there is: (i) Circumscribed broncho-pneumonia and bronchiectasis in the right lower lobe; (2) when there are signs of abscess-formation without apparent cause; (3) when aged people present signs of peculiar somnolence, while the respir- atory tract shows symptoms of disturbance. Reports show that many times there are grave symptoms in the beginning, which disappear again, until years afterwards gangrene or ^othnagel's "Special Pathology and Therapy." Symptoms of Foreign Bodies. 241 lung abscess begins to form. (See respective sections, pages 206 and 211.) The author observed cases in which a healthy man, while at dinner, suddenly became cyanotic, struggled with his arms and fell on the floor, where he remained unconscious for less than a minute, then rallying so much that the intense shock was soon forgotten. There a fish-bone had passed the glottis and obstructed the larynx for a moment, until it moved further down into a bronchus, which brought temporary relief. He also observed the case of a man, who was treated by a laryngologist for several months, without manifesting any alarming symptoms, although a large fragment of a tracheotomy canula was in the bronchus, from which it was expectorated, while the author introduced the bronchoscope. How misleading the symptoms often are, is illustrated by the author's report on foreign bodies in the oesophagus and trachea in the "New Yorker medizinische Wochenschrift,' , April, 1892. As mentioned before, the treatment is either bloodless or operative. The bloodless methods are: Administration of emetics, preferably by subcutaneous injections of the muriate of apo- morphine, special positions and manipulations, or extraction of the foreign body under the guidance of the bronchoscope. The operative methods are: Inferior tracheotomy, intra- thoracic tracheotomy above the bifurcation, bronchotomy from the posterior mediastinum, and pneumo-bronchotomy. As to special positions, it may be said that an effort can be made to dislodge the body by strapping the patient, especially if he be an adult, to a swinging platform, tilted head downwards. The head, may reach the floor. Forced expiration should , be advised, while inspiration must be done slowly and super- ficially. These procedures have a chance of success, as long as the foreign body is still movable. 17 242 Intrathoracic Diseases. The bronchoscope was introduced into practice especially by the untiring efforts of Killian, and has proved to be of great value. In a number of cases fragments of bones, fish-bones, buttons, beans, etc., were removed under its guidance, without resorting to tracheotomy. Of course, the process must always be preceded by skiagraphic localization. The technic of this Fig. 122.— Bronchoscopy, after Killian. new method is rather difficult and should be practised by an expert only (Figs. 122 and 123). When the bloodless methods fail inferior tracheotomy must be performed without delay. If the foreign body was movable the chances are that it is ejected as soon as the trachea is opened. When the foreign body has become anchored, it must be Intrathoracic Tracheotomy. 243 loosened by the aid of suitable forceps under the control of the bronchoscope, which is to be introduced through the tracheal wound (see Fig. 122). When it is found that the foreign body cannot be extracted by these manipulations, access must be gained by intrathoracic tracheotomy or thoracotomy. Intrathoracic tracheotomy is performed by exposing the trachea as far down as to the Fig. 123. — Instruments for Extracting Foreign Bodies from the Bronchi. a, Toothed catcher, b, Blunt catcher, c, Foreign body and catcher in the bronchus. crossing of the innominate vein. This is best done by ex- tending the tracheotomy-wound down to the ensiform process and dividing the sternum by a saw in the median line after the vein is pushed aside. Then the trachea is seized with a strong holding forceps and pulled upward so that the bifurcation is made accessible. This procedure is very risky, however, and always followed by grave mediastinitis. Thoracotomy is far more preferable. After the foreign 244 Intrathoracic Diseases. body is localized by the Rontgen method three rib-portions are resected above the area after the exploratory principle (see page 188). The further procedures are done according to the rules described in the operation for abscess of the lung (page 207). If great haste is not required some prefer to pro- duce pleural adhesions first by the application of a paste of chloride of zinc. For further proceeding into the lung-tissue Paquelin's cautery should be given preference. Sometimes the foreign body is felt by introducing an aspiratory needle, slight manipulations sufficing to dislodge it, so that a cough-attack is apt to expectorate it. In the case of procrastination it is less the foreign body which troubles the surgeon, than its consequences, viz., bron- chiectasis, abscess, or gangrene (see page 211). Compression of the trachea is often the result of foreign bodies in the oesophagus (see above), the direct consequences being dyspnoea, which would necessitate tracheotomy as long as the efforts of extraction are unsuccessful at the time. Septic bronchitis, pneumonia, and pleuritis may be responsible for the fatal outcome in an indirect way. Sharp bodies may produce perforation of the trachea and haemorrhage from an injured vessel. Fig. 124 shows the skiagraph of a child of two years who swallowed a 5-cent piece six days before. Rontgen examination was resorted to, the child not having shown any grave symp- toms during the first few days. On the fifth day respiratory dis- turbances were noted. When the author saw the child six days after the accident he could locate the coin at the level of the first rib. Extensive broncho-pneumonia had supervened in the mean- while. The frequent respiratory movements made it very difficult to obtain a good skiagraph. In spite of the great rest- lessness of the patient an exposure of twenty seconds sufficed to produce a distinct representation of the coin. The plate also shows the ramifications of the bronchi. The extraction of the coin was done too late and the child succumbed to pneumonia. This is the regular course of such cases if their nature is recognized too late. Nowadays there is no excuse for such unusual procrastination. Extraction of Coins. 245 CHAPTER IV. THE VALUE OF THE RONTGEN METHOD IN THORACIC SURGERY. In the diagnosis of the diseases of the chest the screen displays its main virtues, since it permits of the observation of organs while they are in continuous motion. The number, rhythm, and shape of the various motions can be distinctly studied. The chest may be fluoroscoped while the patient is standing or seated on a chair provided with a low back. As a rule, soft tubes should be used for thoracic examination, the harder variety being preferred for the representation of dense foreign bodies only. The dorsal vertebrae, the ribs, the clavicle, their injuries, diseases, and malformations (supernumerary ribs), can be seen. The heart, the lungs, the pleura, and the dia- phragm can be studied thoroughly. Foreign bodies in the tho- racic cavity are easily recognized, and most diseases of the thoracic cavity, as, for instance, enlargement or displacement of the heart and effusion in the pericardium, as well as aneurysm and the various kinds of mediastinal tumors, can be studied. Pneumonic solidification, phthisical foci, cavities, abscesses, tumors, bronchiectasis, emphysema, and retractions of the lungs can be recognized by fluoroscopy as well as by ski- agraphy. Effusions in the pleural cavity, also fibrous swards of the pleura and irregularities of the excursions of the dia- phragm, are noted. For skiagraphing the patient an even table of strong construction or the carpeted floor is selected. Posterior 246 Thoracic Skiagraphy. 247 irradiation is done in the dorsal position, the spinal column, as well as the posterior portions of the ribs, with their heads, necks, and tubercles, becoming apparent, especially at their right side. The direction of the posterior ribs is downward, while that of the anterior is upward. The image of the anterior aspect of the ribs is naturally diffused on account of the much greater distance from the plate. Soft tubes show the ribs best, the time of exposure not to exceed two minutes, if a Wehnelt interrupter is used. In skiagraphing anteriorly by posterior irradiation, the patient lying on his abdomen, the clavicle, the sternum, and the adjoining ribs can be well defined. The distinctness of the skiagraph suffers, however, on account of the patient's oppressed respiration. In view of the distance it seems natural that the spinal column and the posterior ribs appear diffused. The heart being situated so near the anterior chest-wall, shows a well-marked outline. The shadow of the large blood- vessels is less distinct. The shadows of the normal lungs, especially the middle portions, are extremely light. The upper dorsal vertebrae, as far as they are not obstructed by the shadows of the heart and the large vessels, show fairly well. The same applies to the three left dorsal vertebrae. The other portions of the spinal column appear indistinct within their extent of the thorax. Abscesses can sometimes be recognized in this region by using the diaphragm. The outlines appear more marked in oblique projection, but there the skiagraph becomes considerably distorted. The sternum is best represented by a short exposure. For this purpose a hard tube must be chosen, the patient being requested to hold his breath for fifteen to twenty seconds. The sterno-clavicular junction shows well. The presence of tumors, osseous diseases, capillary gummata, etc., must be recognized. For comparison the normal anatomic relations of the thorax should always be kept in mind (Fig. 1 25). 248 Rontgen Method in Thoracic Surgery. Mm slenwhijoidet sternothyrcoid Trachea, 61 t/iyreotda A carot dext ■vMBm tig teres - —\ — Flex coU sin. m- -; Stomach From Beck's " R6ntgen-Ray Diagnosis," copyright, 1904, by D. Appleton and Company. Fig. 125. — Normal Anatomical Relations of Thoracic Organs. Physical and Rontgen Method. 249 In regard to the study of the diseases of the lungs it may be maintained that whoever does not master the principles of auscultation and percussion is not fit to comprehend the fluoroscopic or skiagraphic signs. There are conditions in these organs that can be better elicited by the so-called physical methods, and others that can be ascertained only by means of the Rontgen rays. While the rays show small tumors or infiltrated foci which, on account of their central location, can- not be diagnosticated by the physical methods, they have the disadvantage of always showing the thoracic image in toto — that is, they represent all the shadows of the tissue situated before as well as behind the diseased area at the same time. At the early stage of tuberculosis of the lungs valuable information can be derived from irradiation. Williams found the diaphragm abnormally high at the affected side in inci- pient tuberculosis on fluoroscopic examination. Solidification and atelectasis, as well as exudation and calcification, can be well demonstrated. The infiltrated walls of cavities are recognized as more or less distinct shadows surrounding a light area. The true nature of the various shadows is often better understood, if, after previous skia- graphic representation, the thorax is also fluoroscoped in different positions. In that case we see the area, which causes bronchial breathing, so to say, instead of auscultating it. Fig. in, for instance, represents extensive tuberculous foci in the right lung of a woman of thirty-five years. The large number of the foci and their partial confluence point to an advanced stage. Clinical observation corroborated this as- sumption. The sharply outlined obscure foci are of an older date, while the light shadows surrounded by foggy contours indicate recent destruction. Localization of abscess, bronchiectatic cavity, echino- coccus, and gangrene of the lungs can always be obtained by the Rontgen method. While it may well be appreciated that 250 Rontgen Method in Thoracic Surgery. the uncertainty of the physical method has in former years pro- duced a pardonable timidity on the part of the surgeon, nowa- days there is no more excuse for such procrastination. To study relations the screen offers the best chances, as it gives information about the mobility of the diaphragm and the degree of expansion. Thus during deep inspiration it may be ascertained whether the dark shadow of a focus approaches the thoracic wall or is more centrally located, an area of normal lung-tissue being between them. The size of the foci can be estimated best by stereoscopic exposures, while the photographic plate in proportion to the different projections gives different sizes. Such points are of great importance in all thoracic diseases except in pulmonal cavities, which must be approached by the surgical knife. There it is the question of localization only which is of importance. Consequently the representation of the focus on the skiagraphic plate is the leading factor. Even if the shadow of the focus is so situated that in the ventral as well as in the dorsal position it is overshadowed by the shadow of the heart, we are able by oblique irradiation to represent it. The tissue defects appear as light areas, with which the surrounding cavity walls contrast as dark shadows of an irregular circular or elliptic shape. It is evident, therefore, that the focus is not representable as such, but that it is recognized by its walls, in other words, by the area of pneumonic infiltration around it. This infiltrated sphere is less translucent and its outlines define the greater or lesser shadow in accordance with the greater or lesser degree of infiltration. Of course, if gangrenous frag- ments are situated in the cavity as loose sequestra, they also cast a dark shadow on the plate, but then they are recognized as such inside of the focus. The difference of the projection is determined by comparing the size of the focus in the ventral as well as in the dorsal position. Thus it is recognized whether the focus is nearer the dorsum Coin in Pulmonal Cavity. 251 or the anterior chest- wall. If the shadow shows in the ab- From Beck's "Rontgen-Ray Diagnosis, 11 copyright, 1904, by D. Appleton and Company. Fig. 126. — Introduction of Foreign Body (Coin) into Pulmonal Pus Cavity. dominal position as well as it does in the dorsal, it must be centrally located. 252 Rontgen Method in Thoracic Surgery. In gangrene the gradual clearing up of the formerly solid- ified area can be observed. Similar views apply to echino- coccus. 