Tumors of the lung proper might be made amenable to surgery, in certain

instances, if an exact diagnosis could be made. Occasionally this is

possible, though but very rarely. Particles of lung tumor have been

expectorated and their minute character recognized, so that actual

diagnosis has been made. As in the abdomen, cancer of the thoracic

viscera will usually lead to an accumulation of serous fluid, and, in

both instances, thus obscure rather than simplify recognition. Quincke

has shown that the presence in such pleuritic effusions of fat cells

(hydrops adiposus) is significant, since they rarely if ever occur in

any other exudates.

Primary tumors of the lung are usually _sarcomas_ or _endotheliomas_.

_Carcinoma_ is exceedingly rare, save as secondary to cancer in the

breast. Even sarcoma is itself usually secondary to disease in some

other part of the body, metastasis having occurred through the blood

channels, instead of through the lymphatics, as is the case with

carcinoma. Tumors arising in the pleura may be of endotheliomatous type

and are usually accompanied by the presence of bloody serum. Extremely

rare tumors within the chest are those of _dermoid origin_, connected

more often with the pleura than with the lung proper. These may

suppurate and communicate either externally or internally. One known

case mentioned by Dennis was that in which such a tumor communicated

with a bronchus, so that the patient coughed up hair. _Syphilitic

gummas_ are also found in the lung, either in multiple small form or in

masses of considerable size. They are slow in development and may give

rise to no special disturbance. Dennis has described instances in which

these growths have become encapsulated.

Two other forms of tumor are not very rare in this situation: one is

that produced by _actinomycosis_; the other occurs in _echinococcus_

disease and in the formation of _hydatid cysts_. The former, developing

within the lung proper, tends to migrate toward its surface, to include

the pleura, and finally to invade the chest wall. Such a tumor when

exposed in either location can scarcely be differentiated from a

breaking-down sarcoma, except by the recognition in it of the small,

calcareous particles which are so pathognomonic of this disease. (See

Actinomycosis.) In the living patient the sputum will frequently

contain these particles, while under the microscope the peculiar

club-end, thread-like fungus formation may be recognized. The disease

is usually of slow development, but occasionally, especially when mixed

with a secondary infection, may be rapid. Significant tumors may also

occur in other parts of the body. Actinomycotic tumors upon the surface

may be attacked with curette and cautery. Injections of iodine are also

of value. For actinomycosis of the lung proper potassium iodide and

Lugol’s solution are indicated as well as copper sulphate.

_Hydatid cysts_ occur within the lungs in about 10 per cent. of cases

of echinococcus disease. Their contained fluid is alkaline, of low

specific gravity, colorless, and contains the characteristic hooklets

which are pathognomonic of this disease. A circumscribed collection

of fluid within the chest, shown to be due to this condition, may

be tapped or incised and drained. When occurring in the lung it not

infrequently leads to secondary pyothorax, while operation for the

latter may reveal the existence of the former. Any hydatid cyst of the

lung which can be recognized, or be made accessible, may be treated

by incision and drainage, the lung, if not already adherent, being

first fastened to the chest. Inasmuch as the condition develops in the

lower lobe and on the right side this is occasionally a practicable

procedure. As the diagnosis is usually made only after the primary

cyst has ruptured and small cysts are cast off, producing more or less

pleuritic effusion, the attempt may still be made to do this by a free

incision of the chest wall, perfecting the diagnosis and completing the

procedure at this time.

THE HEART.

There is but little to be said about the heart in addition to that

elsewhere stated, where such injuries as gunshot wounds, stab wounds,

etc., are considered. _Rupture_ of the heart without external injury is

possible under conditions of fatty degeneration or softening produced

in consequence of embolus or thrombus. _Aneurysms of the heart_ are

also known by which it is weakened and permitted later to give way.

The final rupture is usually the consequence of some emotion or extra

exertion, although it may occur with injury to some other part of the

body, as after a blow upon the abdomen. Death may be instantaneous, or

occur more slowly as the result of filling of the pericardial sac and

rapidly increasing embarrassment of heart action.

_Wounds of the heart_ produce syncope and shock, restlessness, extreme

anxiety, with dyspnea and such disturbance of heart activity as to

materially change the sounds heard on auscultation.

The treatment of such cases not primarily fatal should include opium

narcosis, but not stimulants intended to excite the heart to extra

activity. The operations justified under these conditions are elsewhere

described.[50]

[50] Borchardt has collected 83 cases of operations upon the

heart, of which 78 included heart suture. Of these 78, 46 died and

32 recovered. He quotes a statement of Billroth, made when this

surgeon was sixty years of age: “Paracentesis of the pericardium

is an operation which, according to my view, closely approaches to

what might be considered a prostitution of surgical art, or, as

some surgeons would call it, a surgical frivolity, an operation

which altogether has more interest for the anatomist than for the

physician. Possibly a later generation will regard it differently.

Internal medicine is constantly becoming more surgical, and those

physicians who concern themselves especially with internal medicine

will find themselves compelled to make the most daring operation.”

The rapid advances made in surgery during the past three decades

cannot be better illustrated than by contrasting Billroth’s statement

of a few years ago with the standard practice of today.

_Pericarditis_, either of idiopathic or traumatic origin, may produce

a degree of distention, either _hydropericardium_ or _pyopericardium_,

calling for surgical intervention--in the former case with the

aspirating needle, in the latter either with the needle or the knife.

When a pericardium is greatly distended with fluid there is marked

change in the position of the apex beat, with embarrassment of heart

action, accompanied by distress and distention of the veins of the

upper part of the body, as well as much alteration of the ordinary

physical signs, the area of dulness being correspondingly enlarged and

the lung sounds being lost over the area occupied by the distended sac.

Great distention, with marked precordial trouble and distress of heart

and lung function, always requires _paracentesis_.

_Paracentesis pericardii_ is performed ordinarily by puncturing (a

previously sterilized area) 3 to 5 Cm. to the left of the left border

of the sternum, and in the fifth intercostal space, with a sterilized

needle. Here are found the internal mammary artery and the pleura. Too

rapid withdrawal of fluid may lead to syncope. It should, therefore, be

allowed to escape slowly. Should it prove purulent it may be incised,

passing the knife-blade along the needle; or the sac may be emptied,

when, if fluid re-collect, a free incision should then be made. Roberts

has shown that recovery follows in at least 40 per cent. of cases

of empyema of the pericardium thus treated. Gauze drainage may be

provided, but irrigation of the cavity should not be practised.

Allingham has suggested to open the pericardium from below by an

incision three inches in length, carried along the lower margin of

the seventh left costal cartilage, to separate the cartilage from the

abdominal muscles, pull outward and upward the lower surface of the

diaphragm, expose the cellular interval between its attachment to

the cartilages and to the tip of the sternum, to expose and enlarge

by blunt dissection, until there appears a mass of fat which belongs

above the diaphragm in the interval between the pericardium behind,

the sternum in front, and the diaphragm below. When this is removed

the pericardium is exposed and can here be opened. Throughout the

procedure injury to the pericardium which lines the upper surface of

the diaphragm should be avoided. By this method the pleura need not be

opened and better drainage may be secured. (Dennis.)

_Abscess in the heart wall_ is an exceedingly rare lesion, usually

accompanying pyopericardium, but occasionally met without it. It

was the writer’s experience in one case, in puncturing for what was

supposed to be a pyopericardium, to withdraw pus and give temporary

relief. Later postmortem examination showed that this pus came from a

large abscess in the wall of the heart, which had been thus entered by

the aspirating needle without immediate bad consequences, but, on the

contrary, with temporary relief.

THE LUNGS.

In the fact that the lung never completely fills the pleural cavity

we find explanation for the kindred fact that small effusions produce

little if any compression symptoms. Collapse of one lung after opening

the chest is never _complete_ if the other lung be uninjured and

functionating. Moreover, a partial collapse on the affected side will

be quickly atoned for when the pressure of the external atmosphere is

taken off.

Two or three serious pathological conditions of the lung occasionally

require surgical intervention.

HYDATIDS OF THE LUNG.

Hydatids of the lung have been mentioned (see above). Seventy-five per

cent. of these cases terminate fatally without surgical help, and in

reality more prospective benefit can be offered by it than without it.

Serious and even fatal collapse has attended the sudden withdrawal of

fluid from hydatid cysts in this location. Aspiration may be made, but

even this is scarcely less dangerous while it is less satisfactory than

free exposure and drainage.

ACTINOMYCOSIS OF THE LUNG.

Actinomycosis of the lung may be recognized by the sputum and also by

the pus discharged from any breaking-down cavity within the affected

area. (See section on the Pleura.) If a localized focus could be

diagnosticated or recognized after exposure the portion of the lung

thus involved might be removed.

ABSCESS OF THE LUNG.

Abscess of the lung is always the result of some local or distant

infectious process. The mechanism of production of the multiple

metastatic abscesses which characterize pyemia has been described in

the earlier portion of this work. For such conditions surgery affords

no aid. Circumscribed abscess may be the result of the presence of a

foreign body--_i. e._, a bullet or a parasite--or it may result from

embolism with infarct, in consequence of such affections as ulcerative

endocarditis, puerperal septicemia, sloughing fibroid, an otitis media,

or a septic pneumonia produced from any cause. It may be the result of

extension from an osteomyelitis of some portion of the bony wall of

the thorax, which itself may result either from injury or from local

infection. Abscess of the lung is seen not infrequently in connection

with _empyema_, and often results from suppurating tuberculous

_bronchial nodes_. It may be produced, also, by extension of trouble

from below the diaphragm, as hepatic abscess, subphrenic abscess, and

the like. It is always a secondary rather than a primary affection.

Such abscesses are to be recognized by the character and offensiveness

of the sputum, the pus discharged being colored green or brown,

containing shreds of tissue, with masses of bacteria and crystals of

fat. Some believe the presence of elastic fibers to be pathognomonic.

When pulmonary abscess is diagnosticated it is necessary, in addition,

to determine whether multiple lesions or a circumscribed collection

are to be dealt with. In the former instance it is of little avail

to intervene. In the latter the physical signs will usually furnish

evidence of adhesions between the lung and the chest wall, by whose

presence the operative procedure is simplified.

The term _pneumotomy_ is applied to the exposure and evacuation of pus

in the lung, whether it be found in connection with an ordinary abscess

or a suppurating hydatid cyst. It is essentially a thoracotomy, plus

the added measure of whatever may be done to the lung itself, and will

be described in connection with other operations upon the chest.

If a tuberculous abscess could be located it also might be treated upon

the same general principles. Thus Lane and others have suggested early

operations for relief of tuberculous lesions. For obvious reasons,

however, the method has not found general acceptance.

GANGRENE OF THE LUNG.

Gangrene of the lung is the terminal stage of a local infection, and

unless relieved may prove fatal to the patient. It is due to the causes

above mentioned as producing abscess in the lung, while to them may

perhaps be added a few others, especially expressions of embolism or

thrombus of the pulmonary circulation by which, the blood supply being

cut off, death of tissue occurs before there is time for phlegmonous

development. Thus it is met with occasionally after the acute exanthems

and the infectious fevers and after violent pertussis. When diffuse

it is of the miliary type. When circumscribed it may be due to more

localized causes. In any event it is more frequent in the lower

portions of the lung.

Pulmonary gangrene may be recognized by the extreme condition of the

patient, offensive odor of the breath, and expectoration of sputum

which may at first be frothy and bloody, but becomes rapidly purulent

and finally necrotic in type. Meantime, the function of the lung being

materially interfered with, respiration is rapid and there will be more

or less cough, pain, and finally collapse. When the sputum is allowed

to stand in a test tube there will form an upper layer, opaque and

frothy; a middle, more frothy layer; while the lower and denser portion

will be of a dirty green color and contain shreds of dead tissue with

bacteria, crystals of triple phosphates, fat debris, and pus. According

to the nature of the case the cavity or the area of dead lung may be

outlined by physical signs. There is a form of _fetid bronchitis_ which

has been mistaken for pulmonary gangrene, but the character of the

sputum and the progress of the case will be quite different.