1 For describing the modus operandi Fig. 120, which illustrates the case of a man of thirty-five years who was stabbed in the back, may serve. Little reaction following at the time, an in- jury of the lungs was not thought of until, three days later, chills, haemoptysis, and pleuritic symptoms announced the develop- ment of pleuropneumonia. Later a purulent effusion was dis- charged by simple thoracotomy. The suppuration continuing, resection of a rib was performed a few months later. The patient improved then, but recovery did not take place. Three years after the injury, when the author examined the patient for the first time, moderate dyspncea, diminished bronchial breathing, and rhonchi were observed. Elastic fibres were also found. The injection of liquids into the fistulous tract produced violent attacks of coughing. A few minutes after the introduction of a strip of iodoform gauze the patient noted a decided taste of iodoform in his mouth. Fluoroscopic examination showed the whole side, with the exception of the upper lobe, slightly veiled and the excursions of the diaphragm somewhat restrained. Below the scapula the indefinite outlines of a shadow of the size of a silver dollar could be perceived. By skiagraphic exposure an irregular focus of the same size was recognized on a level with the eighth rib. The outlines of the shadow appearing more marked in the dorsal than in the ventral position, the focus was supposed to be nearer to the dorsum. Therefore the seventh rib was resected first below the scapula, access being gained gradually to the pleura by the exploratory method. The margins of the pleural canal showed themselves considerably hypertrophied in some por- 1 See " Echinococcus of the Lungs," " Journal of the American Medical Associ- ation," November 19, 1898. Diaphragm in Hypertrophied Pleurae. 253 tions, which explained the cloudiness of the skiagram. The diameter of some of the swards amounted to an inch. After these fibrous areas were removed, access was gained to a pul- monary cavity the extent of a hen's egg. The granulations which lined it were removed and a loose packing with iodoform gauze used. Fig. 127. — Strip of Iodoform Gauze in Gangrenous Focus. A probe introduced into the cavity showed a depth of 10 centimetres. The question of localization could be well studied in this case by introducing a penny, enveloped in gauze, into the cavity and then attaching lead-letters outside 254 Rontgen Method in Thoracic Surgery. of the thorax by adhesive plaster. Thus the point of conver- gence of two lines can be constructed. The skiagraph taken a week after operation shows penny and probe and the various shadow tints — viz., the very light centre indicating the abscess cavity and the slightly darker outlines of the upper portion of its wall. The lower margin is over- shadowed by the fragment of the eighth rib. At a slight dis- tance from the abscess wall the dark margins of the remainder of the thickened pleura can be recognized. Another skiagraph, taken three months afterward, proves the whole sphere con- siderably cleared up, this fact harmonizing with the splendid condition of the patient. In cases of old standing, where the pleurae became thickened, and particularly where pyothorax was one of the complications, the rib-resection should be most extensive not only in order to permit of thorough inspection but also to favor collapse of the chest-wall. It is advisable in such cases to remove the peri- osteum almost entirely to avoid reformation of osseous tissue, which, while desirable under ordinary circumstances, would prevent thorough agglutination in this peculiar instance. If a portion of the surrounding tissue has undergone such changes that its restoration becomes doubtful, it may be compressed by an elastic ligature, after being mobilized, and removed a few days thereafter. The question whether there is only one focus is also deter- mined by the skiagram. In order to get more detailed in- formation it is necessary, therefore, to use the tubular dia- phragm after a general view of the lungs is obtained. That area which shows the shadow on the large plate is marked and exposed through the diaphragm. By this procedure an ap- parently diffuse process proves to be a conglomeration of a few gangrenous foci, generally a larger one surrounded by two or three smaller ones. Even if the focus is overshadowed by a rib, the border of the focus will at least be shown if the diaphragm Recognition of Small Foci. 255 be used. The same applies to the old cases in which the thickened pleura veils the foci. In previous years the presence of additional foci was assumed as soon as after the opening of one focus the symptoms of re- tention persisted, while the Rontgen method enables us now to A B Fig. 128. A, Ordinary skiagraph showing thickened pulmonal pleura veiling the abscess (al- though the sixth, seventh, and eighth ribs, together with the costal pleura under- neath, were removed). B, View of the field of operation immediately after interference (moss-board ready for covering the wound). recognize their presence at the time of the operation. And if the presence of an additional focus was overlooked the cavity is made more conspicuous on the skiagraphic plate if it is filled with iodoform gauze (see Fig. 127). There the extent 256 Rontgen Method in Thoracic Surgery. of the drained cavity appears in contrast to the area which had not been reached. It is self-evident that its relation to the accessible cavity also serves as a guide for the direction of our further procedures. Repeated skiagraphic examination will thus be a reliable control of the further course. In regard to the treatment of gangrenous foci it may be added, that if a general anaesthetic can be employed at all, which naturally facilitates matters, the author prefers ether, in spite of its disadvantages. In one of the author's delayed cases of pulmonal gangrene the condition of the patient became so grave after rib- resection that the operation was interrupted before the focus could be reached. The patient was resuscitated and the cavity opened on the following day. The patient, a man of forty years, made a good recovery. This modus operandi is recommended in all cases of that kind. The clinical aspects of that type of gangrene of the lung in which the process of necrotic destruction is associated with abundant pus-formation are very much like that of pulmonal abscess. Since the treatment is practically the same, the differ- ence is only of statistical importance. It seems that this com- bination-type is the most frequent. Where perforation of a focus into the pleural sac took place, the symptoms of pyo- thorax prevailed, of course. In such cases a fistula is gener- ally found, which serves as a guide to the cavity. The author knows of no contraindications in gangrene of the lungs because there is no possibility of recovering by any other than operative means. As soon as the diagnosis is made, the focus should be exposed and drained. Pleura. — Pleuritic effusions show a marked opacity through the fluoroscope. The larger the amount of effusion, the greater the degree of opacity. In pyo thorax the opacity is somewhat less complete than in serothorax. Rontgen Method in Pleuritic Effusions. 257 Especially on the right side the outlines of the liver show a marked contrast to the lower boundary-line of the effusion. The inner boundary-line of the effusion generally appears convex, but if the patient inspires deeply, or if he coughs Fig. 129. — Small Gangrenous Focus, shown Below the Eighth Rib by the Diaphragm. Before resection the focus covered by the eighth rib was not recognized on an ordinary skiagram, while with the aid of the diaphragm the outlines were indicated. violently, it loses its convexity and becomes horizontal. By changing the position of the patient, of course displacements of the effusions are observed accordingly. Uniform trans- parency above the effusion points to the result of a simple 258 Rontgen Method in Thoracic Surgery. inflammatory process, while constant opacities of an irregular appearance justify a suspicion of a beginning tuberculosis. As a rule, it is found that the area of dullness corresponds to the area of shadow. Pyothorax. — The diseased tissues in pyothorax show a greater density than those of the lungs. The diaphragm appears to be depressed. The extent of a pyothoracic cavity can be recognized by filling it with iodoform glycerin or with a solution of iodide of potassium. Water will also produce a shadow. The subnitrate of bismuth, which is not permeable by the rays, furnishes a still more marked contrast; but as it interferes with the treatment, its use cannot be recommended for this special purpose. The screen also shows the degree of expan- sibility of the compressed lung. The rays prove, furthermore, that, after subperiosteal resection of a rib, the exsected portion is always more or less reformed (Fig. 100) . Hydropneumothorax shows the very dark outlines of the exudation in contrast to the light shadow of that intratho- racic area which contains air. The dark boundary-lines of the exudation can be recognized by the screen as an ascending and descending line during the respiratory movements. Heart. — The patient may be examined in the sitting as well as in the recumbent posture. The tube should be as near to the thorax as possible, but it must not be overlooked that the size of the shadow of the heart is exaggerated. For proper interpretation the distance of the tube must therefore be noted, especially if tracing is done for later comparison. The importance of recognizing an enlargement of the heart is evident. Our physical methods are so highly developed that the diagnosis of an enlargement will seldom be difficult with their aid. In some instances, however, comparison can be made with a higher degree of mathematical exactness by the Rontgen method than percussion would permit. So, Dextrocardia. 259 for instance, Schott (Nauheim) could demonstrate by the rays that the hearts of bicyclists were temporarily enlarged after a great exertion. Our knowledge as to the effects of valvular lesions, as to fatty degeneration, aneurysm, sclerosis, pericardial adhesions, etc., was very much increased by fluoroscopic examination. The movements of the heart can be thoroughly studied, its regular contractions especially being easily observed. For exact measuring, the various stages of respiratory movements must be carefully noted, so that no errors occur when com- parison is made with later results. The pulsations are most marked during the stage of expiration. The observations of Williams and Benedikt proved that some physiological errors in regard to the mode of contraction of the heart existed. That the heart does not empty itself com- pletely at each systole becomes evident by the presence of a large blood-shadow. Thus we learn that the contractions of the heart are not of the extent assumed heretofore. In pro- portion to the amount of blood filling the ventricles the shadow of the apex appears lighter or darker. During deep inspirations it can be observed that the diaphragm becomes distant from the heart, which proves that the heart is suspended by its blood-vessels and is not supported by the diaphragm. Full inspiration shows the lungs more translucent, so that their shadow appears in greater contrast to the dark outlines of the heart. Dextrocardia is easily represented by the Rontgen rays. In all these cases it should be ascertained whether there is total transposition of the viscera, in which event the appendix is also found on the left. (See author's case of left-sided chole- cystostomy for left-sided cholelithiasis, " Annals of Surgery, 1 ' May, 1899.) Pericarditis is sometimes caused by a fractured rib- fragment which has pierced the pericardium. 260 Rontgen Method in Thoracic Surgery. A trauma of this kind may be elicited by the Rontgen rays. If the clinical symptoms are slight and the rays show no dis- placed splinters, expectant treatment is entirely justifiable. Even if a bullet, after having fractured a rib, has entered the pericardium, there may be no need of surgical interference, providing no comminution is shown and severe symptoms are absent. In a man who was shot, eight years before his death, into the supraclavicular fossa from above, the bullet could be located at the apex of the heart. The patient had never suffered from any symptoms pointing to the presence of the bullet. At the autopsy, performed by the author at the St. Mark's Hospital, the bullet was found embedded in fibrous tissue in the pericardium. The evidence of a large bone-splinter pointing toward the pericardium is an indication for exposing the pericardial sac after the resection of the left fourth, fifth, and sixth ribs. These need not be resected in their totality, but may be folded up at their sternal junctions like a bone flap of the skull. The diagnosis of pericardial adhesions may be verified by the fluoroscopic screen, which would show limited expansion. CHAPTER V. SUBPHRENIC ABSCESS. While subphrenic abscess, as its name indicates, is situated below the diaphragm, that is, outside of the thoracic cavity (Fig. 133), it bears so many relations to the latter that it de- serves thorough consideration in connection with the surgical disorders of the thorax. It is only since a little over a decade that subphrenic abscess was granted a place in medical liter- ature. A few isolated cases were reported, before this time, Leyden, Tillmann, and Sachs in Germany, Penrose and Mackenzie in England, and R. F. Weir, 1 S. J. Meltzer, and the author 3 publishing cases in this country. Notwithstanding that surgery owes most of its recent development to advances in the natural sciences, yet here surgery has been the donor by disclosing to pathology as well as to internal medicine the mysteries of this disease. It was reserved to the genius of a Richard von Volkmann 4 to show, as early as 1879, that abscesses situated below the diaphragm can be reached and cured by the knife. His bold yet successful procedure of opening the pleural cavity and incising the diaphragm called the interest of the whole medical world to this new subject. In the .following year Leyden 5 published his views upon this condition from the standpoint of general medicine, and to him is due the credit of having offered the first clear and 1 "Medical Record," February 13, 1892. 2 "Internationale klinische Rundschau," 1893, Nos. 29, 31, 34. 3 'Medical Record," February 15, 1896. 4 "VerhandlungenderDeutschen Gesellschaft fur Chirurgie," Bd. viii, 1879, p. 19. 5 " Zeitschrift fur klinische Medicin," Bd. i, p. 320. 