Gangrenous areas of limited size have in certain favorable cases

cleared up and the patients have recovered, but ordinarily for this

condition surgery affords the only prospect of relief, the operation

being begun with a _thoracotomy_ and completed by the _removal of the

gangrenous lung tissue_. The operative procedure is essentially the

same as that for abscess and above described.

_Septic pneumonia_ is the term applied to those forms of pneumonitis

which occur in connection with septic lesions in other parts of the

body, or with the less typical forms--_e. g._, aspiration pneumonia,

due to the passage into the finer bronchioles of material from the

mouth or nose. It gives rise to the same physical signs, though it is

perhaps more often irregularly located than is the consolidation of

the ordinary lobar pneumonia. Viewed in this way it will be regarded

as a serious complication of various other conditions, many of which

are surgical, and it is frequently a primary expression of infection.

The physical signs by which it may be recognized are scarcely different

from those of ordinary pneumonia, except that, in addition to the

latter, there may be distinct expressions of general septic infection

and of profound toxemia, and that the disease may progress to the point

of producing pulmonary abscess or gangrene. While the milder types of

septic pneumonia are not necessarily fatal, it is always a serious

complication, and, as such, dreaded by the surgeon. It is not, however,

essentially a surgical complication, but calls for the treatment

generally given to pneumonia, plus whatever may be needed for the

primary condition behind it.

CHYLOTHORAX.

This implies a collection in one of the pleural cavities, usually the

left, of fluid which is practically unchanged chyle, which has probably

escaped from the thoracic duct. The number of cases on record is not

over fifty, of which about one-third have followed unrecognized injury

with probable rupture of the duct. Most of these cases have occurred in

connection with fracture of the spine. The duct may be opened by the

progress of ulcerative disease, and carcinoma is often the predecessor

of chylothorax. Rupture may also occur in connection with tuberculous

lymphatics about the course of the duct, and when the condition occurs

in children this is the usual explanation. It should be differentiated

from so-called _chyloid effusions_ into the pleural cavity, which are

more often seen in connection with cancer than tuberculosis, the fluid

in this case being mixed with fat and degenerated leukocytes or cells.

Pure chyle contains sugar, while chyloid fluid contains but a trace of

it. The former also is thicker, and compares with the latter as does

cream with skimmed milk.

The prognosis is not usually favorable. Nevertheless recovery has

ensued without operation. Mere pressure of the effusion may occlude the

opening through which it occurs until the latter shall heal. When the

fluid gives rise to severe symptoms the chest should be aspirated.

HYDROTHORAX; HEMOTHORAX; PYOTHORAX.

Under these terms are included the presence of fluid in the pleural

cavity, between the lung and the chest wall; this fluid, in the first

instance, being _serum_, which may be slightly admixed with pus and

blood; in the second, _blood_; and in the third, _pus_.

Hydrothorax may be a primary condition, the result of pleurisy with

effusion, or of pleuropneumonia. It may also occur as does a similar

collection in the abdomen, as the result of disease of the chest wall,

the lung itself, or in consequence of serious cardiac or renal disease,

with tendency to dropsical accumulations in various parts of the body.

Thus it is seen in connection with tuberculous disease or cancer of

the lung, as well as cancer of the chest wall. There is, moreover, a

miliary expression of tuberculous pleuritis in which hydrothorax is

always a complication.

The serious features of hydrothorax result from the compression which

it may make upon a lung with consequent embarrassment of lung function

and from the possibility of infection by pyogenic organisms and the

consequent conversion of a hydrothorax into a pyothorax.

Collections of serum within the pleural cavity which manifest a

kindly tendency to disappear by resorption do not require surgical

intervention, but all such accumulations which do not quickly evince

this tendency should be removed by the operation of paracentesis,

which, applied to the thorax, is called _thoracentesis_, _i. e._,

aspiration through the hollow needle. No lung should be allowed to have

its capacity long reduced by compression.

_Hemothorax_ may be idiopathic or traumatic. In the former case it is

an expression of malignant disease, or of advanced septic lesions which

have permitted erosion of bloodvessels and escape of blood. It may also

result from rupture of an aneurysm, and will then prove fatal. It is

seen in surgical cases in connection with injuries to the chest wall or

its contents, as in compound fracture of a rib or perforation of a rib

fragment into the chest, with injury to the lung.

In case of the sudden escape of fluid into the chest, with symptoms

of collapse and lung compression, it may be assumed that an acute

hemothorax affords the explanation. Fluid accumulating _rapidly_ under

any circumstance is more likely to be blood than serum. The exploring

needle may be relied on to furnish the deciding test, in addition to

the ordinary physical signs afforded by auscultation and percussion.

_Pyothorax_ is frequently referred to as _empyema_, the latter term

indicating a collection of pus in a previously existing cavity, and,

by common consent, made to refer to the pleural cavity unless some

other be mentioned. Empyema is seldom a primary condition. Generally it

is the result of a hydrothorax, which has become contaminated either

by direct or by indirect access of germs. Under these circumstances

it indicates the conversion of a relatively innocent collection of

serum into a collection of pus, with all its attendant dangers. It may

be looked for in cases of perforating injury of the chest, _e. g._,

compound fracture of the ribs, gunshot wounds, and the like.

While returning the ordinary physical signs met with in fluid

collections in this location, and being discoverable with the exploring

needle, empyema has this additional feature, that the pus may, when

long retained or accumulated in large amount, burrow and attempt to

escape through whatever path may offer least resistance. In this way

strange freaks will occur, as when it escapes behind a mammary gland

and pushes the latter forward, thus forming a large retromammary

abscess, which requires not merely the ordinary incision, but a

thoracotomy and ample drainage as well. It may penetrate at other

points and thus escape. The most remarkable illustration that the

writer personally has known of this travelling of pus was in a colored

man, in whom it perforated the diaphragm, then separated the peritoneum

from the abdominal wall over a large area, collected in large amounts

between the peritoneum and the abdomen in front, and even extended

down into the pelvis. This man had such a peculiar abdomen that he

was supposed to have dropsy. When the trocar was inserted there was a

discharge of over a pailful of almost pure pus.

In addition to the ordinary embarrassment which a considerable amount

of pus thus collected causes, there should be reckoned the peculiar

septic and toxic features, which can be easily accounted for by

the nature of the contained fluid. Pyothorax will nearly always

have septicemic in addition to local features, which give it an

individuality of its own.

The operations practised for relief of these conditions are discussed

at the conclusion of this chapter.

THE ESOPHAGUS.

Anatomically, the esophagus is a musculomembranous tube with downward

projection into the thorax, its uppermost portion blending with the

lower constrictor of the pharynx, the tube proper beginning at the

level of the cricoid cartilage, and opposite the sixth cervical

vertebra. Its conclusion opposite the tenth dorsal vertebra marks the

cardiac orifice of the stomach. In its upper portion it is placed

centrally, then inclines a little to the left, and, at the level of

the third dorsal, lies about half an inch to the left of the middle

line. This furnishes the reason for approaching it upon the left side

in doing external esophagotomy. From here it passes to the middle line

again until opposite the ninth vertebra, where it once more inclines

a little to the left. It has an anteroposterior curve corresponding

to the shape of the spine. Between it and the trachea, in the neck,

lies the recurrent laryngeal nerve. Its nervous supply is derived from

the sympathetic and the pneumogastric, and its lymphatics connect

with the mediastinal nodes, the latter point being of importance

in connection with cancer of the esophagus. Its average caliber is

about three-quarters of an inch, save where it is crossed by the left

bronchus and at the diaphragmatic opening. There is also a slight

constriction at its upper opening.

CONGENITAL MALFORMATIONS OF THE ESOPHAGUS.

Congenital malformations include its absence, at least throughout some

of its course. Communication between it and the treachea, so-called

tracheo-esophageal fistula, has been noted. Its upper portions, into

which may open the incompletely closed branchial clefts, are also

subject to malformations with incomplete obliteration of the latter

and consequent diverticula. Irregular dilatation is also occasionally

of congenital origin, as well as acquired, in the latter case being

due to fatty degeneration of muscle fibers. These dilatations should

be differentiated from those which are mostly found on the proximal

side of any constricted tubular passage, and which are produced by

accumulation and distention from behind of whatever should be passed

through it.

The most common _malformations_ of the esophagus which are not of

the stenotic character are so-called _diverticula_, which appear in

two forms--namely, _distention_ and _traction_, these being both

acquired forms, while congenital formations of this character are also

occasionally met.

_Congenital diverticula_ may appear anywhere along the course of

the tube, but are probably more common in its upper portion. They

constitute more or less irregular tubular sacs which lie alongside

of and parallel to the main tube. The openings by which they connect

may be large or small. These saccular defects, always small at first,

may assume increasing proportions, because of the entrance therein of

food and their consequent distention by foreign material, as well as

by products of decomposition of the same. Thus slowly and insensibly a

very mild form of such defect may in time assume serious proportions.

The _acquired diverticula_ of the _distention_ type are usually met

with in the upper part, and are practically hernial protrusions of at

least the mucosa through the fibers constituting the muscular portion

of the tube, and cannot occur save by some preceding pathological

change. _Traction diverticula_ are the results of adhesions to

breaking down lymph nodes or other pathological conditions, by

which the esophageal wall is first pulled out of position, then

gradually sacculated, and the condition still further aggravated by

accumulation therein of foreign material. The acquired diverticula

attain considerable size, and when emptied one may be astonished at the

accumulation which has occurred. Such a tube having been completely

emptied may be again filled by the first food which is subsequently

taken. After being filled, the balance of the food may then pass into

the stomach, with partial or complete comfort or satisfaction to the

patient.

The principal indication of an esophageal diverticulum, beside

dysphagia, is regurgitation or vomiting of food. When food which has

undergone decomposition is occasionally rejected, and when, at the same

time, the stomach is shown to be not dilated and not at fault, the

suspicion of a diverticulum may be considered well founded. Its opening

into the esophagus may be so placed as to always engage the instrument

which may be passed down for examination, either bougie or stomach

tube. Should this be a constant phenomenon the diagnosis may be easily

established. In such a case it may be possible to first empty and then

distend the sac with food mixed with bismuth subnitrate, or perhaps

to inject it with an emulsion of the same. If this can be done, the

fluoroscope or a good radiograph will show a distinct shadow, and in

this way a pictorial outline of the condition may be obtained.

=Treatment.=--The treatment of these diverticula is of great

difficulty, especially when the sac has attained a size which permits

of retention of material. Sacs which contain decomposing matter should

be emptied by the stomach tube and washed out at frequent intervals.

If it be then possible to pass the tube beyond them the patient should

be fed through it, or it may be possible to place the patient in the

recumbent position, with the head lower than the body, and cause food

or fluid to be swallowed in this attitude. It will then probably enter

the stomach instead of the sac. Such measures as these failing, and

nothing else affording relief, operations are occasionally undertaken.

Much will depend upon the location of the sac, especially its height.

A diverticulum in the neck may be more easily reached than one in

the chest, and Richardson and myself have had remarkable success in

the relief of aggravated cases of this kind. Cushing has shown the

advantage of the administration of atropine before these operations,

in order to limit the flow of saliva and keep the parts dry. The sac

having been exposed by a long incision in front of the sternomastoid,

it may be filled with a solution containing methyl blue, by which

it may be identified, or it may be filled with paraffin, which,

solidifying, will serve admirably for its identification. It then may

be attacked as would be any solid tumor. The sac having been identified

and extirpated its opening into the esophagus is then closed by sutures

and the neck wound cared for as usual, with provision for drainage

(Figs. 511 and 512).

[Illustration: FIG. 511

Diverticulum freed from its attachments and delivered from the wound.

(Richardson.)]

[Illustration: FIG. 512

Shows the external layers of the esophagus closed by interrupted

Lembert suture of silk. (Richardson.)]

Traction diverticula may be amenable to surgical intervention. Should

the esophagus be diverted by adhesion to an advancing aneurysm nothing

should be attempted. Among the operations which may be practised upon

the thorax there may be mentioned a method of posterior exposure and

attack upon some of these conditions which may or may not afford

advantages, according to the nature and location of the various

conditions.

_Cardiospasm_ (see chapter on the Stomach) produces a sacculation

of the gullet often mistaken for diverticulum, and requiring to be

differentiated from it.

FOREIGN BODIES IN THE ESOPHAGUS.

Foreign bodies may be lodged in any portion of the esophageal tube and

cause a variety of troubles, according to their size, shape, location,

and nature. There is scarcely any conceivable object which may be

introduced into the mouth which has not been known to be impacted

in the esophagus and produce more or less serious symptoms. Young

children, imbeciles, and the insane may suffer unwittingly in this way,

while the condition is usually accidental and unintentional.

The accompanying figures (Figs. 513 and 514), portraying in one case

a jackstone lodged in the esophagus, a coin in the other, a case of

my own, will furnish illustrations of what has just been said. (See

also page 674.) The young and the insane may make no statement which

will furnish a clue for the distress caused in attempts to swallow or

the actual impossibilities of the act. In most instances, however, a

history of impaction and a statement as to the nature of the foreign

body may be obtained. The _symptoms_ produced are those of partial or

complete inability to swallow, of more or less pain accompanying the

act, and of the regurgitation often of blood or of bloody mucus. The

object may be sufficiently large to produce dyspnea and suffocative

symptoms, _e. g._, a plate with false teeth.

[Illustration: FIG. 513

Jackstone lodged in esophagus. (Phelps.)]

[Illustration: FIG. 514

Coin lodged in esophagus, successfully removed by external

esophagotomy. From the Author’s Clinic. (Skiagram by Dr. Plummer.)]

The condition being suspected or made known, the location of the

foreign body may be determined by the esophageal bougie and by the use

of the _x_-rays. With certain irregularly shaped objects the latter

prove a desirable help, especially when irregular plates containing

false teeth, or toys have been passed into the esophagus. They afford

an indication not only as to their exact situation and emplacement, but

also as to the best method of attack, that is, whether from without or

within. Considerable distress may be produced by even small particles,

as chips from an oyster-shell, small pieces of glass, and the like.

[Illustration: FIG. 515

Esophageal forceps.]

[Illustration: FIG. 516

Horse hair probang, expanded and unexpanded.]

=Treatment.=--A foreign body which produces the slightest discomfort

or recognizable symptoms should be removed. Only occasionally can this

be done by making the patient endeavor to swallow something else, this

being too uncertain a method of procedure; although I have known a

peach-stone impacted in the esophagus to be pushed into the stomach

by the passage of an esophageal bougie. The situation and the nature

of the object being known, one then decides how best to proceed. The

available methods of operation are:

1. The introduction of a bougie and the enforced passage of the

object into the stomach (questionable).

2. The use of the esophageal snare.

3. The use of the esophageal forceps or similar means of extraction.

4. The more directly operative methods by external incision.

The _esophagoscope_ is an instrument of comparatively recent device

and perfection. We owe it largely to the ingenuity of Mikulicz. It

is to the esophagus what the endoscope is to the urethra, and may be

regarded as essentially an enlarged endoscope. Its introduction is

comparatively easy, but its retention is distressing to the patient,

so that opportunity may thus not be afforded for profiting by its

use. The employment of cocaine anesthesia, and perhaps of morphine

hypodermically, will sometimes enable it to be used satisfactorily.

It may also be used for exploratory purposes previous to commencing a

formal operation under general anesthesia. There are furnished with the

instrument itself forceps and extractors, by which it may be possible,

when the object is once seen, to grasp and withdraw it. The use of the

esophagoscope is, moreover, not limited to these lesions, since it

can be used in revealing the character of strictures, small wounds,

diverticular openings, and the like. Endeavors may be first made to

locate the body by those possessing such an instrument and expert in

its use.

The _esophageal snare_ is a simple instrument which, after being

introduced, is shortened in such a way as to cause to protrude a

basket-like meshwork of bristles in which, as the instrument is

withdrawn, a small object may be entangled and so withdrawn. In the

same way an ingeniously made _coin catcher_ is furnished, which, in

cases of impacted coins or similar shaped objects in the esophagus, may

be introduced beyond them and then withdrawn, the object being caught

in a miniature cradle, from which it cannot escape until brought up

into the pharynx. Esophageal forceps are made with long blades, curved

like all the instruments used within the pharynx, and serving admirably

for grasping objects impacted high in the tube (Figs. 515 and 516).

Dislodgement being impossible by either of the above-mentioned

expedients, recourse may be had to the operation of _external

esophagotomy_. This may require to be done as an emergency measure,

but is practically always indicated when an impacted object cannot

be otherwise removed. A dangerous location for a foreign body in the

esophagus is at a distance of about nine inches from the upper incisor

tooth, at which point it will be located directly behind the arch of

the aorta, at which level ulceration would perhaps result disastrously,

as Richardson has shown. The operation was devised by Goursault, in

1773, and has proved a satisfactory surgical measure. It is performed

upon the left side of the neck. The incision is made along the anterior

margin of the sternocleidomastoid from the middle of the neck downward.

The larynx and trachea are separated to the inner side, the muscles

and the large vessels to the outer side, the omohyoid divided, the

descendens noni and the recurrent laryngeal nerves, which lie in the

groove between the trachea and the gullet, are protected from injury,

and the esophageal tube thus exposed. The surgeon will feel more secure

in opening it if he now pass downward through the mouth a bougie or

instrument upon whose beak or tip he may cut down. The esophagus being

opened, the margins of the wound are secured by sutures which serve

as retractors, and the interior of the tube is then subjected to the

necessary manipulation. Even now it may not be an easy matter to

dislodge a pointed object, which may have become partially impacted.

Thus it may be dislodged at first by pushing it down a short distance

and turning it, the direction having been already indicated by an

_x_-ray picture. The manipulation should be as gentle as possible.

Extraction having been accomplished, the esophageal wound is closed by

the sutures introduced for traction purposes. Over this the external

wound is closed, with suitable provision for drainage, as it is almost

certain to have been infected during the procedure. In rare cases it

has been necessary to combine a _gastrotomy_ with this operation, in

order that by combined manipulation a peculiarly shaped object may be

dislodged.

_Gastrotomy_ will be necessary in but few instances, as, for instance,

when an object known to be one which cannot pass through the pylorus

has been dislodged into the stomach by pressure from above--as plates

containing false teeth, and various similar objects. It will probably

be safer to open the stomach and remove the object than to leave a

patient to his otherwise uncertain fate. On the other hand objects

which are sure to be in time dissolved or disintegrated by the stomach

juices may be allowed to remain to await this event.

WOUNDS OF THE ESOPHAGUS.

Wounds of the esophagus occurring in other ways than those above

indicated may be the result of gunshot and various perforating

injuries. The tube may be also partially cut across in so-called

_cut-throat_.

Any external wound of the esophagus which can be recognized should be

closed with sutures, and the parts brought together, if possible, with

provision for drainage. Those lacerated wounds constituting some forms

of cut-throat, however, permit of very little in this direction, for

when seen they are too infected. Through an esophageal opening thus

inflicted the patient may be fed for a time by a tube, the wound being

left to close later by granulation or by a secondary operation. When

the esophagus has been anywise injured it would be better to abstain

from feeding or else to introduce food through an esophageal tube.

RUPTURE OF THE ESOPHAGUS.

Rupture of the esophagus has been known to occur in consequence of

severe vomiting, there being some twenty-five cases of this character

now on record. (Dennis.) A tear is rarely complete, but it may be

followed by hernia and formation of a diverticulum. The accident will

be indicated by violent pain following severe vomiting in connection

with an effort to dislodge a foreign body. There will be more or less

shock and perhaps collapse, with escape of blood. Emphysema of the neck

and upper part of the chest may result and the injury prove fatal. The

condition being suspected, it would be advisable to do an external

esophagotomy or else to carefully introduce a stomach tube and leave it

_in situ_.

PERFORATION OF THE ESOPHAGUS.

Perforation--_i. e._, rupture _without traumatism_--may result from the

existence of ulcers or from the advance of malignant disease. It may

occur in either direction. Thus while the mediastinum may be infected

from entrance of septic material into it the direction may be reversed

and an abscess or other lesion of the surrounding tissues may evacuate

itself into the esophagus. Should this prove to be an aneurysm the

patient will die with uncontrollable escape of blood. The treatment of

such a case, if any be permitted, will depend entirely on the nature of

the exciting cause. Perforation has also followed injudicious use of

bougies when exploring or treating strictures (especially cancerous) of

the esophagus.

ESOPHAGISMUS.

Esophagismus, or spasmodic contraction of the esophagus, is usually

an expression of hysteria, or else is a reflex spasmodic effect due

to the presence of some neighboring irritation. In the esophagus, as

in the urethra, there may be spasmodic stricture, which will afford

considerable obstruction. Thus I have seen it as a functional neurosis,

absolutely without explanation, in an apparently healthy workingman.

It is noticed also in connection with hemorrhoids and with hepatic

lesions. It is seen in pregnancy, and a certain degree of it will

complicate many cases of gastric ulcer, gastritis, or esophagitis such

as is produced by swallowing mild caustics. While producing dysphagia

and obstructive phenomena it is intermittent and interposes little

real obstacle to the passage of a full-sized bougie or tube. It is

frequently accompanied in the hysterical by globus hystericus, and by

regurgitation of whatever food the patient attempts to swallow.

The local treatment consists of dilatation by the passage of full-sized

instruments at frequent intervals. If a neurosis the patient may

require other treatment, addressed either to the nervous system or to

any well-marked constitutional condition.

STRICTURE OF THE ESOPHAGUS.

Stricture of the esophagus has an etiology practically identical with

that which pertains to stricture of any other passage of the body. It

may be due to extrinsic or intrinsic influence. Among the former may

be mentioned the presence of tumors, either benign or malignant, or

of cicatricial tissue, while among the latter should be mentioned the

injuries resulting from the presence of foreign bodies, the extensive

ulcerations due to the swallowing of various caustic fluids, and the

cicatricial contraction which may follow other lesions like ulceration.

Those cases which are due to serious congenital defects will usually

die early. Of the ulcerative lesions which lead to stricture the most

common are the cancerous. Syphilitic and tuberculous ulcerations may

occasionally produce the same effect. By far the most common causes are

the traumatic, which are connected either with foreign bodies or with

the unfortunate accidental use of caustics.

_Esophageal strictures_ are recognized by the difficulty in swallowing

which they produce and the later dilatation of the esophagus above,

which is the frequent result of their long existence. The degree

of difficulty experienced by the patient in deglutition is to a

considerable degree a measure of the extent of contraction. It may

be nearly always assumed that such a stricture as is produced by

the swallowing of caustic fluids will leave a tortuously contracted

passage-way, and the instrument passed for its recognition, while

arrested in its upper portion, may give little or no correct idea as to

the arrangement below. In some instances it may be possible here, as in

the case of diverticula, to introduce sufficient bismuth emulsion into

the esophagus to make it cause a shadow in an _x_-ray picture, and in

this way to give pictorial information not otherwise attainable.

The surgeon should distinguish between hysterical spasm or esophagismus

and cicatricial stenosis. The former will offer but little obstacle

to the passage of a full-sized bougie. In fact it will be frequently

benefited, usually cured by it, while in the latter instance this is

almost impossible.

[Illustration: FIG. 517

Stricture of the esophagus. (Dennis.)]

[Illustration: FIG. 518

Esophageal bougies.]

Fig. 517 shows the possibilities in a case of actual obstruction, and

how different such a condition is from mere esophagismus or globus

hystericus. It has been recently shown, especially by Dennis, that

during or just after typhoid fever, ulcers occur in the esophagus

which may produce serious stenosis. At present writing I have under

observation a little girl of nine years who has an extreme condition

of this kind. It is with difficulty that she can swallow fluid

nourishment, and she was so nearly starved that her life was only saved

by a gastrotomy. Those congenital defects which may produce esophageal

stricture are usually of such a serious and extensive character as to

afford no opportunity for relief.

The location and caliber of these strictures may be ascertained by the

use of esophageal bougies, such as represented in Fig. 518. These are

made of various sizes, and are fastened upon the end of a flexible

rubber handle, which affords a degree of elasticity in manipulation.