261 262 Subphrenic Abscess. simple methods for its diagnosis. How much the knowledge of this subject has increased is evident from the fact that, while from 1879 to 1890 only twenty-eight operations were per- formed for subphrenic abscesses, the period from 1890 to 1893 shows thirty- two cases. The record has since risen to more than one thousand cases, most of which were operated upon. Notwithstanding our advanced knowledge there are still num- erous aetiological and diagnostic points which await elucidation. This is the more to be deplored that here, as in many other suppurative processes, early diagnosis is essential to successful surgical treatment. Even the most experienced observers sometimes meet with great difficulties in diagnosis, which can be overcome only by clearing up the manifold aetiological factors. The first classical efforts in this direction were made by K. Maydl. 1 Subphrenic abscesses are classified best in conjunction with their anatomical points of origin. At the same time the primary disease which caused the abscess must be studied whenever possible. Since diagnosis and prognosis, as well as therapy, are naturally dependent upon the seat of the primary affection, anatomy has served also as the basis for the author's own deductions. Before going further, the topography and pathological anatomy of the disease as the basis for diagnosis, prognosis, and therapy will be considered. Topography. — The subphrenic space, in which sub- phrenic abscess forms, is bounded by the epigastrium and the two hypochondria. The right hypochondrium contains the right lobe of the liver, the sharp lower margin of which is overlapped by the gall-bladder in the region of the, cartilages of the ninth and tenth ribs. Below the liver is the right half of the transverse colon. The right suprarenal capsule and the upper margin of the right kidney, which always leaves a 1 " Ueber subphrenische Abscesse," Wien, 1894. Topography of Subphrenic Abscess. 263 slight impression upon the liver, occupy the most dependent part of the right hypochondrium (Fig. 130). The left hypochondrium, containing the fundus ventriculi, is covered by the larger portion of the left lobe of the liver. A little further below lies the spleen, connected with the curva- Z.Tib Fig. osi?. 130. — Vertical Section through the Human Body, One Inch to the Right oe the External Margin of the Left Rectus Abdominis. ture of the stomach by the ligamentum gastro-lienale and the vasa breviora. In front of the spleen lies the left part of the transverse colon. That part of the epigastrium adjacent to the anterior abdominal wall contains a part of the left lobe of 264 Subphrenic Abscess. the liver, separated from the wall of the abdomen by the sus- pensory ligament. The pylorus and a portion of the duode- num are below the liver. About on a level with the lower margin of the nipple (lower margin of ninth to eleventh dorsal vertebrae posteriorly), the diaphragm forms a figure-of-eight, whose knot is situated between the oesophagus and the pericardium. The peritoneal coat of these organs is incomplete at three portions: (1) at the suspensory ligament of the liver; (2) where the lobus Spigelii touches the minor omental bursa, at the lower surface of the liver; and (3) at the portion situated between the end of the bursa omenti and the posterior end of the peritoneal cavity, which adapts itself to the liver from in front. Fig. 130 shows the upper half of the anterior surface of the left kidney covered by peritoneum, while the lower half is not covered by serosa. It is separated behind the stomach from the great omental bursa by the suprarenal capsule and the pancreas. The anterior surface of the stomach has a serous coat which faces the great peritoneal cavity, while its posterior serous coat forms the anterior wall of the great omental bursa. The posterior portion of the same covers the anterior surface of the pancreas and the end of the duodenum. The serous coat of the stomach running downward covers the transverse colon. The upper portion of the transverse mesocolon passes over to the pancreas, thereby forming the posterior wall of the great omental bursa, while the lower portion passes over into the mesentery of the small intestine. These anatomical facts show that, with the exception of the cardiac region and the junction of the great and small omental bursa, the stomach does not anywhere adapt itself directly to the subphrenium, but touches it with a serous coat which comes from another organ. Consequently the stomach may be the medium of intraperitoneal as well as of extraperi- toneal subphrenic abscess. Extraperitoneal Abscess. 265 Extraperitoneal abscess could also originate from the left lobe of the liver, if it perforate alongside the triangular ligament into the subphrenic space. On the right side (see Figs. 131 and 132), the whole dia- Aep.fl.col. Fig. 131.— Vertical Section through the Right Rectus Abdominis. phragmatic garret is filled by the right lobe of the liver. Pos- teriorly the right kidney slightly indents the liver, touching the diaphragm with the upper half of its posterior surface and the psoas muscle with the lower half. The liver is covered with 266 Subphrenic Abscess. peritoneum from its lower margin up to trie hilus. The pos- terior surface of its convexity, as well as its posterior margin the posterior half of its lower surface, are not covered with and peritoneum toward the median line, but have a peritoneal coat / / Fig. 132. — Anatomical Relations of the Right Thoracic Half. laterally. Only the upper surface adapts itself to the dia- phragm directly. In front of the lower surface of the kidney is the duodenum, partly covered by the serosa of the small omental bursa. In front of it projects the pyloric portion of the stomach, whose Pathology of Subphrenic Abscess. 267 anterior surface is coated with the serosa of the lower anterior surface of the liver. The transverse colon is often found in front of the pylorus, while neither the transverse nor the ascending colon has ever been found between the convexity of the liver and the anterior abdominal wall, as the external convexity of the liver always lies close to the abdominal wall. The peritoneal coat of the liver sometimes embraces the gall-bladder completely, forming a mesentery for it, from which it hangs ; sometimes it merely passes over its lower sur- face and binds it closely to the lower surface of the liver. The pancreas is separated from the posterior surface of the stomach by the great and small omental bursae, and lies very close to the diaphragm. Pathological Anatomy. — From a pathological point of view subphrenic abscess (synonyms: hypophrenic abscess, subdiaphragmatic abscess, subphrenic empyema, empyema hypophrenicum, pyopneumothorax subphrenicus, perigastric abscess, perigastritis, false pneumothorax, localized tympanites, suppurative perihepatitis, suprahepatic abscess, pneumoper- forative peritonitis, subperitonitis) is divided into intraperitoneal and extraperitoneal. In the first variety the abscess lies wholly within the peri- toneal cavity. In the second variety the abscess wall may or may not be formed in part by peritoneum, but in any case only by its external surface. An important differential point in these conditions is that, since an extraperitoneal abscess never detaches the peritoneal serosa of the diaphragm from it, it is perforce confined within narrow limits and consequently does not fill the subphrenium so completely as does one of the intraperitoneal variety. Another characteristic feature of the extraperitoneal form is that it has a greater tendency to per- forate into the thorax, especially into the pleural sac. Intraperitoneal subphrenic abscess assumes an entirely different significance according to whether it is located on the 268 Subphrenic Abscess. right or the left side of the falciform ligament. This ligament forms the median line between the right and left subphrenium. As the whole right subphrenic space is filled by the liver, the lower wall of an abscess situated on the right side is formed by the upper convexity of the liver; while on the left side the stomach, as well as the spleen, the transverse colon, and the left lobe of the liver, may form a wall. Extraperitoneal abscesses are most frequently found on the right side. This is quite natural, since clinical as well as post-mortem observation has very often traced their source to the caecal region. Rarely this form of abscess arises from the kidneys or ribs. Diagnosis. — As mentioned, subphrenic abscess has a proteus-like physiognomy. The beginning of its formation is sometimes announced by a chill. Frequently there is intense pain at the starting-point of the disease. The fever is of a most irregular type, sometimes there is no temperature at all. Nutrition is always greatly disturbed and emaciation always present. Local tenderness and resistance often point to the seat of the abscess. Regarding differential diagnosis, three cardinal questions frequently arise, namely: Is the condition one of pyothorax, subphrenic abscess, or subphrenic pyopneumo- thorax? The pathognomonic essentials of these different conditions, as first advanced by Leyden, almost invariably remain authoritative. In subphrenic pyopneumothorax deep percussion above the retracted lung yields resonance. From the third rib downward it is generally full and tympanitic. Instead of the liver dullness on the right thoracic margin, a profound and full sound is present. Below the right costal arch the liver is pushed far into the abdomen, and its lower border is easily recognized by palpation and percussion. Auscultation shows the absence of respiratory murmur from the third rib downward. Amphoric breathing and metal- lic tinkling take its place. In auscultatory percussion, metallic Diagnosis of Subphrenic Abscess. 269 phenomena are noticed. There is no vocal fremitus on the lower part of the right thorax. The succussion sound can be heard by shaking the patient. If the effusion can be made out by percussion on the lower thoracic portion, it is found to change its seat easily and quickly, whenever the patient is turned. If the effusion is situated on the right side, the heart will be slightly displaced toward the left, and vice versa. It must be remembered, furthermore, that an admixture of gas is a characteristic feature of subphrenic pneumothorax (Fig. 135). Gas is the product of putrid decomposition, and seems to give the pus a capacity for rapidly eroding the sur- rounding tissue. An exploratory puncture reveals ichorous pus of offensive odor. It is superfluous to say that when the ad- mixture of gas is recognized by an exploratory puncture, a most valuable point for differential diagnosis is obtained. The history is often an important guide as to the location of the abscess. It is characteristic for subphrenic abscess that there is often a history of previous abdominal disturbance, while cough and expectoration are absent. The heart is little, if at all, displaced, and there is no ectasy of the thorax or of the intercostal spaces. In the lungs, vesicular breathing is found below the clavicle. Pectoral fremitus is also clearly perceptible. There is a well-marked limit to the region of vesicular breathing, below which the expiratory murmur is replaced by amphoric sounds. Deep inspiration pushes the boundary-line of the region of vesicular breathing much farther down, into areas in which formerly no respiratory murmur could be perceived. This would indicate a well- marked separation between the lungs and the abscess cavity, the boundary-line of the lungs protruding toward the abscess cavity during deep inspiration. It is sometimes impossible to distinguish an encysted pleuritic effusion from a subphrenic abscess. The pathog- nomonic signs of such pleuritic effusions emphasized by Leyden 270 Subphrenic Abscess. were absence of cough and expectoration, slight displacement of heart, and rapid change of note if the patient is rapidly turned. But, according to the author's observations, 1 pleuritic effusion, particularly pyothorax, sometimes occurs without these symptoms. In reference to the absence of thoracic ectasy and the inversion of the intercostal spaces as pathognomonic^ sub- phrenic pyopneumothorax, it must be said that Herrlich From Beck's " Rontgen-Ray Diagnosis." Copyright, 1904, by D. Appleton and Company. Fig. 133. — Subphrenic Abscess. a, Abscess; d, diaphragm. holds the opposite view, and claims that ectasy of the lower thoracic sphere is rather characteristic of the presence of this condition (Fig. 134). The motions of the exploratory needle, introduced into the abscess, were also regarded as pathognomonic by Fuer- bringer. But, bearing in mind that in subphrenic abscess the function of the diaphragm is greatly impaired, and that, furthermore, the point of the exploratory needle may be fixed 1 "Pyothorax and its Treatment," "Medical Record," May 19, 1894. Diaphragmatic Excursions. 271 by the diaphragm as well as by the abscess membrane, neither the presence nor the absence of the motions can be regarded as determining factors of a pathognomonic nature. Fig. 134. — Left-sided Pyopneumothorax. Fig. 135. — Left-sided Subphrenic Abscess (Containing Gas). If the diaphragm, being pushed up high, tightly adheres to the thoracic walls, the needle may invade the subphrenic abscess without being fixed by the diaphragm. Consequently, 272 Subphrenic Abscess. even if the diaphragm should still be able to make respiratory movements, the needle would not necessarily be moved by them. The value of Litten's diaphragm-phenomenon is not yet established. Jendrassik asserts his ability to note a well- marked concave undulating curve parallel to the costal margins in the mammary as well as the axillary line during deep inspira- tion. In one of his cases he based the diagnosis of subphrenic abscess upon this phenomenon. The correctness thereof was demonstrated by subsequent operation. All these points go to show that, aside from the history, there are but few absolutely reliable pathognomonic data for the diagnosis of subphrenic abscess. Practically, however, it will make little difference to the surgeon whether pyothorax or subphrenic abscess is present, as the essential part of the treatment of either condition is free opening. The main question will always be: Is there an abscess or not? When- ever suspicion exists, the introduction of the exploratory needle is a matter of course. The same aseptic precautions should be observed as in any other operation. The skin of the patient, as well as the hands of the surgeon, should be rendered clean, and the syringe and needle thoroughly sterile. If the first attempt be negative, the needle should be introduced several times into different portions, as the pus cavity may either be of small extent, or may contain a cheesy accumulation, or, finally, may be divided into several minor cavities by adhesions. In the first event the cavity may be missed altogether by the exploratory needle, and in the second the needle, being introduced into the solid cheesy mass, can draw no pus. After each negative result, therefore, a wire should be pushed through the needle (which must not be of too small a calibre). Thus some pus, which had remained adherent to the inner surface of the needle, will become attached to the wire. Occasionally it will be useful to fill the syringe with sterile water after the Prognosis of Subphrenic Abscess. 273 operation, and force the water through the needle into a Petri dish. In case cheesy masses are present,, small particles are sometimes drawn into the calibre of the needle which cannot be perceived by the unaided eye; but which, by being mixed with the sterile water, can be recognized under the microscope. In case the microscope does not give sufficient information, resort should be had to cultures of the fluid. (Compare aspira- tion in pyothorax, page 147.) The Rontgen method also made its powerful influence felt in the differential diagnosis of subphrenic abscess. It is, in fact, greatly simplified now by fluoroscopy as well as by skiagraphy, the space between the diaphragm and the lower boundary-lines of the abscess showing distinctly. If the patient is seated on a chair, the screen being held in front of the thorax and the Rontgen tube behind him, the upper portion of the diseased side must appear normal — that is, light. Below this area a dark one appears which indicates the diaphragm (Fig. 135). Below the diaphragm a very dark shadow is found in case of the presence of a fluid. This would correspond to the area of the abscess. When the patient's position is changed the dark area, in- dicating the fluid, also changes. If there is an accumu- lation of gas in the subphrenic abscess, a light area will be seen above the dark shadow. As soon as the patient is shaken, the horizontal line, indicating the border-line between gas and fluid, becomes wavy. In the recumbent position only the dark area is shown, even if gas be present. Prognosis. — Experience shows that the prognosis of sub- phrenic abscesses, except those of malignant origin, such as carcinoma pylori, for instance, depends almost entirely upon early diagnosis. The author did not lose any of his simple cases which were operated upon early. In none of them, how- ever, were there any complications or large sized abscesses. 274 Subphrenic Abscess. In the great majority of the author's cases the ^etiological source could be found in the appendix. They were ten in number, seven of them recovering. The cured patients were all operated upon at an early stage. Next to it the aetiological moments could be traced to the sphere of the liver and gall-bladder. They figure with six cases, four of them recovering. In their totality the author's statistics from January 3, 1892, are as follows: /Etiological Source. Number of Cases. Recoveries. Appendix 10 7 Liver and gall-bladder 6 4 Pyothorax 6 4 Stomach 4 2 Costal necrosis 3 3 Perinephritis 3 2 Spleen 3 2 Duodenum 2 1 Pancreas 1 o Unknown sources 6 4 44 29 This means 15 deaths among 44 cases; in other words, a mortality rate of 34.1 per cent. The mortality rate of 50 per cent., as given by Maydl, seems to be too high. Con- sidering that Scheurlen's mortality rate was 82.5 per cent., while Sachs, in a series of six cases, lost none, it can clearly be seen that the kinds of cases reported differ notably. Further- more, it must be borne in mind that very few of the cases reported in the unfortunate series of Scheurlen were operated upon. Thus it becomes evident that an approximate judgment can be based only on a large number of well-defined cases. Spontaneous healing of subphrenic abscess is extremely rare, as is that of pyothorax. Perforation may take place into a hollow organ, like the stomach, or a bronchus, or the bladder. Literature shows spontaneous cures of subphrenic abscess six times in one hundred and four cases. As the mechanism of such natural healing is unknown to us, and there- Bacteria in Subphrenic Abscess. 275 fore cannot be controlled by any medical therapy, it can only be by chance that so hazardous a cure is ever effected. Since the pathology of appendicitis has been more widely recognized, poulticing and opium have ceased to be the pan- aceas, early opening being demanded now. The same views apply to subphrenic abscess. Its expectant treatment will be discarded as soon as its importance and nature are better recognized. Microscopic and bacteriological examination of the aspirated pus gave no prognostic aid in the author's cases. But it may fairly be assumed that with greater interest in this disease and the higher development of our examining methods, more valuable information on these points will be obtained. It is to be regretted that, according to the reports of reliable investi- gators, most of the pus-culture experiments made so far were negative. Probably the microbes are dead, since even the pus taken from the subphrenic abscess of tuberculous patients has repeatedly failed to produce reaction when injected into rabbits. Thus far the pus of these abscesses has been found to contain the staphylococcus pyogenes aureus, streptococcus, bacillus coli communis, bacillus pyogenes fcetidus (Passet), micrococcus tetragonus, various species of proteus (Hauser), saccharomyces, and diplococcus citreus conglomeratus. As the analogy with pyothorax is obvious, it may be remembered that the pus of that condition shows streptococcus, bacillus tubercu- losis, typhus bacillus, staphylococcus aureus and albus, and diplococcus lanceolatus (Frankel). As mentioned above, Netter in 109 cases of pyothorax found streptococcus 50 times, pneumococcus 32 times, saprogenous micro-organisms 15 times, Koch's bacillus 12 times. The presence of pneumo- coccus in subphrenic abscess would suggest a pulmonic origin. We know that the presence of streptococcus in pyothorax seems to favor the formation of solid masses in the effusion, and, 276 Subphrenic Abscess. furthermore, that this coccus has a predilection for the infec- tious diseases of adults, whereas FrankePs coccus shows the most benign character of all microbes found in pyothorax. Whether this is accidental or not, and how much the analogy can be utilized for the prognosis of subphrenic abscess, the future must show. Undoubtedly the prognosis is also influenced by the extent of the accumulation, the consistency, appearance, and odor of the pus, the age and the constitution of the patient, the pulse, the temperature, and, perhaps the most important of all, the stage of the disease. If the percentage of successful operations, as reported in literature, is still far from being satisfactory, it can be due only to disregard for the principle of early operation and to the fact that the unsuccessful cases are the result of a defect in diagnosis quite as much as in operative technics. In all these cases the autopsy showed the presence of another abscess, so that the essential condition for success, a thorough evacuation, was not fulfilled. In six cases, besides subphrenic abscess, pyothorax was present. In nine cases abscesses were present in adjacent organs, i. e., in the spleen, liver, kidney, etc. In four cases the additional disease was suppurative peritonitis. In ten cases there was pneumonia, in addition to pyaemia, tuberculosis, actinomycosis of vertebrae, etc. In several cases an incision was made, but the abscess was not detected during life. Varieties classified according to source : By far the greater number of subphrenic abscesses are the result of pathological processes in the appendix. In view of its situation this fre- quency is a natural outcome. Especially in procrastinated cases, where isolated abscesses form between adherent loops of the intestine, the foundation is laid for further infectious pro- cesses. The custom of leaving a gangrenous appendix in the abdominal cavity when the appendicular abscess is walled off, is also to be held responsible. This policy, tempting as it Intestinal Origin of Subphrenic Abscess. 277 appears on superficial contemplation, is entirely unsurgical and cannot be condemned too strongly. Whenever gangrenous tis- sue can be reached it should be seized under any circum- stances and eliminated. Regarding the intestine, it is to be considered that it is no- where attached to the diaphragm. Consequently other con- ditions prevail here than in those organs which are in direct contact with the diaphragm. The experiments of Sanger clearly illustrate the manner in which a subphrenic abscess may arise from the intestine. This author noticed that when he injected a solution of Berlin blue into the retroce- cal tissue, only a trifling amount of the colored solution could be driven around the caecum and alongside the linea in- nominata down to the inguinal canal. But the liquid column rose behind the ascending colon, formed a considerable fluid collection around the right kidney, and, passing the inferior horizontal portion of the duodenum, reached the dull margin of the liver and the diaphragm. Little fluid reached the transverse mesocolon, and none at all the mesentery of the small intestine. From this experiment the rule may be deduced that subphrenic abscess is more apt to arise from perforation of the caecum, ascending colon, or duodenum, than of the small in- testine or transverse colon. The experience gained from autopsies is in entire accord with this theoretical assumption, as in thirteen intestinal cases, reported by Maydl, perforation of the duodenum was found eight times; of the colon, four times; while perforation of the ileum was found only once, and that, too, near the colon. It is of interest to notice that the aetiological factors of these perforations of the gut, with the exception of one case which was caused by a foreign body, were all ulcerative pro- cesses. Traumatism could never be made out as a primary source. The ulcers of typhoid fever, since their favorite seat is the small intestine, cannot, according to Sanger's experiments, enter into the formation of subphrenic abscesses. Autopsies 27^ ■[ Subphrenic Abscess. have shown that appendicitis causes subphrenic abscess by perforation from the appendix into the retroperitoneal space, the resulting abscess extending up behind the kidney and liver to the subphrenium. From the anatomical situation of the appendix, such abscesses are generally found on the right side, but in a few cases they passed from behind the right kidney, over the vertebrae, to the left kidney. Frequent seats of subphrenic abscess are the stomach and upper part of the duodenum. There may be direct perforation into the subphrenium, due to a peptic ulcer or a neoplasm (carcinoma), or infection may occur through the lymphatics which drain that part of the stomach involved in the path- ological process. Most of the cases reported, however, point to simple ulcerative processes as setiological factors. As mentioned above, cases of echinococcus are seldom seen in this country, but in Germany, Austria, France, and England, where it is more common, it frequently figures as a cause of subphrenic abscess. Of the subphrenic abscesses due to this cause, seventeen were operated upon, as far as literature shows, with the result of seven deaths. No case recovered after per- foration of the abscess into the pleura, except those treated by operative means. The starting-point is generally an echinococcus cyst, formed in the cellular tissue between the diaphragm and the liver. A cyst of this kind may, however, be developed between the diaphragm and the left kidney or the spleen, since both these organs are occasionally the seat of the parasite, and are both in contact with the diaphragm. Simon-Brown, Mosler, and Fiaux have reported abscesses from this source. In what manner subcutaneous trauma give rise to the forma- tion of subphrenic abscess is not always evident. The explanation may be that trauma originally causes a simple extravasation, into which pus-producing organisms emigrate from the neighboring intestine. These microbes are usually Biliary Origin of Subphrenic Abscess. 279 abundantly present in the gut and are found in tissues whose vitality has been lowered by trauma, which means a most favor- able soil for their further development. It is also conceivable that trauma producing a capillary separation in the continuity of kidney, pancreas, or liver, causes oozing of the secretions of these organs, which may then irritate and infect the adjacent tissue. Or a more extensive rupture of one of these organs may cause the formation of an abscess within it, which might burst into the subphrenic space later. Sometimes trauma may be produced by an apparently insignificant amount of force. Simply lifting a heavy weight, for instance, is reported to have caused it. Literature has seventeen cases showing this aetiology, six of them recovering after operation and two spontaneously. The gall-bladder and the intrahepatic and extrahepatic bile-ducts naturally offer marked opportunities for the for- mation of subphrenic abscess. Bearing in mind that the anterior surface of the gall-bladder adapts itself to the right inferior insertions of the diaphragm, it seems obvious that in- flammatory processes of this organ extend by means of the lymphatics, or by ulcerative perforation to the lower surface of diaphragm. Stagnation in the flow of bile undoubtably favors the infection of the gall-passages from the intestine. (See "Cholelithiasis," "New York Medical Journal," September 8, 1906.) Retention cysts containing bile may originate in the liver itself as well as on its surface, and may burst and discharge into the subphrenium. Thus subphrenic abscess may arise from purulent cholecystitis terminating in ulceration and perfo- ration, or from cholangiectasia due to obliteration of a large bile-duct, or from cholangioitis terminating in purulent hepati- tis, or from purulent inflammation of the ductus choledochus communis itself, followed by rupture. There are reports of sixteen cases of cholangioitic origin (the author's excepted). Of these, fourteen were not recognized 280 Subphrenic Abscess. until the autopsy, while two were operated upon successfully. In several of the cases gall-stones were found. In all of them, naturally, the subphrenic abscess was located on the right side. Every one of the patients had complained of well- defined acute pain in the right hypochondrium. The anatomical situation of the kidneys gives them an important relation to the formation of subphrenic abscess. They are situated in the lumbar region of the abdominal cavity, and are covered by peritoneum in front. The right kidney lies in contact with the ascending, the left one with the descending colon. They are bounded behind by the lumbar portion of the dia- phragm, and above by the suprarenal capsules. The left kid- ney extends a little higher into the pleural domain, so to speak, than the right, so that in perforation from the renal sphere into the pleura, the left side is more frequently concerned than the right. The most frequent cause of perinephritic abscess is a primary perinephritis, arising from a contusion in the renal region or from one of the infectious diseases. Another cause may be pyelonephritis calculosa, suppurativa, or tuberculosa. As to repeated exposure to cold as an aetiological element, see page 142, on pyothorax. Since suppurative pyelonephritis is often the outcome of disease of the uropoietic apparatus, viz., prostatitis, stone, carcinoma of the bladder, etc., it will be wise to consider the possibility of the formation of a subphrenic abscess in all such conditions. The lower border of perinephritic subphrenic abscess is generally formed by the ascending or descending colon, some- times by the duodenum. In reference to diagnosis, it is maintained that if the abscess occupies the whole anterior or posterior surface of the kidney, there is generally tenderness or pain, swelling, and oedema on the anterior surface of the abdomen. The author's expe- rience, however, does not accord with this, as, with the excep- Thoracic Origin of Subphrenic Abscess. 