_They should be used with care and caution_, as minor degrees of injury

produced by them may cause a spreading infection, while still more harm

may be done by rupture of an ulcerated area, or perhaps the perforation

of an aneurysm.

The patient should sit before the surgeon, with the head thrown

backward, the mouth comfortably widely opened, while the surgeon,

standing, introduces the left forefinger into the pharynx and with

it depresses the tongue and guides the tip of the instrument, be it

bougie or tube, along this finger, which serves as a guide. Unruly or

hysterical patients will not only gag, but may attempt to bite the

operator’s finger. To prevent such accidents a metal thimble is made,

which, being inserted between the teeth, protects the finger, but makes

the manipulation more awkward. Should the patient show any tendency

to folly of this kind, it should be remembered that when the finger

is forced back into the pharynx the mouth is instinctively opened.

If necessary, at the same time, the nostrils may be grasped and held

closed, in which case the patient is sure to open the mouth widely and

thus release the finger. After the tip of the instrument is engaged in

the pharynx it sometimes assists in the manipulation if the patient’s

head be now tipped a little forward. This manipulation is not very

different from that by which a small and long flexible rubber tube may

be inserted through the nostril into the stomach for the purpose of

feeding, as is frequently done with the insane who refuse to eat, or

may be done in the presence of certain diseased conditions.

The intent in this exploration is to determine the distance from the

upper incisor teeth of the obstruction, as well as its caliber. When

the instrument is withdrawn the surgeon marks the location of the

teeth by grasping it at this point with the thumb, and the distance is

measured off afterward so that it may be read in inches if desired. The

caliber is determined by the success or non-success met with in passing

an instrument of given diameter. The size with which the attempt should

be made may be determined largely by the history and statement of the

patient. With a patient who cannot swallow no ordinary bougie should

be expected to pass, while a small solid instrument might produce a

perforation. Flexible bougies are also provided by the instrument

makers, made as are the silk catheters, some of them being loaded with

small shot in order to give them a certain degree of weight. A small,

soft, flexible instrument may be thus passed when the ordinary probang

would fail. Here, as in the urethra, an olivary bougie may pass, after

which the same sort of resistance will be offered upon its withdrawal.

In this case the stricture is passed twice, going and coming. A

slight degree of constriction is met opposite the cricoid cartilage

at the entrance to the esophagus. This should not be mistaken for a

pathological condition. Information may be afforded by material brought

up by the instrument, such as shreds of tissue, blood, etc. A small

bougie coated with sponge may be used for the purpose of retaining and

bringing back such material as it may engage.

It will be of assistance to let the patients dissolve in the mouth

a tablet containing a little cocaine and swallow it, or to spray or

gargle the pharynx with a weak solution. It prevents the gagging and

discomfort of an operation which otherwise is almost painless.

ESOPHAGEAL HEMORRHAGE.

Esophageal hemorrhage occurs especially in connection with cirrhosis

of the liver. Stockton and others have called attention to a peculiar

varicose condition of the esophageal veins in certain of these cases,

and the possibility of repeated hemorrhages which may terminate

fatally. The same is true of obstructive jaundice with Riedel liver.

CANCER OF THE ESOPHAGUS.

Cancer of the esophagus may be either primary or secondary, and may be

either sarcoma or carcinoma. Its first expression will be ulcerative

or stenotic, according as it originates on the inner surface or not.

Sooner or later it will produce stricture, with the ordinary evidences

thereof, and is to be detected in the same way. Cancer is usually of

the carcinomatous type or squamous epithelioma. The disease is more

common near the lower than the upper end of the canal. The disease

spreads and involves the adjoining lymphatics, as well as various other

structures. In addition to the ordinary evidences of stricture it is

accompanied by a certain degree of pain, which is likely to be referred

to the _interscapular_ region or the back of the neck. The emaciation

which always accompanies it is not merely an expression of the disease

itself, but of the starvation which stricture in time produces.

Frequent expulsion of bloody mucus or shreds is extremely indicative.

Esophageal cancer admits only of esophagectomy, as a very unusual

method of relief, or gastrostomy, which is a palliative measure

intended to prevent death from starvation, but not affording exemption

from the advance of the disease.

OPERATIONS UPON THE ESOPHAGUS.

Operations upon the esophageal canal include:

1. Dilatation;

2. Internal esophagotomy;

3. External esophagotomy;

4. Esophagectomy.

1. _Dilatation_ is practised ordinarily with olivary or conical-tipped

bougies. The former are usually metal or ivory tips fastened to a

firmer handle, while the latter are fashioned like silk catheters

having more or less conical tips. These are introduced until they

are engaged within the stricture, after which the amount of pressure

or force used should be graduated to the character of the trouble,

the density of the tissues, and the tolerance of the patient. Daily

dilatation may be practised either for the prevention or relief of

strictures following cicatrices due to caustic fluids and the like.

A small passage may in time be stretched up to nearly the normal

diameter, after which instruments may be passed at regular intervals,

as the tendency to recontraction is inevitable. These methods of

dilatation have taken the place of more complicated mechanical

procedures performed with instruments like those intended for use in

the urethra. The writer has, however, in one or two instances used with

advantage the Otis dilating urethrotome in cicatricial strictures of

the gullet.

2. _Internal esophagotomy_ is practised either with instruments

carrying concealed blades, like those used within the urethra, or by

a method suggested by Abbe, where the stomach is first opened, and a

retrograde divulsion effected, or at least a small bougie is pushed

upward from beneath. When its tip is felt in the mouth there is

firmly attached to it a strong silk thread which, as the instrument

is withdrawn, is brought down into the stomach and then out through

the stomach opening. With one hand in the stomach and the other in the

mouth this thread is then manipulated in such a way as to saw through

the strictured passage. It is well, should the surgeon use silk in

this way as he would use a Gigli saw, to pass it through a piece of

rubber tubing, both above and below, in order that its sawing effect

may be limited to the esophagus proper. This is a procedure which

should be done with great precaution. The operator should stop at

short intervals, and, by using a bougie, satisfy himself whether the

strictured passage has been enlarged. When the desired result has been

attained the thread is withdrawn, the stomach and abdominal wounds

closed, and dilatation resorted to every day or two in order that the

benefit gained may be maintained.

The use of the _esophagoscope_ may permit the exposure of a cicatricial

band or an annular stricture, so placed that it may be divided by a

fine knife directed through the tube. Whatever cutting is done in this

region should be done cautiously, so as to avoid injuring adjoining

structures.

3. _External esophagotomy_ is easily performed for the removal of

foreign bodies. When done from below it may be combined with a

gastrotomy, the cardiac end of the esophagus being thus exposed and

exploring instruments or those intended for either removal of foreign

material or division of stricture being thus introduced. After the

measure is complete the stomach is first closed and then the abdomen.

4. _Esophagectomy_ is an operation undertaken from without, and is

seldom performed for other purposes than for the removal of malignant

growths. A cancer of the esophagus should be seen early and be

favorably located in order to be amenable to such a radical measure,

yet cases of this kind have been successful. Too often, however, they

are done too late. The esophagus is exposed by the same incision as

that described for esophagotomy, namely, on the left side along the

anterior border of the sternomastoid, the vessels and nerves being

retracted to either side in such a way as to permit its clear exposure.

The portion to be removed is then isolated by blunt dissection and

resected. This leaves two ends of the canal, which can usually be

brought together by sutures, after the fashion of an end-to-end

intestinal anastomosis. The principal difficulty met with will be

adhesions and infiltration caused by extension of disease, and these

of themselves in well-marked cases would be contra-indications to

operation.

=Transthoracic Resection of the Esophagus.=--Bryant and others have

shown how the esophagus may be exposed from the posterior aspect of

the thorax by a _posterior thoracotomy_, made in the third and fifth

intercostal spaces, where, by resection of the ribs and dissection,

the esophagus may be exposed behind the hilum of the lung. The azygos

vein which crosses it at about this level should be either retracted or

divided after a double ligation. Experimentation has shown that it is

possible at this point to stretch the tube in such a way as to permit

of restoration of its caliber, if but a small amount have been removed,

but great care should be exercised, otherwise tension would be extreme.

Because of the doubt regarding the success of such a resection Mikulicz

has suggested the following procedure of _externalization of the

esophagus_: After exposure the distal end of the esophagus is closed

and dropped back. An opening is next made along the anterior border

of the sternomastoid, where the esophagus is exposed, pulled up and

out of its situation--_i. e._, dislocated--and brought out through the

upper opening, which can be done because of its loose connective-tissue

surroundings. A third incision is then made over the second intercostal

space in front, where a bridge of skin is lifted up, the esophagus

drawn down beneath it and fastened, the intent being to connect this

opening with the stomach through a gastric fistula by means of some

special apparatus, thus making it possible to again feed the patient

through the mouth. The incisions in the back are closed by layer

sutures. The principal objection to this method is that the passage of

fluid through the _externalized_ portion of the esophagus would have to

be accomplished by massaging the part and forcing it down through the

tube. Sauerbruch and others have shown that in animals at least it is

possible to make a transdiaphragmatic anastomosis of the stomach and

esophagus. By much the same method as that last above described, _i.

e._, through a posterior opening, the esophagus can be exposed near its

lower end, resected, and then turned into an opening in the stomach,

the latter having been brought up through an opening in the diaphragm.

It is hardly necessary to go into details of this operation here,

since the occasions which would justify it are almost as rare as the

individuals who could be entrusted with its performance.

OPERATIONS UPON THE THORAX.

_Exploratory puncture_, either of the pericardial sac or of a pleural

cavity, is an exceedingly simple matter, the ordinary hypodermic needle

sufficing for many instances, while in some cases the contained fluid

will be too thick to flow through a finer needle and will necessitate

the use of a larger one. Such needles are furnished, with so-called

exploring syringes, and their use is a convenient preliminary to the

use of the aspirator--_i. e._, _thoracentesis_--or open division--_i.

e._, _thoracotomy_. It is essential that both the patient’s integument,

the instrument, and the operator’s hands be absolutely clean. When

several points are explored at one time and fluid is found at but one

it is well to indicate this with a little nitrate of silver or tincture

of iodine, which will make a temporary mark. Thoracentesis implies a

withdrawal of fluid through a hollow needle, which will make a small

puncture that will promptly close, a vacuum apparatus of some kind

being attached to it. The needle may be introduced at various points

to enter either the pericardium or the pleura. Ordinarily no harm

pertains to exploratory puncture and but little to withdrawal of fluid,

providing certain precautions are used, though fatal syncope has been

known to immediately follow it. Beyond absolute sterilization the most

important feature is to withdraw fluid slowly rather than rapidly,

and to desist so soon as symptoms of a serious nature appear, such as

faintness or collapse. When a collection of fluid has existed for some

time in one of the pleural cavities it may have gradually so displaced

the heart that its too sudden withdrawal may permit a too sudden

restoration to its normal position--so sudden, in fact, as to place

extra stress upon it and perhaps to seriously embarrass or completely

check its action. This is always a matter requiring attention. The

position of the patient also should be regarded, and a patient who

is seated in a chair, in order that fluid may gravitate to the lower

part of the chest cavity, should be promptly placed in the recumbent

position so soon as alteration in pulse or coughing or serious

embarrassment of respiration are noted.

The skin over the point selected for puncture may be anesthetized with

the freezing spray or with a sterile cocaine solution. The needle

point should be driven in sufficiently to secure fluid and not such

a distance as to puncture the heart or the lung within. The better

aspirating needles are provided with rounded points rather than with

sharp ones, in order that scratching with a sharp end may be thus

avoided. When using a more blunt needle of this type it is well to

make a trifling puncture in the skin with a small knife-blade. While

the more elaborate instrument outfits sold by the dealers are pleasing

to use, fluid may be siphoned through a needle and tube with a fountain

syringe just as in lavage of the stomach. Consequently it is not

necessary in emergency cases to have anything more than a satisfactory

needle. Care should always be given that no air is introduced. Thus in

managing the last-named expedient the tube and the needle itself should

be filled with fluid before the latter is introduced. Then the bag

may be lowered in order that no fluid escape into the chest. It is an

advantage to have a piece of glass tubing connected with the apparatus,

in order that the character of the fluid first withdrawn may be easily

ascertained. If the patient begin to cough or to have a feeling of

oppression the operator should temporarily cease, and if symptoms are

not ameliorated he should withdraw the needle, renewing the procedure

a day or two later. A lung too suddenly forced to expand by removal

of fluid may not only give distress to the patient, but there is a

possibility of hemorrhage.