281 tion of pain, he found no local symptom in one of his own cases even as late as seven weeks after the onset of the disease. If the abscess has formed on the upper surface of the kidneys, pleuritic symptoms, combined with oedema of both legs, jaundice, ascites, and vomiting, may be observed. Of eleven such cases reported in literature, only one was saved, the unfavorable course probably being due to delayed diagnosis. Perhaps, too, the kidney is so much affected in this condition that nephrectomy should be added to the operation for evacuation of the abscess. Subphrenic abscess originating in the ribs (from a tuber- culous osteomyelitis, caries, etc., as a rule) was considered to be of rare occurrence. If situated on the right side it may easily be confounded with cholangioitic subphrenic abscess. In the cases reported in literature, the tuberculous process was local- ized, and consequently there was quick recovery. But with our advanced knowledge this source is very much more frequently detected as such. Fig. 136 shows one of the cases of the author in which the diagnosis empyema of the gall-bladder due to cholelithiasis was made. The patient, a man of thirty-eight years, suffered from costal osteomyelitis, perforation having taken place into the sub- phrenicum. The great tendency of subphrenic abscess to perforate into the thoracic cavity has been mentioned before. On the other hand, there are subphrenic abscesses of true thoracic origin. The most frequent purulent affections of the thoracic cavity are pyothorax and abscess 0} the lung. Suppurative pericarditis is rare. A circumscribed pyothorax may per- forate directly, while abscess of the lung will first produce an inflammatory adhesion of the adjacent visceral and diaphrag- matic pleurae. Free pyothorax has a tendency to perforate the middle of the diaphragm. 282 Subphrenic Abscess. Of nine cases reported in literature, one case recovered spontaneously by perforating into the gut; one after surgical Fig. 136. — Anterior Incision Line in Subphrenic Abscess Due to Costal Osteomyelitis. (Six Weeks after Operation.) Fig. 137. — Dull Area as it is Generally Found in Cases of Subphrenic Abscess of the Type Illustrated by Fig. 136, before Operation. operation ; three died with, and four without, surgical interfer- ence. - Traumatic Origin of Subphrenic Abscess. 283 Metastasis is another important aetiological factor, but is, as a rule, observed only in the tropics. It has been found after trauma in connection with pyaemia (septic phlegmon of the forearm and tuberculous coxitis — Godlee); following ulcerative processes in the digestive tract (perforation of fish-bone into the vena portae) ; and associated with fistula ani and gangrene of the appendix. Abscess of the spleen, per- forating into the portal branches, as well as suppurative proc- esses in the mesentery and mesenteric glands, may cause abscess of the liver. Malaria, enteritis, and dysentery may do the same. In tropical dysentery Koch 1 could always prove the presence of amcebae in portions of the intestine, and regarded them as the aetiological factor. Abscesses of the liver were also demonstrated by von Bergmann. Other authors claim that the amcebae are not the cause of the abscess, but only the characteristic admixture of the secretion transported from the seat of ulceration to the liver. An attempt was made to obtain cultures from the pus of thirteen' cases of dysenteric abscess of the liver. In eight cases the results were negative. Among the positive results staphy- lococcus pyogenes aureus was found twice; staphylococcus albus, bacillus pyogenes foetidus and proteus, once each. But in sections and cover-glass preparations amcebae were found in every one of twenty-two cases. In ten cases they were mixed with bacilli. Of eleven cases reported in literature, ten died. In one case recovery was obtained by surgical interference. Only two of the fatal cases were operated upon. A wound inflicted directly to the diaphragmatic space may also in rare instances cause subphrenic abscess, some- what as do the subcutaneous traumata described above. The wound is generally produced by a bullet. There are in the literature reports of autopsies in four cases. The liver, kidneys, and thoracic cavity may be involved at the same time. 1 Gaffky: "Reports on Investigations of Cholera," 18S3. 284 Subphrenic Abscess. Besides' the varieties described above, another group of subphrenic abscesses must be mentioned, whose original sources either are questionable or cannot be discovered. Eleven such cases are reported in literature besides the author's. In three of them successful operations were performed. One recovered after perforation into a bronchus. The other seven died under expectant treatment. In one case actinomy- cosis of the vertebrae was found, while there was pyosalpinx in the case which finally perforated into a bronchus. In those cases of subphrenic abscess originating in diseases of the female sexual organs, e. g., endometritis, pyosalpinx, perimetritic exudations, the route to the subphrenium is through the retroperitoneal space. Course. — As said above, subphrenic abscess may arise from infection carried from an area of suppuration by means of the lymphatics. It oftener originates in an abscess of an adjacent organ, which bursts into the subphrenium. The fistulous tract representing its route may then become oblit- erated, or may remain and gradually grow larger. If perforation of a subphrenic abscess into the lung has taken place, the rusty sputa and their offensive odor, as well as that of the breath, together with the microscopic demonstration of elastic fibres, point to a limited gangrenous process as the initiative factor of the perforation. The cough, which then is always present, generally brings up fetid pus, in which particles of food, such as starch grains or margarin crystals, can be seen by the naked eye or demon- strated by the microscope. This would, of course, point to a gastro-intestinal or cholangioitic source. While in a small number of such cases recovery is obtained by the perforation, the majority of patients succumb either to the shock of the perforation itself, or to a foreign-body pneu- monia later on. The symptoms of perforation into the pleura consist in intense pain, rapidly developing dyspnoea, and The Treatment of Subphrenic Abscess. 285 collapse (see page 84); while those of perforation into the peritoneal cavity are identical with the well-known symptoms of the general type of peritoneal perforation. Therapy. — The treatment of subphrenic abscess must be surgical. Before the days of asepsis, the surgeon naturally hesitated to open the chest or abdomen, but now such fear need no longer prevent him from procuring timely exposure. Thorough evacuation can be effected only by wide opening. This is secured best by resecting a piece of a rib, as the subphrenic abscess is generally within the extent of the ribs. Exceptionally it is to be approached below the costal arches or the xiphoid process. The author cannot agree with those authors who pronounce it an ill occurrence for the patient when the abscess must be reached by the transpleural route. On the contrary, it seems that no other route, except the lumbar, offers so many advantages in after- treatment (Fig. 140). While for prognostic pur- , , , Fig. 138. — Transpleural Route poses It IS important to know IN Subphrenic Abscess. whether the pleurae are adherent or present a cavity filled with serum or pus, so far as surgical procedures are concerned it makes very little difference. The adversaries of the transpleural route maintain that to open the pleural sac, if it be in a normal state, would expose it to the dangers of pneumothorax, as well as to infection from the atmosphere or from the escaping pus. Regarding the first objection, pneumothorax, it must be borne in mind that in subphrenic abscess the aspirating power of the diaphragm is greatly impaired. As is evident by the dullness found on percussion, the diaphragm is pushed so far up toward the thoracic cavity that it is pressed against 286 Subphrenic Abscess. the thoracic walls to a considerable extent, and has its summit brought into permanent contact with the costal pleura. It may even be so overstretched as to be entirely paralyzed. Furthermore, the lower part of the thorax itself is generally expanded, thus diminishing its aspirating power. WTien pneumothorax does occur after the exposure of the pleural sac, and a feeble patient suffers shock, final incision and evacuation may be deferred until the following day. In reference to atmospheric infection, the author may refer to Petri's and Cleves-Symmer's experiments, which demon- strated bacteriologically what had long appeared probable from clinical observation, viz., that the microbes contained in the atmosphere are non-pathogenic under ordinary circum- stances. Furthermore, he does not see why the pleura should be more inclined to become infected than other parts of the body, provided thorough aseptic precautions were observed. While the incision should be made in the centre of the dull area, the exploratory needle will always indicate its ultimate route. The technic of the operation is practically the same as that of resection of a rib for pyothorax (see Figs. 83, 84, 85, 91). As a rule, the eighth, ninth, or tenth rib is selected. The author prefers the median axillary line, as thence the abscess walls can be reached equally well in front and behind. It also enables the patient to be brought to the edge of the table during the operation, and permits him to assume the dorsal decubitus; while, if the incision were made farther back, he would be obliged to lie on the healthy side, thus rendering evacuation more difficult. If, however, the dull area, as it sometimes occurs in abscesses of small extent, is situated dis- tant from the median axillary line, the resection must take place at the point where the aspiratory needle revealed the pus. It goes without saying that thorough aseptic precautions must be taken. If the pleural sac be found empty the pus cavity is located Operative Technics in Subphrenic Abscess. 287 by means of the exploring needle, and an opening is made through the diaphragmatic pleura just large enough to permit the introduction of a grooved director. Before this, aseptic tampons are packed around the pleural sac to occlude it from the escaping pus. As soon as pus appears in the groove of the director, a, small Pean forceps is introduced and the open- ing gently dilated. Evacuation of the pus must take place slowly. A sponge should be pressed against the opening from time to time to interrupt the stream, so as to avoid too rapid expansion of the lungs. If the condition of the patient permit, the finger is now introduced and any solid masses, such as fibrinous clots or necrosed tissue adhering to the abscess wall, are wiped out with the index-finger or with a blunt spoon made for this purpose. For inspection, the author's dilating specu- lum can sometimes be used to advantage. If haemorrhage should occur or if signs of shock be present, such procedures may be deferred for a day or two, as may also irrigation of the cavity with a sterile salt solution, which is used to secure thorough evacuation. When malodorous pus is found, an antiseptic wash, preferably bichloride, 1 to 10,000, is used for this once, instead of the sterile salt solution. The pleura or the edges of the diaphragm are stitched to the skin with four silk sutures (preferably iodoform silk), one at each end of the wound and one on each side, with strong Hagedorn needles. Thus the wound surface is entirely cov- ered and the adjacent tissues protected against infection. At the same time secondary haemorrhage is thereby prevented and the wound kept open. Then the cavity, if of small extent, is packed with iodoform gauze. If large, a rubber drain may be introduced besides. It is only after the rigorous procedures described above that the cavity can be pronounced entirely evacuated. No necessity of subsequent irrigation arises, which, besides being irritating, destroys those very adhesions which are much needed for the obliteration of the cavity. When the discharge 288 Subphrenic Abscess. becomes serous and scant, a small strip of iodoform gauze or a wick suffice to absorb the secretion. Now the patient must be watched very carefully, because the cavity may be obliter- ated after twenty-four hours, but very often the union is only superficial and retention of pus occurs, as shown by an eleva- tion of temperature. In such a case reopening is indicated, the same manoeuvre to be repeated after a week, until for about four days after the obliteration of the pus cavity no discharge appears and the temperature re- mains normal. In a doubtful case careful introduction of a grooved director through the scar tissue may reveal the presence of retained pus. The dressing should be changed every day for the first week; later every two days, and after three weeks it will suffice to change the dressing every third or fourth day. The patient, if at all able, should get up after one week. During after-treatment, for the first few days small doses of morphine are administered for the purpose of immobilization. If the pulse be weak, strophanthus or caf- feine may be added. Nourishment is given frequently and in small quantities to avoid overdistention of the stomach. Full anaesthesia should be administered only if the pulse is strong. As to further details regarding anaesthesia see sec- tion on pyothorax (page 159). If resection for subphrenic abscess is done anteriorly, an incision must be made from the anterior axillary line between the seventh and eighth rib (see Fig. 139). Having divided the Fig. 139. — Anterior Resection in the Seventh Intercos- tal Space. Lumbar Route in Subphrenic Abscess. 