=Thoracotomy.=--The term thoracotomy implies an incision made through

the chest wall, usually for withdrawal of fluid, with or without

removal of some portion of its bony structure. Thoracotomy performed

for pericardial collections of fluid has been described. That for

removal of ordinary empyemic collections is usually a simple measure.

It may be practised under local anesthesia. In a general way the extent

of the fluid collection is made out by percussion, and its character

by exploratory puncture. The endeavor should be to make the opening

laterally and posteriorly near the lower aspect of the cavity to be

emptied in order that it may drain by ordinary force of gravity with

the patient in the dorsal position. Unless it be intended to remove a

portion of rib the incision need not be more than one inch in length.

Ordinarily the skin is pushed a little one way or the other so that a

rib can be seen underlying it, in order to steady it for the external

incision. Then it is allowed to glide back to its normal position

and the knife-blade is so directed as to at once enter the thoracic

cavity. Only rarely is it necessary to make a careful dissection. It

is not often that vessels of importance will be divided, and one may

usually proceed boldly with the incision. It will be promptly followed

by appearance and usually by forcible expulsion of fluid, perhaps even

in a jet, for which a basin should be provided. In fresh cases this

fluid will be thin; in old empyemic cases there will be so much caseous

material mixed therewith that it may obstruct the opening and check

escape of fluid. In these cases it may be pushed aside with forceps

or by the introduction of a finger. When such material is present,

however, there is need also for its evacuation, and in such cases the

incision should be extended and an inch or more of rib may be removed

in order to afford sufficient exit.

The objection above mentioned regarding speedy evacuation applies

theoretically rather than practically to this procedure, for when it is

necessary to open the chest cavity widely it is because the walls of

the cavity thus opened have already become so thickened or stiffened by

the disease process that there is not the danger of sudden change of

position of the thoracic viscera which obtains in the less serious and

more acute cases.

The fluid having been removed the next question is one of _irrigation_.

This is only rarely necessary or even justifiable. Even in cases

where the evacuated pus has a more or less offensive odor it is found

sufficient to remove it, while experience shows the inadvisability,

sometimes the practical danger of prolonging the procedure and trying

at this time to wash out the chest cavity. If irrigation be practised

it should be with a bland fluid, for antiseptics are here peculiarly

irritating.

The third question is one of _drainage_. In recent cases it will

often be sufficient to insert some flexible material, like a piece of

oiled silk folded upon itself, secured externally by a safety-pin, or

stitched to the skin in such a way that it shall not be lost within

the cavity. In the older and more serious cases more complete drainage

should be provided. This is usually effected with a short piece of

rubber tubing, which needs to be amply secured against loss, either

with a large safety-pin or by being stitched to the skin with silk

rather than with gut, lest the latter soften too soon. This tube

should ordinarily be quite short, in order that it may not irritate

the pleural surface of the expanding lung. It is rarely necessary to

make valve-like protection of the opening, nor is it usually advisable

to insert any sutures in the external wound. These openings in most

instances close too soon rather than too slowly.

The surgeon should avoid making the opening too low, lest the

diaphragm, having been pushed downward by the accumulation above it,

rise and cover the end of the tube. Well-marked cases of empyema will

often improve more quickly if a counteropening be made. It is an easy

matter to introduce the end of a long forceps and determine the best

point at which to make this opening. The forceps being then held at

this point, one may easily cut down upon its end, force it through,

and utilize it for drawing backward, completely through the chest, a

long piece of perforated drainage tube, which perhaps may be eventually

replaced by a few strands of silkworm gut. A very large and copious

external dressing should be applied, and changed as often as need be,

in order to receive and provide for such discharge as may take place.

Sometimes this will be quite considerable, and necessitate, for the

first two or three days, a change every few hours.

Some surgeons have endeavored to make drainage more complete by a

vacuum irrigating apparatus, on the Bunsen pump principle. Should it be

necessary to resort to this the more complicated older methods may be

supplanted by the simple procedure, illustrated later in this work, for

continuous drainage or siphonage of the bladder.

One should never attack a case of this kind without being prepared to

_remove a section of one or more ribs_. Indications for this will be

found in the character of the contained fluid, or in the thickness

of the wall of the abscess, _i. e._, the old pleural cavity. The

difficulty usually is that these openings tend to close too promptly,

and that, especially in children, the proximity of the ribs to each

other affords too small space for the maintenance of drainage. When

it becomes necessary to remove a piece of one or more ribs there is

little object in trying to preserve the periosteum, and the operation

may be made within a few seconds by simply retracting the skin wound

and the musculature, introducing the bone-cutting forceps, with which

the rib or ribs are divided at points one inch or more apart, the

intervening portion being promptly lifted out with forceps and cut away

with strong scissors. The operation of dividing the rib will often so

compress the intercostal arteries that there will be little hemorrhage

from this source. Should they bleed too much strong forceps should be

used to compress the lower edge of the rib, and, by crushing it produce

hemostasis, as though the artery were itself seized with forceps, or

the vessel itself may be seized and secured. A special form of forceps

for dividing ribs, known as the _costotome_, has been devised and has

proved serviceable, since it is so made as to prevent easy slipping of

the rib from the grasp of the blade.

The larger opening thus made is treated in practically the same way as

the smaller. Through it the fingers or a blunt spoon may be inserted

and any cheesy material lifted out, or a sponge or gauze swab held in

the grasp of a long forceps may be introduced, and with it the cavity

thus opened may be wiped out or swabbed. In this way a considerable

amount of caseous material or shreds of membrane may be removed. The

more that can be removed the better, since there is so much less to

come away later. Such manipulation is, however, sometimes attended by

embarrassment of respiration, and one should use discretion in the

extent to which he practises it. Hemostasis having been secured, it

will depend on the case and its extent whether any effort is made to

partially close the wound or whether it should be left open. Even large

defects thus made usually heal kindly and fine or careful suturing is

rarely needed.

The subsequent management of such a case is usually simple. After the

first few days it may be advisable to practise irrigation. According to

the age of the case will be found the expansile capacity of the lung.

The lung itself expands by relief of pressure and by its own inherent

tendencies and returning function. Again by a process of granulation

it is gradually made to attach itself to the chest wall and is thus

withdrawn toward its surface. The combination of these agencies will

usually in time produce satisfactory results. The functionating power

of the lung may be determined by filling the cavity with fluid, the

patient lying upon the other side, and then noticing the difference

between the amount of fluid held in extreme inspiration and extreme

expiration.

=Thoracoplastic Operations.=--In old and neglected cases of empyema,

especially of tuberculous type, the pleura itself becomes more or

less thickened and stiffened, and affords such an obstacle to lung

expansion as to justify more radical measures. These have sometimes

to be undertaken as secondary operations, while in other instances,

where there has been spontaneous perforation and escape of purulent

overflow, perhaps for months or years, the necessity for such measures

may be foreseen. This necessity was first appreciated by Warren Stone,

an American surgeon, but the procedure was first formally placed before

the profession by Estlander, of Helsingfors. The principle upon which

it and all similar operations has been based may be likened to the

various efforts which it is necessary to make when a person tries to

collapse an ordinary barrel whose heads have been knocked out. So long

as the hoops of the barrel are intact the staves cause it to retain its

cylindrical form. If, however, the hoops be divided it easily falls

apart. In the case of a human chest, the lung, having been so long

bound down, is incapable of expansion, and the chest walls are rigidly

maintained by virtue of the hoop-like arrangement of the ribs. It is

necessary then to divide and remove a section from several of these

ribs, in order that the wall, falling in, may meet, at least half-way,

the lung, which may be expected to partially expand to meet it.

[Illustration: FIG. 519

Incision for resection of thorax. (Bergmann.)]

[Illustration: FIG. 520

Trap-door thoracotomy. (Lejars.)]

The original _Estlander operation_ has been modified by Schede, and as

now practised is made by a long incision passing obliquely across the

lateral aspect of the chest, from the origin of the pectoralis major,

at the level of the axilla, to the tenth rib in the posterior axillary

line, and then ascending to a point between the spine and the scapula.

The large flap thus outlined is made to envelop all the tissues outside

the ribs. The ribs thus exposed are resected from the tubercles forward

to their insertion into the costal cartilages. The large area of the

chest wall thus exposed is then removed with the underlying pleura,

and all hemorrhage checked. This flap includes the periosteum, the

intercostal muscles, the ribs, and the pleura, and thoroughly uncovers

the entire abscess cavity. It makes a formidable procedure, but is more

often life-saving than the reverse. Over the opening the skin flap may

be later drawn down and tacked in place at points sufficiently near to

each other to properly hold it in place (Figs. 519 and 520).

This procedure may be modified to suit the indications of any given

case, and simply includes what may be done in extreme cases. The

surgeon who thus for the first time uncovers such a cavity will be

surprised at its interior appearance, and at the shreds of tissue and

debris which hang from its walls. The measure thus described provides

for collapse of the chest wall. Fowler and others have shown, however,

that even now the principal obstacle to expansion of the lung is

not removed, and have suggested what Fowler has aptly described as

_decortication of the lung_--namely, a removal of its thickened pleura

by a process of dissection and stripping, which may be made partial

or complete, as circumstances permit. In some respects this adds to

the gravity of the case and will perhaps better be done at a second

operation. Should it, however, be justified by the condition of the

patient it is best done in connection with the resection of the chest

wall.

When decortication cannot be practised Fowler has advised that a series

of incisions be made, and that by thus gridironing the thickened

membrane it may be weakened or caused to lose its inelasticity and thus

a mild degree of similar effect secured. Fig. 521 illustrates the end

result of such an extensive thoracoplasty.

[Illustration: FIG. 521

End result of an extensive thoracoplasty. (Park.)]

=Pneumotomy.=--This is a term applied to an attack upon the lung

itself, it having been exposed by a thoracotomy. It is necessary in

cases of gangrene, abscess, hydatid cyst, and occasionally in large

bronchiectatic cavities. It is not ordinarily a difficult procedure

when the lung has attached itself to the chest wall in the course of

the disease process. Here the lesion having been located a part of

one or more ribs is removed, as may be needed, thus exposing the lung

surface, the cavity is then opened either with a knife or by dilatation

with the blades of a forceps, or preferably with the thermocautery

blade, by which hemorrhage is better controlled and possibilities of

absorption reduced. If such a cavity can be located it may be opened

with a large trocar and cannula, which should be introduced with great

care, lest it be thrust too far, the method by incision being therefore

preferable. If after opening the chest the lung be found non-adherent,

it depends on the character of the lesion whether adhesion should be

provoked or the cavity itself attacked. In the former case adhesions

may be produced by stitching the exposed lung surface to the margins

of the wound, and waiting for sufficient exudate to be poured out to

ensure that the pleural cavity has been hermetically sealed. The same

result may be obtained more crudely by packing gauze around the opening.

In case of urgency it would probably be best to attach the lung to the

chest wall with sutures and secure it there. This is a comparatively

safe method in dealing with hydatid cysts, and will give a fair measure

of success in many other instances. The suppurating or gangrenous

cavity being opened its contents should be removed, dead or sloughing

tissue excised, and the cavity then packed for drainage purposes, the

external wound being kept open until it can be safely allowed to close.

_Pneumonectomy_, that is, removal of a portion of the lung substance,

may be done with comparative safety upon animals, but rarely upon

human patients. It is occasionally required in connection with the

removal of malignant tumors of the chest wall, to which the lung has

affixed itself. In exceedingly rare instances it may be justified for

localized tumors of the lung itself. It would be equally valuable for

circumscribed, primary tuberculosis of the lung, were it possible to

recognize this in time. This an Italian surgeon once thought that he

had done, in the case of his fiancée, and proceeded to resect the upper

lobe of one of her lungs. His lack of success quickly led to his own

suicide a few days later.