289 fascia of the external oblique muscle, the seventh and eighth ribs are exposed and resected. The further procedures are the same in this operation as described above. The lumbar route (Fig. 140) merits special consideration in subphrenic abscesses of perinephritic origin. The incision in such cases should begin on the prominence of the sacro- lumbalis muscle and extend to the anterior axillary line. After the thick lumbo-dorsal fascia and the latissimus dorsi and serratus posticus inferior muscles are cut through, the sacro- Fig. 140. — Lumbar Route. Incision Passing under the Twelfth Rib. lumbalis muscle is drawn toward the spinal column. The lumbo-costal fascia is next divided. Now the quadratus lum- borum muscle appears running vertically, parallel to the border of the sacro-lumbalis muscle. A grooved director, introduced alongside the outer margin of this muscle, will lead to the pus cavity, which after being carefully and slowly evacuated, must be packed with gauze, preferably iodoform gauze (3 per cent.). The after-treatment should be conducted according to the principles of aseptic open-wound treatment. CHAPTER VI. DISEASES OF THE BREAST. ANATOMICAL PART. The mammae, breasts (ubera in animals), are two pectoral organs, serving as external accessory glands of the generative system. In most animals they are situated on the abdomen. The monkey carries it at the lateral region of the anterior chest surface, while in the human female they are attached to the pec- Fig. 141. — Mammilla and Its Areola (a) in a Virgin; (b) in a Pregnant Woman. 1, Mammilla. 2, Areola. 3, Morgagni's and Montgomery's tubercles. 4, Fur- rows at the mammillary base. 5, Mammary integument. 5', Secondary areola. 6, Haller's venous circle. toralis major muscle and extend from the intervals between the third and seventh ribs and from the lateral margin of the ster- num to the axilla. The mammas are the characteristics of the first category of the vertebrates, wherefrom they are termed " mammalia." 290 Anatomy of Mamma. 291 The shape of the mammae is hemispherical and depends, just as much as its size, upon various conditions, among which the age and the natural physiological changes, the nationality and the climate may be mentioned. Near the middle each mamma is surmounted by the nipple (mammilla), a small wart-like prominence, the surface of which is colored by dark pig- ment. It is surrounded by a circular brownish area, called the areola. In virgins the areola is more of a rosy tint. The nipple Acini of gland Fig. 142. — The Female Mamma during Lactation. — {Morris, after Luschka.) is wrinkled and possesses a large number of papillae. At its tip it is perforated by the orifices of the lactiferous ducts. A sulcus, running parallel to the sternum, separates both mammae from each other. It is called the sinus. In the male the breast remains in a rudimentary state, but there are cases in which lactation was kept up for months. A. Humboldt reports the case of a man who nursed his child during the illness of his wife for four months. The secreting part of the mamma consists of ten to sixteen 292 Diseases of the Breast. compound racemose glands, which are connected by fibrous tissue, the latter investing the entire mammary surface. The excretory ducts (lactiferous or galactophorous ducts, ductus lactiferi or galactophori) of these glandular lobes converge to- ward the base of the nipple, beneath which they become dilated into reservoirs, called ampullae (sinus lactei), and without under- going anastomoses terminate at the summit of the nipple, form- ing constricted orifices between the wrinkles of the nipple near its apex. The walls of the ducts consist of connective tissue mixed with elastic fibres and appear thinned at the terminal acini. Their calibre is constricted by a rich structure of cylindrical epithelium. The development of the acini does not begin before puberty. The presence of circular and radiating fibres of unstriped muscle permits nipple as well as areola to contract. The surface of the mamma and the interval between its lobes are mostly taken up by abundant adipose tissue, upon the extent of which the size and form of the organ largely depends. The arteries of the breast are derived from the arteria mammaria interna and the axillaris. The veins terminate correspondingly. As to congenital malformations of the breast see section on malformations, page 53. DISEASES OF THE NIPPLE. The skin of the nipple is very thin and tender. This accounts for the frequent occurrence of excoriations, in nursing mothers. The superficial epithelium is macerated by the re- peated acts of motion and friction, and if there is want of cleanliness, bacteria gain free access and cause infection. To prevent cracking of the nipples, washing with a saturated solution of boric acid immediately after nursing is advisable. Eczema of Nipple and Paget's Disease. 293 If there are marked signs of inflammation, application with Lugol's solution . should be made. When fissures have formed, they should be washed with a 5 per cent, solution of chloride of zinc. The same rules apply to the treatment of eczema of the nipple, which is more or less caused by lack of cleanliness. The crusts must be removed, which is best done by gradually softening them up with moist applications (1:10,000 bichlorid of mercury). If an eczematous area assumes a red granular or excoriated appearance, and discharges a yellowish viscid secretion, we speak of malignant dermatitis or Paget's disease, which is characterized by the continuous presence of more or less lancinating pains. There is a marked tendency to spread far below the areola. Local treatment before the Rontgen era always proved to be a failure, the only remedy consisting in amputation of the breast. Nowadays the Rontgen treatment is usually successful. Observation showed that about two years after the onset of Paget's disease carcinoma developed, another corroboration of the assumption that integumental epithelioma originates from an epithelial proliferation at the skin surface. The areola is sometimes the seat of suppuration in girls about the age of puberty. This process originates in the sebaceous follicles and is treated after general surgical princi- ples. In engaging a wet-nurse great care must be exercised in examining the nipples, as there are chancres found some- times. Primary epithelioma is rarely found in the nipple. It demands amputation of the breast. Papilloma and sebaceous cysts are also observed. They require simple excision. 294 Diseases of the Breast INFLAMMATORY PROCESSES IN THE BREAST (MASTITIS). The peculiar structure of the mammary gland, especially the large number of ducts and alveoli, and besides the compli- cated arrangement of the lymphatics (Figs. 143 and 144), makes it a favored seat for inflammatory processes. Mastitis is ob- served during every period of life, but its marked prevalence is in nursing mothers. Brachial group Central group Anterior pectoral chain Duct from the mammary Anterior pectora 1 node Duct from the mammary gland Collecting duct Subareolar plexus Duct from lateral thoracic wall Duct passing to internal mam- mary node Collecting ducts Duct passing to internal mam- mary node Fig. 143. — The Axillary Lymph-nodes. — (Morris, after Poirier and Cuneo.) In the new-born swelling of the mammary glands, asso- ciated with redness of the skin, is often seen. In most cases a clear or milky secretion can be squeezed out. The aetiology of this phenomenon is unknown. The treatment consists in applications of Burow's solution. Sometimes there is suppu- ration, in which case an incision is to be made. Ducts from network Lobule of gland, un- infected Ducts from network Fig. 144. — Lymphatics of the Subareolar Plexus of the Breast. — (Morris, after Sappey.) Pyramidal Fig. 145. — Horizontal Diameter of the Right Mamma. — (Morris* "Anatomy") 295 296 Diseases of the Breast. During puberty girls as well as boys show a painful intu- mescence of the mammary gland sometimes, which becomes much enlarged and hardened. The areola appears pig- mented and reddened then. As a rule, the swelling subsides Pectoralis major- Retinaculum cutis Pyramidal process Lactiferous duct Lactiferous sinus Pyramidal process Rectinaculum cutis ^ at External oblique Fig. 146. — Sagittal Section of the Right Mamma of a Woman Twenty-two Years Old. — {Morris, after Testut.) after two or three weeks, but in some instances the gland remains enlarged to double its size for many weeks. It may still disappear then, but sometimes suppuration is the final outcome. Then, of course, a broad opening is to be made. Puerperal Mastitis. 297 Mastitis may also occur in non-puerperal women as the result of an injury, or of pyaemia. After the disappearance of the swelling in infectious paro- titis a metastatic form may be observed in the mammary gland. Puerperal mastitis is by far the most frequent type of in- flammation of the mammary gland. It originates from a sore or cracked nipple, which presents the avenue of infection, the pyogenic cocci invading the lymph-channels or entering the milk-ducts directly. As a rule, the first signs of puerperal mastitis manifest themselves during the first four weeks after confinement, espe- cially after the third week. In the incipient stage only a few lobuli are infected, and if early surgical interference is sought, the infection may remain confined to a circumscribed area. The signs of acute mastitis are fever — as a rule, heralding itself by a chill. The breast becomes intensely painful and swollen, so that nursing can hardly be tolerated by the mother. One or another glandular nodule appears to be enlarged or indurated. On pressure the pain is increased. The inflam- mation spreads gradually until the periphery becomes involved. The presence of oedema is ascertained by digital pressure, which produces a groove in the skin. If surgical interference is post- poned, the whole breast will finally participate (see Fig. 147). In those rare cases of acute mastitis in which the symptoms are of a mild nature, expectant treatment is justifiable in the incipient stage. Then the inflamed mamma needs to be sup- ported by a sling, preferably of gauze, and treated by moist applications. When the inflammation subsides, compression must be exerted by a muslin bandage (Fig. 148). How far com- pression after Bier's method is apt to check inflammation, is not sufficiently proved yet. In selected cases the new method has certainly aborted the inflammation. But in the far greater majority of cases puerperal inflam- 298 Diseases of the Breast. mation of the breast leads to suppuration. Proper treatment consists in early incision. This must be large, so that the surgeon is able to introduce his finger into the abscess cavity. By doing this it will often be found that there are several abscess cavities, which are sepa- Fig. 147. — Inflammation of Left Breast Five Weeks after Puerperium. Note extensive pigmentation caused by previous dermatitis. rated from each other by a wall consisting of more or less degenerated or even necrotic tissue (Fig. 150). Such tissue is only detected by the introduced linger, which at the same time frees it, so that the debris can be washed out by irrigation. Evacuation of Mammary Abscess. 299 If these masses are left, they become decomposed in spite of frequent irrigation. Besides this they prevent thorough evacuation of the neigh- boring abscess cavities. If an incision is made then at the Fig. 148. — Compression Bandage (Figure-of-eight). fluctuating point only, there is but temporary relief, the feb- rile condition still persisting, as the other abscesses also make an effort to perforate in different directions. A large incision, which combines all abscess cavities, so that one large cavity 300 Diseases of the Breast. is formed from which all necrotic fragments are removed, is the only procedure which answers the demand of modern surgical principles. This can be done bluntly sometimes; in the majority of cases a sharp spoon or scissors and forceps are required for the thorough elimination of the masses. To get good access the wound-margins are kept separated by retrac- tors. The cavity is packed tightly with gauze on the first day, as there is considerable oozing. On the following day pack- ing may be done loosely. Sometimes the abscesses are located in the subcutaneous tissue or only in the superficial lobules (supra/mammary abscess). The principles of treatment are the same in this mild form, but it is immaterial in which direction the incision is made. In the common type of intramammary abscess, where the pus has distended the lobules and infiltrated the enveloping connective tissue, the incision line must radiate from the nipple, in order to prevent injury to the ducts. If this incision is made long enough and the cavity well exposed, no additional incisions ever become necessary. The rarer type, called retromammary abscess, spreads from the deep lobules, in which case the whole gland is pushed forward so that it floats, so to say, on a purulent bed. There a large elliptic incision is best made at the base of the breast, where fluctuation is most marked. Otherwise the principles of treatment are the same. Of course, if previous incisions were made, their fistulous tracts may be divided, so that one large cavity is formed (Fig. 149). The operations for mammary abscess can, as a rule, be done under local anaesthesia (ethyl chloride or Schleich's infiltra- tion) . One of the sequelae of mastitis is extensive cicatrization, which results in a shrinkage of the gland. This may in a later period of life give an impetus to the development of carcinoma. In other cases cicatrization may obstruct a duct, so that the Chronic Mastitis. 301 secretion is retained at the point of obliteration and dilates the canal like an ampulla, thus giving rise to the formation of galactocele. The treatment of galactocele consists in free division and packing. If operative interference is deferred, the retained milk becomes thickened at first and presents an oily or batter- like appearance later. In some instances the fluid contents are absorbed and mortar-like connections form. Fig. 149. — Seven Fistulous Tracts United into One Large Opening in Old Retromammary Abscess. Chronic (Interstitial) Mastitis. — This is a type of mas- titis observed shortly before or after the menopause, which is characterized by the formation of dense or circumscribed infil- trations in the mammary gland. Its course is chronic. Its similarity to carcinoma is so much more obvious as there are often swollen glands present in the axillary region. In tegu- mental inversion is also observed sometimes. This form of in- 3 02 Diseases of the Breast. flammation generally starts synchronously on both sides. In contradistinction to carcinoma, size and consistency of the inflammatory area change often. The diagnosis is sometimes made ex juvantibus et nocentibus. Iodide of potassium in Fig. 150. — The Principal Types of Mammary Abscess-formation. 1. Muscularis pectoralis major. 2. Retromammary space. 3. Third rib. 4. Intercostal spaces. 5. Lung and pleura. 6. Subcutaneous tissue, a. Submammary abscess, a". Opening into the subcutaneous tissue, b and d. Isolated mammary abscesses, c. Circumscribed areolar abscess, e. Subcutaneous abscess. medium doses (15 to 20 drops of a saturated solution t. i. d.), applications of blue ointment, or massage are generally effi- cient, if the diagnosis was correct. Recently the Rontgen treatment has also given good results in such cases. Chronic Lobar Mastitis. 3°3 As to differentiation it may be said, however, that in such cases usually both breasts are involved and that the mammary gland participates in its totality, while at the early stage of carcinoma a small portion is palpable only. The skin is generally movable and entirely free from the infiltrated mass, which never adheres to the pectoral fascia. While axillary glands are sometimes found, they are more frequently absent and never as hard nor as much enlarged as in carcinoma. Fig. 151. — Chronic Interstitial Inflammation in Left Breast of a Woman of Forty-one Years, Cured by Internal and Rontgen Treatment, Note brownish hue of left areola while the right is normal, also slight inversion of the left nipple. The author called attention to the frequent pigment formation in the areola of the breast in chronic inflammation. Small nodules are also found sometimes in the diseased areola (Fig. 151)- Chronic lobar mastitis is a much rarer type of chronic inflammation. It is either caused by trauma (blow or squeeze) or by incomplete involution at the cessation of lactation. The 304 Diseases of the Breast. inflamed lobule is enlarged and the patient suffers considerable pain, which is increased during the period of menstruation. The treatment consists in supporting the gland and keeping the arm of the inflamed side in a sling. Warm applications of Burow's solution are also advisable. MAMMARY CYSTS. Galactocele as a result of cicatricial obstruction of the ducts was mentioned in the foregoing section. Their walls are lined with epithelium of the columnar or cuboidal types if a part of the lobe or of the duct is involved. If the cyst enlarges the epithelium may be flat and squamous or may become sur- rounded by a fibro-cellular layer. If cysts form in chronic interstitial inflammation, they are called involution- cysts. Cystic dilatation may also be ob- served in association with carcinoma or papilloma of the ducts, or in cystadenoma. Cysts which develop in the interstitial tissue are called interacinous, and are either of a serous nature or represent the type of hydatids or dermoids. The serous variety is the result of a dilatation of the lymph- spaces and is either uni- or multi-locular. Its lining is a smooth epithelial layer. It contains serum, slightly tinged with blood. In old cases colostrum is also found. Not being in direct connection with the gland, the serous cyst does not show any discharge from the nipple. If the cyst- wall remains thin, translucency is noticed, just as in hydrocele. Regarding differentiation from carcinoma, it should be appreciated that the serous cyst shows elastic resistance on pal- pation, while carcinoma is characterized by its hardness. Re- traction of the nipple or enlargement of the axillary glands is never observed. In case of doubt exploratory aspiration with Tuberculosis Mammae. 305 a large needle will clear the situation. The treatment should consist in thorough removal. The other cyst-types are rare and their treatment is essen- tially the same. Cysts originating from adjacent carcinoma- tous or sarcomatous tissue require no special consideration. SPECIAL INFLAMMATORY PROCESSES IN THE MAMMARY GLAND. The special inflammatory processes in the mammary gland are tuberculosis, actinomycosis, and syphilis. Tuberculosis mammae is rare and is nearly always found in the female, especially in anaemic individuals, who present the tuberculous habitus. It is never observed before the period of puberty. Its avenues of infection are either the ducts or the circulation. The bacillus may also be transmitted from the neighboring organs, viz., the ribs, the pleura, or the axillary glands. The clinical signs vary greatly. There may be a circum- scribed abscess in the gland, which causes its enlargement, so that an elastic and fluctuating intumescence is palpated, while the integument is entirely normal. If an incision is made, cheesy sero-pus is discharged. The abscess cavity shows the same lining membrane which is found in so-called cold ab- scesses. In other cases the character is diffuse, tuberculous nodules being scattered and then developing in the interacinous tissue. Pus is forming and perforates the skin at various places, so that the breast is finally riddled with sinuses which discharge cheesy pus. The nipple becomes inverted, while the base of the gland remains freely movable. The axillary glands are swollen and show the signs of caseous degeneration and destruction. In the incipient stage the diagnosis is sometimes difficult. Later, when fistulaa form, tuberculosis is obviously thought of, 306 Diseases of the Breast. as the character of the discharge and microscopical examina- tion corroborate the diagnosis. In cases of doubt inoculation of a lower animal settles the question. The treatment consists in the amputation of the mammary gland and the evidement of the axillary space. The after- treatment is essentially the same as in carcinoma mammae (see page 328). If the process was confined to the gland, the prognosis is favorable. Actinomycosis mammae is very rare. The diagnosis is made on the principles described in actinomycosis of the ribs (page 10 1). The treatment consists in ablation of the mam- mary gland. Successful operations' are reported by Ammer- torp, Muller, and von Angerer. Syphilis mammae is rare. As mentioned before, a pri- mary lesion may be observed on the nipple. Tertiary forms assume the character of superficial as well as of deep-seated gummata. The treatment is internal (inunctions with blue ointment combined with the administration of iodide of potas- sium); the author also favors the long-continued administra- tion of protojoduretum hydrargyri in pill form. 1 ECHINOCOCCUS OF THE MAMMARY GLAND. Echinococcus of the mammary gland is rare, especially in the United States of America. The signs resemble those of ordinary cyst formation, as described (page 304). Their onset is slow and painless. In case of irritation by trauma inflammation and suppuration may take place, so that the echinococcus-cyst is taken for an abscess. The treatment consists in the thorough extirpation of the sac. 1 I^. Protojoduret. hydrargyri, Opii puri, aa 0.3. Extr. acori, q. s., ut f. pilul. No. xxx. SiG. — Three pills a day. Neuralgia and Hypertrophy of Breast. 307 NEURALGIA OF THE MAMMARY GLAND (MASTODYNIA). Mastodynia occurs in breasts which are apparently normal. Hysteric women are especially subject to it. Frequently it is associated with disturbances of the sexual sphere, also with intercostal neuralgia. The pain becomes intensified shortly before menstruation, the patient then often being in a state of great nervous excite- ment. Sometimes small indurations (neurofibroma) are found in healthy individuals. The treatment must be directed against the fundamental factors. Thus a cure is effected by gynaecological treatment in the majority of cases. If this should not alleviate the pain, local therapy should be tried, sus- pension of the breast, hot applications, electricity, etc. The author has observed surprising relief in one of his cases from exposure to the Rontgen rays. HYPERTROPHY OF THE BREAST. Benign hypertrophy of the breast is observed at the period of puberty, or in young pregnant women in the great majority of cases (Fig. 152). As a rule, both breasts participate in the swelling, which develops in a few months. The sub- stance of the gland, as well as the interstitial tissue, become involved in the hyperplastic proliferation, which is of a fibro- adenomatous character. The whole mammary gland appears indurated then, growing so large that it hangs down as far as to the umbilicus. Pain is generally absent. The weight of the hypertrophied breasts causes functional disturb- ance, whereupon partial as well as total amputation was resorted to. Fig. 153 illustrates the case of a woman of thirty years, in whom keloid-formation followed partial excision. The internal treatment of this disease does not show any 3 o8 Diseases of the Breast. In men the mammary glands develop to such an extent, sometimes, that they appear like female breasts (gynecomastia). In these rare cases the glandular, fatty, and connective tissue is overdeveloped. Fig. 152. -Hypertrophy ,of Both Breasts in a Woman of Twenty-five Years. TUMORS OF THE MAMMARY GLAND. Tumors of the breast are extremely frequent and show a large number of varieties, the differentiation of which is often difficult. For practical reasons we may distinguish benign and malignant tumors. In general, we may say that the benign Tumors of Breast. 309 tumors consist of homologous tissue, that is, of such tissue as is found on their own soil, as, for instance, fibroma and adenoma. The malignant tumors consist of heterologous tissue, that is, of such tissue as is not found on their own soil, as, for instance, sarcoma and carcinoma. There are, however, some exceptions to this general rule. Enchondroma is a heterological type and is still mostly of a benign nature. Fig. 153. — Keloid Formation after Partial Excision of Hypertrophieo Breast. It is one of the characteristics of the benign tumors that they remain circumscribed and well defined from their vicin- ity. They push the adjacent tissue aside only, while the malig- nant tumors permeate and infiltrate it. This is the main reason why benign growths are freely movable. Benign tumors are generally found at an early age, carci- noma, for instance, rarelv being observed before the thir- 3 io Diseases of the Breast. tieth year, while fibroma is generally found at the period of . puberty. The family history often gives some hints regarding malignancy. The relation of the tumor to the mammary gland, as well as its form and consistency, must be elicited by a careful ex- amination. It must be ascertained whether there is any fluctu- ation, whether mobility exists, and whether this be superficial or deep. Any protrusion of tumor or gland must be noted, as well as dimpling of the integument, and the appearance of the nipple (Fig. 1 54) . Both breasts must be carefully compared . The axillary relations should also be investigated, while the arm is raised. ABC Fig. 154. — Sagittal Diameter of Various Deformities of the Mammilla. A, Normal mammilla. B, Shortness of the mammilla. C, Invagination of mammilla. D. Umbilication of the mammilla. E, Retraction of mammilla in cancer. It must furthermore be elicited at what time the tumor was detected at first. The more rapid the growth of the tumor is, the greater is its abundance of cells; consequently, the softer and the more vascular it will be. The further course of malignant tumors is characterized by cachexia. ADENOFIBROMA (FIBROADENOMA). Adenofibroma is the most frequent representative of the benign type in the breast. It is especially observed in indi- Benign Tumors of Breast. 311 viduals between the ages of twenty and thirty, in rare cases up to the fortieth year. Its etiology often points to a trauma. Its size varies from that of a filbert up to a man's head. Most of these growths remain small for years. Its main characteristic is its free mobility. The consistency is firm and hard. If increasing in size, it may become elastic on some portions. Pain is generally absent, but sometimes found in neurotic women. The shape is globular or oval, and the surface smooth. The tumors are encapsuled, which explains that they never invade the surrounding tissues. Anatomical examination shows a foliated texture, like cab- bage, of a gray or whitish color. The tumor is composed of glandular elements, which are imperfectly developed, but show the type of the mammary gland. They are enveloped by firm connective tissue. The treatment is distinctly surgical, enucleation being gen- erally possible under local anaesthesia. The direction of the incision must be radiating from the nipple. ADENOMA. Pure adenoma is extremely rare. In the great majority of cases it is confounded with adenofibroma, its characteristic features being recognized by microscopical examination only. LIPOMA, ATHEROMA, MYXOMA, ANGIOMA, CHON- DROMA, AND OSTEOMA MAMMAE. All these tumors are of rare occurrence. Lipoma is easily recognized, as it can be well defined from the gland. It origi- nates either laterally or posteriorly of the mammary gland, which it pushes aside. Sometimes lipoma mammae reaches large size. Atheroma (syn., cholesteatoma) mammae resembles seba- ceous cyst, its fatty contents consisting of cholestearin-like 312 Diseases of the Breast. substances. The cyst-wall is thin and can be easily enucleated. It consists of connective tissue, lined with epithelium. Myxoma as well as angioma mammae are extremely rare, and their clinical course shows the same features as adenofi- broma. Chondroma and osteoma are also rare. If there is any doubt as to their nature, the Rontgen rays will furnish infor- mation as to the character of their texture. SARCOMA OF THE MAMMA. Sarcoma mammae is very much less frequent than carci- noma. Among the tumors of the breast sarcoma figures with about 88 per cent., the predominant type being the spindle-celled. Most of the cases show cystic degeneration at the same time. The spindle-celled sarcoma and also the cystic variety are especially found in women of the age of twenty to thirty-five years. Both types are characterized by their slow growth. The spindle-celled sarcoma mammae (Fig. 155) is of glob- ular or oval shape and at its initial stage is easily confounded with adenoflbroma. But in its further course it shows close connection with the adjacent tissue, which it soon permeates and infiltrates. The microscopical examination, however, must be principally relied upon for an exact diagnosis. The axillary glands are but rarely affected. When the diagnosis is made, extensive removal of the breast after the principles of extirpatio mammae in carcinoma is indicated. The same applies to the round-celled sarcoma mammae (Fig. 156), which is softer than the spindle-celled and more elastic. It soon permeates the adjacent tissue and grows rapidly. Often metastases are found in the axilla. Sometimes metastatic nodules are found through the whole body. Cystic Sarcoma Mammae. 