The lung is exceedingly vascular and at the same time bears sutures

well. The suturing, however, should be accurate in order to prevent

secondary hemorrhage and favor the process of repair.

Other operations may be practised upon the chest wall for relief of

such conditions as _acute osteomyelitis of the ribs or sternum_,

_caries_ of the ribs, _necrosis_, and the like. It should be scarcely

necessary to give explicit directions, save that the pleural cavity

should never be opened unless the pleura itself be involved in the

disease. Every case demanding such operative relief should be measured

by its own needs, and the operative procedure adapted to them. Necrosed

portions of bone may be completely removed. The suppurative and carious

conditions necessitate rather a sufficiently wide exposure from without

and then a judicious use of the bone curette. One need never hesitate

to remove so much bone as is diseased, this being true even of the

sternum.

THE THYMUS.

The possibility of suffocative and other disturbances proceeding

from enlargement of the thymus has been discussed, as well as

the use of long trachea tubes in cases of this character which

call for tracheotomy, as they usually do if they permit of any

surgical intervention. The thymus is seldom the site of primary

malignant disease. Certain acute lesions are due to a peculiar

form of _hypertrophy_ in the young, which takes place instead of

that spontaneous disappearance which should have occurred during

the earliest months of infancy. Its connection with the _status

lymphaticus_, with thymic asthma, and laryngismus stridulus has

already been mentioned. While it can hardly be considered absolutely

exempt from ordinary infections and the like it nevertheless is rarely

involved.

The thymus has been removed by operation, usually with success. Should

it become necessary to resort to such a measure it should be preceded

by the removal of the sternum, for only in this way can sufficient

exposure be obtained, and sufficient opportunity for checking such

hemorrhage as might result from its enucleation.

THE AXILLA.

The axilla as a surgical region belongs as much to the thorax as to any

part of the body, although none of its diseases are peculiar to this

area.

It is frequently the site of furuncles of local origin, which

occasionally assume carbuncular type, and which are expressions of

local infection along the hair follicles or mammary ducts. It is full

of lymph nodes, through which are filtered the lymph streams coming

from the upper extremities. In this way there are entangled therein

septic germs, which frequently give rise to small or large _phlegmons_

proportionate in size to the magnitude of the lesion beyond them. It

takes but a trifling infection of the finger, for instance, to produce

such involvement of axillary lymph nodes as to make them palpable

under the finger. Such lymph nodes once genuinely inflamed frequently

coalesce, and the resulting abscess cavity may be large, especially if

neglected. The sooner these phlegmons are incised and cleaned out the

better for the patient. In order to do thorough work an anesthetic is

usually required.

In the axilla also are frequently seen _tuberculous_ manifestations,

the result of propagated infection from some part of the arm or hand.

These may be involved in a mixed infection and quickly break down, or

may assume the type of the chronically enlarged nodes, which undergo

caseation and more or less encapsulation, with such infiltration of the

surrounding tissues that when extirpated considerable difficulty is met

in the dissection.

In _syphilis_, also, the lymph nodes become involved, frequently

enlarging to a degree making them palpable, and sometimes participating

in a mixed infection in such a way as to break down into abscesses.

Again, in the axilla are occasionally seen conspicuous evidences of

_Hodgkin’s disease_. Any disease of constitutional character which

precipitates trouble in one axilla will cause nearly duplicate

alterations in the other, whereas disease of local origin is usually

confined to one side.

Any phlegmonous cavity or tuberculous lesion which has been incised

through the axilla should be carefully cleaned out and then drained,

lest the external incision close before the deeper parts are ready for

it. Incisions made in the axilla should be parallel with the great

vessels and nerve trunks, by which they are better exposed and avoided.

A wound made in the axillary vein may be sutured or the vein be doubly

ligated. The former is much the better course, very fine silk sutures

being employed. In some lesions where it has not been possible to

discover the bleeding point the writer has not hesitated to secure it

with the ends of pressure forceps and to leave these forceps included

in the dressings for forty-eight hours. He has never seen harm result

from this procedure.

[Illustration: FIG. 522

Congenital diaphragmatic hernia, with other congenital defects. Wood

Museum. (Dennis.)]

Finally the axilla is almost always involved in cases of _malignant

disease of the breast_, of the arm itself, and sometimes of the regions

adjoining. Primary malignant disease in this region is rare, while

secondary cancer is not unusual. According to the modern plan of

treatment of cancer there is reason for scrupulous extirpation of every

particle of infected tissue and all involved lymphatics, and in dealing

with such cases the surgeon need not hesitate to divide or extirpate

the pectoral muscles, in order to permit of thorough work. The disease

being present nothing can be so serious for the patient as to allow any

particle of it to remain.

THE DIAPHRAGM.

The diaphragm may show certain _congenital defects_, consisting mainly

of fissures or openings which permit displacement of viscera, usually

from the abdomen below into the thorax above. This is often fatal,

constituting a form of _diaphragmatic hernia_, which is particularly

liable to strangulation. Fig. 522 indicates a case of this kind,

showing the hopelessness of the condition.

Anatomically it is worth while to recall that the diaphragm may rise to

a level with the third cartilage during forced expiration, and descend

to the level of the fifth intercostal space on the right side, and a

little lower on the left, during forced inspiration. When forced upward

by pressure from below it may rise even higher than stated above. These

facts are of surgical interest in considering the possibility of injury

or perforation of the diaphragm in connection with gunshot and other

perforating injuries to the thorax or abdomen.

_Diaphragmatic paralysis_ is the necessary result of injury to the

phrenic nerve. It may occur as the result of injury to the thoracic

viscera, especially those of the posterior mediastinum, or injuries

to the cervical or upper dorsal vertebræ, usually fractures or

dislocations, followed by ascending degeneration and involvement of

the phrenic nerve roots. Double phrenic paralysis is in these cases

obviously fatal. Paralysis of a single side will cause at least serious

embarrassment of respiration. An hysterical form of diaphragmatic

paralysis has also been described.

_Primary tumors_ are exceedingly rare in this muscular partition.

Advancing growths, however, attach themselves to it or perforate it, as

may also aneurysms.

Aside from the ordinary injuries which the diaphragm may suffer from

without, and already mentioned, there are peculiar forms of _rupture_,

the result of force applied from below, usually at right angles to

the surface of the body, this being permitted on account of the

dome-like shape of the muscle. When thus ruptured abdominal viscera

may be forced into the chest and even out through openings between

the ribs. A gunshot wound of the diaphragm will be serious mainly in

proportion to other injuries involving the viscera above or below it.

These injuries produce no typical symptoms, but are nearly always

accompanied by severe pain radiating toward the shoulders, with dyspnea

and a substitution of abdominal for diaphragmatic respiration. When the

viscera have been forced upward they will displace the heart, and this

may produce cardiac symptoms. It is said that the so-called “sardonic

grin” is still observed on the faces of corpses who came to sudden

death from some injury to the diaphragm.

Thus diaphragmatic wounds are not of themselves of serious import. When

inferentially present they may, therefore, be disregarded so long as no

serious symptoms are produced. On the other hand, exploratory celiotomy

should be performed at any time, should conditions seem to justify it.

SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS.

While this is a condition pertaining, strictly speaking, to the

abdominal cavity, it nevertheless arises so frequently from

intrathoracic causes as to justify its consideration here, as well as

because of its close relations to the diaphragm. It was Volkmann who,

in 1879, first showed how these abscesses could be successfully and

surgically treated. The term is applied to collections of pus beneath

the diaphragm, usually between it and the liver, which, however, may

extend to and later involve surrounding viscera.

The _causes_ may be divided into those met with above the diaphragm

and those below. The former may include empyema, pus having escaped

beyond the normal pleural limits, advancing tuberculous disease from

any of the structures above the diaphragm, echinococcus in the lung,

or suppurative mediastinitis. From below the diaphragm the infectious

process may travel from the direction of a gastric or a duodenal ulcer,

hydatid disease in the liver, phlegmon around the liver or kidney.

The contained pus may, on culture, show the presence of colon bacilli

or pneumococci, as well as the ordinary pyogenic cocci and tubercle

bacilli. If connected with hydatid disease hooklets may be seen in pus

which is not too old.

Subphrenic abscess may result in large collections of pus, which may

travel a considerable distance, separating the peritoneum from the

diaphragm and from the lateral abdominal walls, appearing even low

down in the pelvis. The same is true of escaping pus from a case of

empyema. The primary trouble gives rise to a localized peritonitis

or perihepatitis, by which are produced certain barriers that serve

to retain pus within bounds, and to keep it from spreading save as

above mentioned. Should it be due to extension of abscess or disease

within the liver it may be confined by adhesions about it. Fig. 523

illustrates the relations which such a collection may sustain to the

liver and the diaphragm, as well as how the opening by which it may

be best evacuated should be made through the thoracic walls. Even

with this condition produced by disease below the diaphragm it is not

infrequent to find some collection of fluid or evidence of exudate

above it.

A study of this condition will nearly always lead one back to a history

of some illness which may furnish the explanation for the commencement

of the trouble. Thus, there may be obtained a history of pulmonary

tuberculosis, of empyema, of gastric ulcer, of gallstone trouble, or

of abscess in the liver or in or about the kidney. When the result of

perforation from above, the chest wall may furnish signs which will be

sufficiently indicative.

The _symptoms_ will include swelling, pain, tenderness, with fixation

of the liver, and apparent enlargement of its boundaries, because it is

pushed away from the diaphragm. The abdominal wall will frequently be

edematous. The ordinary signs of the presence of pus are rarely absent,

including the evidences furnished by a differential blood count.

Diagnosis is proved by the use of the exploring needle. The disease

is nearly always situated upon the right side. The more distended the

abscess cavity the less respiratory murmur will be heard over the

lower part of the chest, while the line of the hepatic dulness may be

considerably above the normal. Sometimes a succussion sound may be

obtained.

Should pus be withdrawn from the lower part of the chest by the

exploring needle there might still be doubt as to its actual location,

whether above or below the diaphragm. The absence of cough and of

indications of pleural involvement would prove much in favor of the

latter.

Subphrenic abscesses tend in time to evacuate themselves. Thus they

sometimes perforate the diaphragm and escape into the pleural cavity,

or through a lung which has attached itself at its base, and thus

afforded an outlet for pus through the bronchi and the mouth. On the

other hand, pus may burrow downward and appear in the flank or beneath

the skin near the liver and in front of it. The nearer it comes to the

surface the more easily it is recognized.

[Illustration: FIG. 523

Transthoracic opening for subphrenic abscess. (Beck.)]

=Treatment.=--The treatment of subdiaphragmatic abscess, like that

of all other abscesses, consists in evacuation of the contained pus,

with provision for drainage. In some instances this may be done with

an ordinary trocar and cannula, but serious cases are best treated by

incision, with resection, if necessary, of a portion of a rib. When

the chest wall is entered the best place is between the ninth and

tenth ribs in the axillary line. Nevertheless pus which is presenting

at any other point may be best reached by taking advantage of the

indication thus afforded. An opening having been made the question of

counteropening may be raised. This should be decided in each instance

upon its merits. While an opening made in front does not drain so

well as one placed posteriorly it may be made to drain by keeping the

patient upon the side or face for a portion of the ensuing few days.

When it seems desirable to go through the chest wall it should be

incised carefully, and if the pleura has been opened before reaching

the abscess, the pleural surfaces may be either stitched together or

packed; after waiting a day or two for protective adhesions to form

the abscess may then be opened. The less extensive operations may be

performed with local anesthesia. Rib resection and extensive incision

will usually require general anesthesia.

CHAPTER XLIV.

THE BREAST.

ANOMALIES OF THE BREAST.

_Amastia_, or complete absence of one or both breasts, is a rare

defect. _Polymastia_, or the occurrence of _supernumerary breasts_,

is more frequent.[51] These may be found on any portion of the thorax

or abdomen, and may constitute masses of trifling size or may bear

considerable resemblance to the normal breast. A supernumerary breast

has even been found upon the thigh. The condition is to be regarded as

atavistic, and a return to the polymastia of animals, which produce

a litter at one birth. Similarly absence of the nipple, _amazia_, is

occasionally seen, or more frequently _polymazia_, the occurrence of

more than one nipple, either upon the normal breast or in some abnormal

position. Some of these lesions are so small as to escape observation,

or to be considered moles unless carefully noted and recognized when

found.

[51] History records interesting examples of the importance attached

to these conditions. Thus the beautiful Anne Boleyn fell under the

displeasure of King Henry because of a supernumerary breast, and it

is said that the mother of the Roman Emperor Alexander Severus was

given the name of Julia Mammæ because of a similar abnormality.

Ordinarily supernumerary breasts are met near the middle line and

below the normal mammary gland. A more common condition is one of

defect of the nipple, which fails to assume its normal prominence and

remains ill-developed, so as not to be seized by the infant in the act

of attempting to nurse. Nevertheless with the physiological activity

which occurs in the breast at the time of pregnancy these ill-developed

nipples usually expand sufficiently to fulfil their function, even

though imperfectly.

_Hemorrhages_ from the breast sometimes take place idiopathically,

at others as vicarious efforts at menstruation. There is a peculiar

sympathy between the pelvic organs of women and the mammary glands,

and the latter evince this in more than one way, becoming sometimes

extremely tender or swollen at the menstrual period, or at other times

peculiarly sensitive or even neuralgic, while at times congestion

will proceed to the point of hemorrhage. These conditions do not

require particular attention, but are not to be confused with a bloody

discharge that may occur later in life, in connection with certain

forms of malignant disease occurring in the interior of the breast.

[Illustration: FIG. 524

Idiopathic hypertrophy of breasts in a girl of sixteen. (Bebee.)]

There exist the widest differences in development of the breasts in

different individuals. The term “breast” is used intentionally, since

the difference is not so much in the actual glandular development as

in the surrounding connective tissue and fat. Thus a plump breast

may contain very little more secreting structure than one apparently

ill-developed. Nowhere outside the uterus save in the breast do such

compensatory changes take place under the stimulus of pregnancy. In

fact, a mammary gland in preparation for lactation is a physiological

adenoma. At conclusion of lactation there is absorption and atrophy

from disuse, usually not to the original degree, although in some

instances the fatty tissue disappears irregularly and leaves the

breasts in quite different shape from their originals. In this way the

breasts may become exceedingly pendulous, so much so as to lead to pain

and soreness from traction, and to call for their support.

_Idiopathic hypertrophy_ of one or both breasts is a rare deformity,

occurring usually in the young, sometimes in girls, involving them to

an indefinite degree, but in some producing enormous overgrowth, with

corresponding deformity. For such hypertrophy no known cause has been

assigned. Fig. 524 illustrates an instance of this character in a young

girl, occurring under the observation of my colleague, Dr. Bebee.

INJURIES TO THE BREAST.

These consist largely of _contusions_ to which, from their positions,

the breasts are peculiarly exposed, and these may be followed by

hemorrhage, by extensive ecchymosis, or by any of the consequences

of infection. They may also be followed by more or less permanent

_induration_. The fact that in the course of time certain contusions

of the breast are followed by development of cancer is incontestable,

although the relation which may exist between the accident and the

neoplasm has not yet been made clear. The breasts are also subject to

the same possibilities of injury as other parts of the thorax, which

has been considered in the previous chapter. The _nipples_ are more

often injured by efforts of the nursing infant, or by the friction

of ill-fitting stays or rough clothing, than in any other way. These

injuries, at first of a minor character, are not infrequently followed

by serious results, erysipelas, septic infection, or tuberculosis being

conveyed through trifling abrasions thus inflicted.

The nipple of a nursing woman once excoriated, or its surface broken,

is kept constantly liable to maceration and surface infection. In this

way a trifling lesion may result in a linear ulcer known as a _fissure_

(“cracked nipple”), or in a more extensive involvement. These fissured

nipples are very erethistic, and great pain is caused by each attempt

at nursing. On this, account the mother postpones the act as long as

possible, and until her breast has become overdistended, the result

being injury to the breast itself, with a greater possibility of

infection and of subsequent abscess formation.

The slightest _excoriation of the nipple_, under any circumstances,

should lead to the adoption of every precaution for its cleansing

and protection. Both before and after nursing it should be carefully

washed, while, after removal of the child from the breast, it should be

carefully dried and dusted with dry boric acid or a similar antiseptic.

Any abrasion which fails to heal should be treated with silver nitrate.

More pronounced abrasions and ulcers should be cocainized, then

cauterized, and afterward treated as above. Finally in extreme cases it

may be necessary to discontinue nursing and allow the breast to dry.

If this policy be adopted it should be applied to both breasts, for

such is the sympathy between them that the use of one gland seems to

stimulate the other. The local use of such preparations as belladonna

ointment, etc., is to be avoided. Pressure, rest, and the care above

described afford more relief.

_Paget’s disease of the nipple_ implies an eczematous condition, first

described by Paget as a precursor of many cancers. It is a more or

less chronic affection, involves the nipple and the areola, is quite

intractable to treatment, gives more or less discomfort, and is to be

dreaded when noted. It seems to sustain about the same relation to

later cancerous involvement as does leukoplakia in the mouth and on the

tongue.

There is no reason why any person may not have an attack of eczema

about the nipple, but cases in which the condition is persistent and

obstinate, and especially in which the underlying tissues gradually

become infiltrated or indurated, should be viewed with suspicion, and

should be treated by eradication of the area involved, even though this

may require extirpation of the nipple or of the entire breast. When the

condition is developed no ordinary treatment will suffice, although a

fair trial might be given to the cathode rays.

MASTITIS.

A true inflammation of the mammary gland may occur at one of three

periods: (1) At _birth_, when the tiny breasts of the newborn infant

secrete a milk-like fluid, become more or less congested and tender,

and when they are unintelligently treated by massage or interference of

any kind; (2) at _puberty_, when a perfectly natural turgescence and

congestion occur, which, however, rarely proceed to suppuration unless

infected or unless violence or some indiscreet treatment have been

received; (3) during _pregnancy and lactation_, this being the time

when mastitis is most common.

Considering that the nipple affords a number of open paths, from an

area which it is difficult to keep clean, extending into the depths of

inflammable tissue, it is strange that infection through the milk ducts

does not occur in most cases. Such a path of infection affords the

explanation for at least a large proportion of mammary abscesses. Again

the presence of excoriations, abrasions of any kind, and especially of

deep fissures which are not easily cleansed, will account for infection

through the lymphatics. In these two ways nearly all cases of mastitis

and of mammary abscess are to be explained, and both these accidents

are likely to occur during pregnancy and lactation.

The consequence of such infection is _mastitis_, which begins with

painful induration and local indications of inflammation, but which

may under suitable treatment undergo resolution. This failing, the

infectious process proceeds to suppuration, and the consequence is a

superficial, deep, or retromammary _abscess_, all but the last named

often in multiple form. The lobular construction of the breast permits

the independent occurrence of distinctive suppuration, occurring

synchronously at several different points, and hence it may be that a

breast is riddled with abscesses, which form successively or almost

simultaneously.

There is a _superficial form_, which occurs usually near the nipple,

and in which the deeper structure of the breast is scarcely involved.

This comes usually through infection of some surface lesion. Simple

incision is usually sufficient, and the local lesion is thus quickly

terminated. _Deep or intramammary abscess_, single or multiple, is

always painful, sometimes distressing and occasionally an extremely

serious condition. Occurring in a breast already well developed and

fatty, abscesses may form at such depth as to be recognized with

difficulty. The surgeon infers their existence rather than discovers

it. This is unfortunate, for the longer the delay the greater the

local disturbance, with a tendency to burrowing, and the worse are the

consequences for the patient. It is, therefore, far safer to early note

the minor signs of deep suppuration and to freely incise, than it is to

wait for pus to come toward the surface and give its ordinary surface

indications. The amount of induration, sometimes dense and brawny,

which such conditions will produce within the breast, the size which

the latter may assume, and the consequent suffering to the patient

from neglected conditions of this kind, need to be seen to be fully

appreciated.

_Retromammary abscess_ may be the result of conditions not primary to

the breast itself. Thus the writer has seen spontaneous perforation

of the thoracic wall in a case of empyema, with escape of pus into

the loose cellular tissue behind the breast, and the consequent

protrusion forward of the latter until it presented as an enormous

tumor. Treatment in such cases would mean not alone evacuation of

the retromammary collection, but emptying the pleural cavity of its

accumulated fluid.

An infected breast will produce not only the ordinary local

indications, but will be characterized by extreme tenderness, with

enlargement of the lymph nodes in the axilla and later abscess

formation in this location. In proportion to the amount of pus

thus imprisoned, and the virulence of the infecting organisms,

constitutional symptoms may be mild or extreme.

Nowhere is there greater need for release of an imprisoned amount of

pus than under these circumstances, although the incisions necessary

for the purpose may be sometimes multiple and deep. Every incision made

for evacuation of a mammary abscess should be placed _radially_--_i.

e._, in a line radiating from the nipple--in order that lobules may

be incised along their course, and that neither they nor vessels be

cut across transversely. There is also need for complete drainage, and

several tubes may be used for this purpose, being passed completely

across or beneath the breast.

=Chronic Mastitis.=--Chronic mastitis may be the termination of a

partially resolved acute process, or of injury, or of apparently

unknown causes, being in these instances of apparently spontaneous

origin. Pathologically it comprises induration, with more or less

infiltration of the interacinous and interlobular tissue, and with some

infiltration of the other structures of the breast, by which fixation,

retraction of the nipple, or condensation of the surrounding structures

and adhesion of the overlying skin are produced. The result may be to

produce either an enlargement or diminution in size of the breast. One

or both glands may be involved. It is a disease usually of late adult

life.

Breasts thus affected are often tender and painful, especially during

menstruation, and upon palpation are found to be irregular in shape,

more or less nodulated, extremely firm in some cases and places, and

perhaps so infiltrated as to strongly simulate cancer. The changes

which are thus produced are slow, and it is important to note that

the lymphatics are usually not enlarged, and that after attaining a

certain degree the diseased condition becomes stationary. The general

health usually does not suffer beyond a certain point; at least even in

the more chronic cases there is no characteristic cachexia. While the

condition is more frequent in women who have nursed it may be met in

those who have never borne children nor have been married.

_Suitable examination_ of all these cases can only be made with the

upper portion of the patient stripped, the body in the horizontal

position, and both breasts compared and examined, first with the flat

hand in order that differences of shape, size, mobility, and fixation

may be determined. Subsequently the patient should be raised to the

sitting position, the surgeon standing behind to examine each breast

with one hand and simultaneously, in order that differences may be more

accurately noted. Any tumor present will be more easily discovered

with the flat hand than with the finger-tip, while chronic induration

will not give the sensation given by neoplasms. The axillæ should also

be carefully examined, as well as the supraclavicular regions, for

evidences of lymphatic involvement. When the entire breast is involved

diagnosis is less difficult than when one or more lobules alone are

concerned. These constitute the painful nodular conditions to which so

many names have been given by different writers.

Significant features in their differentiation from cancer are the

disproportionate pain and tenderness, their diffuse leathery hardness,

and the fact that both breasts are usually similarly involved,

though perhaps not to the same extent. Cancer is, on the other hand,

somewhat dense and confined to one breast, and affords a sensation

of infiltration of the surrounding tissues, with the peculiar

“saddle-skin” retraction or adhesion of the overhang skin and nipple.

Moreover, the growth is more rapid and localized, and the lymphatics

are involved in nearly every instance. Some of these cases are so

obscure that diagnosis previous to operation is impossible, while

innocent lesions may gradually merge into malignant, and no one can say

when the transition begins or has begun.

=Treatment.=--The milder forms of chronic mastitis gradually

improve under the influence of local applications such as the

ichthyol-mercurial ointment, to which menthol may be added for its

soothing effect. Pendulous or painful breasts should be supported

as much as possible. Otherwise these cases are best let alone--_i.

e._, they should not be rubbed or massaged. There is usually a

constitutional condition which is closely related, and in nearly every

instance there is more or less failure of elimination. These features

should be studied and treated as they are identified. Finally there

are some intractable forms of innocently indurated breast which give

so much trouble that it is best to remove them as though they were

cancerous.