3 J 3 as well as myxomatous degeneration is also frequently observed in this type. Its predilection is for women between the ages of thirty and forty. Its rapid growth, the absence of integumental dimp- ling and of retraction of the nipple are pathognomonic signs in FiG'155. — Fibrosarcoma Mammas (Spindle-celled) in a Woman of Twenty- three Years. contradistinction to carcinoma. The treatment is the same as that of the foregoing variety. The other types, viz., the giant-celled, the medullary or alveolar, besides angio-, lympho-, chondro-, and melano-sarco- mata, practically fall under the same consideration. After 314 Diseases of the Breast. extensive removal Rontgen treatment at intervals should be given for at least a year. (As to the principles of the technic, see following section.) Fig. 156. — Incipient Stage of Cystic Sarcoma (Round-celled) in a Woman of Twenty-one Years. CARCINOMA MAMJVLE. Excepting uterus and stomach, no other organ of the hu- man body is so frequently the seat of carcinoma as the mam- mary gland in women. In men carcinoma of the breast is observed about a hundred times less frequently. The author ^Etiology of Cancer. 315 observed five cases, all of which were operated upon, and suc- cumbed finally after repeated recurrence. 1 The marked disposition of the mammary gland to can- cerous degeneration is well understood, if the repeated changes in its functional activity — its abundant blood-supply (see Figs. 141, 142, 143, and 144) — as well as the relations to the sexual organs are considered. All movements which cause frequent and intense fluctuations in its state of nutrition as well as in its development, explain the tendency to metamorphosis. That it is preeminently the function of the gland, which is to be re- garded as a predisposing factor, is evident from the fact that carcinoma mammae is never observed before puberty. At the climacterium the gland undergoes a process of fibrous degen- eration, which must be considered normal, but there is no doubt that during this period the gland is more inclined to heterological metamorphosis than at any other. The author has seldom seen a case in which the patient did not attribute her carcinoma to an injury. But while there is no doubt that trauma is a contributing element in the aetiology of carcinoma mammae as well as in other malignant neoplasms, there is no proof that it is the essential factor. No doubt, a blow or a squeeze is very frequently inflicted upon the breast without showing any ill consequences, and soon escapes the patient's memory, while if there is a growth, the occurrence is remembered well and the degree of violence generally exagger- ated. It seems that the continuous irritation exerted by a badly-fitting corset, is very apt to act as a predisposing element. If in cutting bread the loaf is pressed against the mamma, as is customary among some women, irritation may frequently be produced. Attention may also be called to the development of carcinoma in old scars (see Fig. 60), in lacerations of the cer- vix, in psoriasis of the tongue, in phimosis, in the scrotum of chimney-sweepers, on the lip and tongue of heavy smokers. 1 "Clinical Recorder," October, 1896. 316 Diseases of the Breast. Heredity may also be considered, but too much importance should not be attributed to it. As we know to-day, the morphological character of carci- noma is entirely epithelial. The cells of the carcinomatous tissue show epithelial structure, not only in regard to their nuclei and their protoplasm, but also with respect to their origin. As mentioned before, it is a characteristic feature of the tissue of malignant growths that it is decidedly hetero- logical. Therefore a connective-tissue cell cannot be trans- formed into an epithelial cell, nor can the latter be made from the former. Only the various kinds of epithelium can be transformed into another kind, as, for instance, a squamous cell can be transformed into one of a cylindrical type. So the essential element of carcinoma is the epithelial cancer cell. In some carcinoma types the epithelial cells are, in fact, the only cancer element present, as in the lumen of the lymph- vessels in the lungs or the uterus. In other types there is a well- marked stroma, the character of which would indicate nothing of special importance as far as the dignity of the process is con- cerned ; in other words, the stroma is simply an accessory con- stituent. Thus it is to be realized that every form of carcinoma is in reality an epithelioma. The carcinomatous varieties must then be determined by the various branches of the arrangement of the morphological and the biological nature of the cells. We may thus distinguish epithelial cells with a typical as well as with an atypical ar- rangement (Fig. 157). The variety which is characterized by the typical arrangement is of a glandular nature (adenomatous) and consists of cylindrical cells forming glandular canals (ducts) or shows an arrangement in strata. They resemble the epider- mis and are, therefore, generally called cancroids. In the atypi- cal variety the cells are arranged irregularly and are found in masses and patches. The different varieties are distinguished according to the special organs in which the parent growth Transplantation of Cancerous Tissue. 317 has originated. This variety is the cancer par excellence. Be- tween these two large groups we find a number of varieties of mixed and transitional forms. Whether the limitless and aberrant growth of epithelial cells, which constitutes carcinoma, originates from a parasite, cannot be proved by our present means of knowledge. While the attempts to transplant carci- noma, that is, to produce an artificial metastasis, so to say, have been successful once in a while, so far a primary carcinoma 38&f 7i5- " On Surgery of the Thorax, Brit. Med. Journ., 1892, vol. ii, p. 831. Gravier: Des fistules bronchocutanees nontraumatiques, These de Paris, 1897. Groenstad: Gangran beider Unterextremitaten nach Contusion des Thorax, Norsk. Mag. for Laegevid, 1887, Ref. Centralbl. f. Chir., No. 13, 1888. Gross, H.: Commotion des Thorax, Bruns' Beitr. z. klin. Chir., Bd. xxiv. Gross (Krause) : Erfahrungen liber Pleura- und Lungenchirurgie, Beitr. z. klin. Chir., 1899, Bd. xxiv, Heft 2. Gurlt: Handbuch der Lehre von den Knochenbruchen, 1860-65. Gussenbauer: Contusion des Thorax, Deutsche Chir., 1880, Lieferung 15. 35 8 Bibliography. Habart: Die Geschosswirkung der 8-mm.-Handfeuerwaffen, Wien, 1892. Hagmann: Angeborene Missbildungen des Thorax, Jahrb. d. Kinder- heilk., N. F., Bd. xv, 1880. 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Abscess of lungs, 206 diagnosis of, 206 localization by Rontgen method, 249 treatment of, 207 Actinomycosis of breast, 306 of chest wall, 101 of lungs, 211 Adenonbroma mammae, 310 Adenoma mammae, 311 Air-chamber of Sauerbruch, 136 Anaesthesia in abscess of lung, 211 accidents in, 164 in pyothorax, 159 Anatomy of thoracic wall, 1 Aneurysm of thoracic aorta, 226 Arteries, axillary branches, 35 of costal region, 35 of heart, 121 Artery, acromial thoracic, 35 internal mammary, 35 superior intercostal, 36 thoracic, 35 thoracico-dorsal, 35 Articulations, costo-central, 26 costo-chondral, 29 costo-spinal, 26 costo-sternal, 24 costo-transverse, 27 interchondral, 28 Asepsis, 61, 64 Aspiration of pericardium, 116 of pleural effusion, 147 Aspiratory puncture, 132 in subphrenic abscess, 272 syringe, 132 Atheroma mammae, 311 Axillary lines, 5 Bacteria of skin, 62 Bacteriology in pyothorax, 141, 146 Blade of sternum, 9 Body of ribs, 11 Bone-formation after rib-resection, 200 Boundary lines of thoracic cavity, 1 Breast, diseases of, 290 Bronchi, anatomy of, 236 Bronchiectasis, 213 Bronchiectatic cavity, localization of, by Rontgen method, 249 Bronchoscopy, 242 Buelau's suction method in pyothorax, 171 Burns of chest wall, 73 Carbuncle of chest wall, 88 Carcinoma, aetiology of, 315 general views, 316 of breast, 314 of chest, developing in scar, 81 of chest wall, 106 Caries of rib, 92 Cartilages, costal, 29 Chest wall, flatness of exterior, 60 Chondroma mammae, 312 Chronic mastitis, 301 lobar, 303 Chylothorax, 202 Contusion of thorax, 82 Costal region, 31 Cysts, sebaceous, of chest wall, 10 1 mammary, 304 Decortication, 192 Defects, costal, 44 Dermoids of chest wall, 101 intrathoracic, 222 Dextrocardia, 259 Diameter of thoracic cavity, 2 Diaphragm, anatomy of, 40 surgical diseases of, 225 wounds of, 125 Dislocation of rib, 73 Drainage in pyothorax, 177 Echinococcus causing subphrenic ab- scess, 278 of chest wall, 112 of lungs, 214 localization of, by Rontgen method, 249 Eczema of nipple, 293 Embryonic thorax, 4 Empyema, pleural. 137 necessitatis, 167 25 3 6 9 37o Index. Enchondroma of ribs, 105 of sternum, 105 Exploratory pleurotomy, 133 principle in thoracic resection, 187 Exterior aspect of chest, 2, 6 Fascia, endothoracic, 34 Fibroma of chest wall, 102 molluscum of chest wall, 102 Foreign bodies in respiratory passages, 239 extraction of, 241 Fracture of costal cartilage, 73 of rib, 69 of sternum, 68 Furuncles of chest wall, 87, 349 Galactocele, 301, 304 Gangrene of lungs, localization of, by Rontgen method, 249 Gas in subphrenic abscess, 269 Gelatin-injection in aneurysm, 234 Growths of chest wall, benign, 101 malignant, 105 Gumma of chest wall, 105 Gunshot wounds of thorax, 67 Hemangioma, cavernous, of chest wall, 103 Haemopericardium, 116 Hemothorax, 201 Handle of sternum, 6 Heart, anatomy of, 120 Rontgen method of examining, 258 suture of, 125 Hodgkin's disease, 108 Hydropneumothorax, Rontgen method in , 2 5 8 Hydrothorax, 201 Hypertrophy of breast, 307 Inflammatory processes of chest wall, 86 Influenza bacillus in pyo thorax, 144 Infusion, submammary, 133 Injection treatment, 94 Injuries of heart, 122 of pericardium, 116 of thoracic wall, non-penetrating, 61 penetrating, 83 Intercostal muscles, external, 32 internal, ^^ spaces, 175 Intramammary abscess, 300 Intrathoracic diseases, 114 tumors, 222 Involution-cyst of mamma, 304 Iodoform-injection in tuberculosis, 93 Keloid of thoracic integument, 102 treatment of, 348 Kyphosis, 55 Ligaments of thoracic bones, 24 Lipoma of chest wall, 10 1 mammae, 311 Lisfranc's tubercle, 15 Localization, 5, 249 Lordosis, 57 Lungs, abscess of, 206 actinomycosis of, 217 anatomy of, 203 carcinoma of, 223 echinococcus of, 214 gangrene of, 211 sarcoma of, 224 surgical diseases of, 206 tuberculosis of, 219 Lymphangioma of chest wall, 104 Lymphatics of axilla, 294 of costal region, 40 Malformations of thorax, 43 Mamma, enlargement of, 53 in hermaphroditism, 54 removal of, 324 Mammae, supernumerary, 53 Mammillary line, 5 Mastitis, 294 puerperal, 297 Mastodynia, 307 Median line, 5 Mediastinum, 115 portions, 126, 127 Moss-board as a dressing, 66, 255 Movement of ribs, 16 Myxoma mammae, 312 Nevus of thoracic integument, 103 Nerves of costal region, 40 Neuroma of thoracic wall, 104 Nipple, diseases of, 292 (Esophagus, foreign bodies in, 244 Ossification of ribs, stage of, 15 Osteoma of breast, 312 of chest wall, 105 Osteomyelitic rib-abscess, 91 Index. 37i Parasternal lines, 5 Pectoralis major muscle, anatomy of, 31 minor muscle, anatomy of, 31 Pectus carinatum, 60 Pericardiotomy, 118 Pericarditis, 72 Pericardium, anatomy of, 114 Rontgen method of examining, 259 Perimetric figures of thorax, 3 Periosteotome, author's, 154 Phlegmon of thoracic wall, 90 Pleura, anatomy of, 125 diseases of, 128 Rontgen picture of, 256 Pleural speculum, author's, 156 suture in abscess of lungs, 210 Pleuritis sicca, 72 Pleurotomy, exploratory, 133 Pneumococcus in pyothorax, 144, 145 Point of sternum, 10 Pressure symptoms in injuries of heart, 123 in serothorax, 131 Processes, articular, of vertebrae, 20 spinous, of vertebras, 18 transverse, of vertebras, 19 Prolapse of lung tissue, 85 Protrusion of lower rib cartilages, 60 Pseudoleukemia, 108 Pyothorax, 137 aetiology of, 141 criticisms of various methods of diagnosis of, 148 old cases, 180 operation of, 151, 166 Rontgen method in, 257 statistics in, 177 Recurrence of carcinoma mammae, 337 Regeneration of ribs, illustrated by Ront- gen method, 199 Resection of rib, 151 in old cases, 181 simultaneous, of two ribs, 158 Respiratory passages, foreign bodies in, 239 Retromammary abscess, 300 Ribs, anatomy of, 10 cervical, 45 operation for, 49 Rib-shears, author's, 153 Rontgen method in thoracic surgery, 246 treatment of carcinoma mammae, 335 of thoracic dermatoses, 340, 345 , 348 Sarcoma of breast, 312 of chest wall, 105 Sayre's apparatus, 59 Scapular lines, 5 Schede's principle in thoracic resection, 184 Scoliosis, 58 Serothorax, 129 Serratus anticus major muscle, anatomy of, 32 Skin grafting in burns of chest wall, 78 Solid masses, importance of, in pyothorax, 156, 169, 174 Spina bifida dorsalis, 54 Staphylococcus in pyothorax, 144 Sternal extremity of ribs, 11 lines, 5 region, 6 muscles of, 29 nerves of, 31 vessels of, 29 Sterno-costal lines, 6 Sternum, anatomy of, 6, 23 malformations of, 43 representation of, by Rontgen method, 247 Streptococcus in pyothorax, 144, 145 Subclavius muscle, anatomy of, 31 Subphrenic abscess, 261 Synostosis of ribs, caused by drainage- tubes, 198 Syphilis of breast, 306 of rib, 100 of sternum, 100 Thoracic aorta, aneurysm of, 226 Trachea, anatomy of, 236 Triangularis sterni muscle, anatomy of, 34 Tuberculosis of breast, 305 of lungs, 219 of rib, 98 of sternum, 96, 99 Tuberculous pyothorax, 145, 162 Tubular diaphragm in hypertrophied pleurae, 253, 254 Tumors of chest wall, 101 intrathoracic, 222 of mammary gland, 308 Vertebrae, thoracic, 16 peculiarities of, 21 Vertebral extremity of ribs, 1 1 Vulpius' operation for costal defects, 45 Wound-margins, protection of, 04 Wounds of heart, 1^4 of thoracic wall, treatment of, 61 Wound-treatment, 04 APR 2 190?