NEURALGIA OF THE BREAST; MASTODYNIA.

Many women suffer from annoying and painful affections of the breast

for which no sufficient excuse is found, while others who have small

fibrous nodules or innocent lobular tumors will suffer an amount of

pain which is disproportionate, and in instances of either type we

are prone to point to the neurotic or hysterical features of the case

and to say that it must be, at least to a certain extent, neurotic.

Inasmuch as these cases usually occur in young and otherwise neurotic

women, often of the more impressionable type, it is generally proper to

consider them as to some extent hysterical, while in others there are

pelvic accompaniments which may perhaps account for neuralgic breasts,

because of the well-known intimate relations between the pelvic organs

and these glands. In some cases, again, are found actual small tumors,

single or multiple, but of innocent character. In other cases there are

hypersensitive areas of entire breasts, to a degree where the patient

cannot stand the slightest handling. These cases are hyperesthetic,

even if not hysterical, and some are unsatisfactory to treat. The pains

are more or less periodical, and often radiate down the arm or the side

of the thorax; this may be explained through the intercostohumeral and

other nerve connections.

=Treatment.=--The treatment of mastodynia should include

constitutional, local, and moral measures, but of these the local

are the least important. The excision of painful nodules is often

disappointing, the remaining scars becoming even more sensitive

than the original lesions. Women who under these circumstances have

insisted upon the removal of an entire breast have still suffered

from intercostal neuralgia or other remaining painful conditions, so

that their ultimate condition has not been much improved. Each case

should be studied upon its merits, and while one may be benefited by

some pelvic operation, or another by Turkish baths and improvement of

elimination, others are best let alone, or given a minimum of drugs

with a maximum of general and sexual hygiene.

TUBERCULOSIS OF THE BREAST.

I cannot agree with writers like Fowler, who claim that tuberculosis

of the mammary gland is extremely rare. I think it not infrequent. In

the breast may be noted the presence of lesions, either separate or

coalescing, and gummas as such, or breaking down into caseous masses or

into cold abscesses. In connection with the local lesions there may be

more or less involvement, even to ulceration, of the overlying skin,

with the formation of lupoid ulcers, while the axillary lymphatics

will be nearly always involved. In some instances the disease may have

gone on to suppuration and burrowing of pus, with its discharge, and

the existence of tuberculous sinuses; or in others may be seen results

of a secondary infection of the remains of multiple mammary abscess.

The condition is most often met with in the young and fair, but may be

seen in elderly women. Around the distinctly tuberculous lesions there

may be considerable tissue sclerosis. The actual proportion of cases

is about one of this condition to fifty of cancer. Lesions are more

frequent in the outer quadrant of the breast than the inner, and they

occasionally produce retraction of the nipple or adhesion of the skin,

above described, before its distinct involvement.

In any of these circumstances secondary purulent infection may occur,

and an acute phlegmonous process may seriously complicate the previous

chronic condition.

=Treatment.=--There is but one satisfactory method of dealing with

tuberculous disease of the breast--_i. e._, its extirpation. The

entire breast, or so much of it as may be distinctly involved, should

be extirpated as though it were cancerous, while the axilla should be

opened and its contents cleared out, if it appear in the slightest

degree involved. Moreover, every other tuberculous lesion in the

neighborhood should be eradicated, either with the knife, the scissors,

or the sharp spoon. After such radical treatment results are usually

satisfactory.

ACTINOMYCOSIS; SYPHILIS OF THE BREAST.

_Actinomycosis_ is not common in this location; nevertheless tissue

conditions are such that it would furnish accessible and diagnosticable

features which would be distinctive, at least until some secondary

infection had occurred.

_Syphilis appears_ in this location in many of its protean

manifestations. _Chancres about the nipples_ and on the surface of

the breast are not uncommon, the disease being often conveyed from

syphilitic infants through cracked nipples, while many other methods

of contamination have been reported. Near the nipple the chancre may

not have those characteristics which usually distinguish it upon the

genitals, but may appear rather as an indurated, intractable ulcer,

with firm base, accompanied by distinct involvement of the axillary and

supraclavicular nodes, and unless early recognized and promptly treated

as such will so endure until the occurrence of the first significant

secondary eruption, whose appearance should dispel doubt and lead to

radical treatment.

There is difficulty, sometimes, in distinguishing between tuberculous

and syphilitic skin lesions upon the breast, especially near the

nipple. When other methods fail the therapeutic test will nearly always

clear up the difficulty. All truly syphilitic lesions here, as well as

elsewhere, yield promptly to well-directed treatment.

TUMORS OF THE BREAST.

The mammary gland is a frequent site for tumors, although neoplasms of

embryonic origin are not as frequent here as might perhaps be expected.

Nearly one-fifth of all tumors occurring in the body will be found

in this location, while the larger proportion of breast tumors are

malignant.

_Cysts_ abound in this locality, occurring in one or both breasts,

and singly or in exceedingly multiple form, the latter being small

and containing but a few drops of fluid. Their cystic contents are

colorless and of a serous consistency, sometimes thick and mucous,

occasionally discolored, and in rare instances almost like unchanged

milk. In the latter case the condition is known as _galactocele_.

In an organ so thoroughly provided with ducts it is easy to understand

how _retention cysts_ may readily occur from plugging of some duct and

the accumulation of secretion behind it. Should it occur at a time when

milk is forming galactocele may be readily explained. At other times

it is in every respect an abnormal development. This occlusion of the

ducts may be the result of disease or of injury, and is not always

complete, for it often happens that from a distended duct more or less

accumulated material may be expressed by gentle pressure. In this case

it will be found thick and loaded with the epithelial cells which line

the passages. These retention cysts are spoken of as serous, mucous,

or sanguinolent (blood cysts), according to their contents, while

the lacteal contain material more or less resembling butter. _True

galactocele_ seems to be rare. While the original contents are milky

it is claimed that through changes taking place in the neighborhood

induration and proliferation in the surrounding membrane may result, or

that mammary tissue may soften and break down into pulpy detritus.

_Cystic tumors_ in the breast may be of innocent character, or may

assume all degrees of malignancy. A cyst whose lining membrane is

smooth, without reduplications or irregularities, may be regarded as

innocent, while the complete extirpation of its walls will be all that

is required. This may be made more complete after injecting it and

staining it with methyl blue, or filling it with melted paraffin in

order to occupy the place of the fluid, which should have been drawn

off. On the other hand, every cyst whose interior is roughened, _or

presents the slightest papillomatous appearance_, or which is unduly

_adherent_, or has about it any mark of _infiltration_, calls not only

for its own eradication, but for practically the complete removal of

the breast.

The _signs of cystic tumor_ in the breast are essentially those of any

other neoplasm, except that it is frequently possible to recognize

its cystic character by fluctuation. A cyst ordinarily presents as a

distinct tumor, and when innocent is circumscribed and non-adherent,

lacking the clinical evidences of malignancy. Pain is an uncertain

feature. Most cysts develop slowly, but a cyst developing suddenly

after parturition or during lactation, without previous local

inflammatory changes, is probably a galactocele. The small multiple

form of cyst, with which one or both breasts may be studded, is

frequently confused with chronic mastitis, from which it is difficult

to separate it. The escape of sebaceous material or of milky fluid

from the nipple, or the possibility of making it appear by gentle

pressure, will probably afford the best indication. If along with this

possibility the nipple be found ulcerated, or if the extruded fluid be

bloody, complete extirpation of the breast would be the only suitable

measure.

=Treatment.=--The general treatment of cyst has been indicated. It is

a question simply of how extensively the eradication should be made.

The advice of the older text-books is misleading, and it is the studies

of very recent years which have shown how early the lining membrane of

apparently innocent cysts may undergo malignant changes, by which the

breast is soon compromised and which necessitate its entire removal.[52]

[52] It will be a safe rule to follow if it be assumed that every

cyst whose contents are bloody, unless this can be traced to recent

accident, and especially every cyst whose interior is papillomatous,

is on the border-land of malignancy, if not malignant in character.

All such tumors then should be extirpated. If they occur in the

breast a complete operation, as for cancer, should be done.

Of the _benign_ tumors _lipomas_ in the substance of the gland are

rare, while they may frequently develop in its fatty surroundings.

_Adenoma_ and _fibroma_, with their various combinations, are the

most common of the innocent tumors, and they constitute single or

multiple nodules, located in the substance of the gland, or in evident

communication with it, constituting masses of well-marked density, slow

growth, nearly always mobile and non-adherent to the skin, causing

neither retraction of the nipple nor lymphatic involvement, and being

frequently accompanied by a very disproportionate amount of pain and

tenderness, some of them being, in fact, exquisitely sensitive. While

these growths are rare previous to puberty they are frequently met

in girls and young women, and, occurring in these neurotic subjects,

they cause considerable mental as well as physical trouble. In these

patients there may be found coincident pelvic disorder. The removal

of these sensitive masses, which seems to be plainly indicated, is

often disappointing, as the remaining scar may retain the original

hypersensitiveness, and patients often suffer as much as before the

operation.

The enlargement of the breast, which normally prepares it for

lactation, is to be regarded as the development of a normal or

_physiological adenoma_. Anything which simulates this under other

conditions is abnormal, and any overdevelopment of true mammary gland

tissue, when localized and circumscribed, should be referred to as

_adenoma_. In such tumors cystic changes often occur, as well a later

transformation into _adenocarcinoma_, something always to be dreaded.

These changes are more likely to take place during lactation, at which

time the blood supply to the breast is more free. The development,

then, of _an adenoma in the breast of a nursing woman_ should be

regarded with suspicion, and unless benign it should be regarded

as demanding removal of the entire organ. These tumors also are

non-adherent and lack the ordinary signs of malignancy.

=Cancer of the Breast.=--Cancer occurs in the breast more often than

anywhere else, and _carcinoma_ constitutes about 85 per cent. of these

malignant tumors, the balance being mostly sarcomas, the remaining

small number being made up of endotheliomas and the other rare forms.

The most common type of carcinoma is the so-called _scirrhus_, in which

there is a large amount of dense stroma, and which forms a strong

contrast with the rare forms of rapidly growing, true soft cancer--_i.

e._, the _encephaloid_ or _medullary_ as they used to be called--in

which the cancer cells proliferate with greater rapidity and in which

there is a small amount of stroma, so that in consequence the tumor

itself is soft or almost gelatinous.

_Sarcoma_ of the breast may assume either of its well-known types, and

is a tumor seen in the earlier rather than in the later years of life.

It sometimes grows rapidly and attains large size, seeming to approach

the surface more rapidly and readily than ordinary forms of carcinoma.

In consequence it may be mistaken for abscess. As a rule, however, the

skin is not so likely to be adherent to the tumor as in carcinoma, and

the lymph nodes are not so early involved, while in a cut section of

the tumor the fat is not so disposed as in carcinoma, where it may be

seen in layers, while in the former case it has been transformed into

malignant tissue.

The two principal forms of _carcinoma_ are the _acinous_ and the

_tubular_, in the former the cells being packed into the alveoli and

surrounded with a firm and adventitious stroma, while in the latter

the primary development seems to be within the milk ducts, which

being first involved cause a more multiple minute invasion and a less

distended tumor formation.

The _general indications of cancer in the breast_ are as follows:

The presence of _tumor_, sometimes of regular and definite outline,

sometimes diffuse and not easily outlined.

_Fixation of this tumor_ in the surrounding tissues in such a way that

it cannot be moved without disturbing them.

_Fixation of the general area_, either to the skin above or to the

pectoral fascia below, or both. This gives to the part an immobility in

contrast with normal conditions.

_Retraction of the nipple_, when the growth is large or located near

it. This is a feature perhaps not noticeable in the primary stages when

it is so important to recognize the disease if present.

_Retraction of the overlying skin_, at points if not over a

considerable area, giving it a peculiar “saddle-skin” or “pig-skin”

appearance. This indication of itself is always suspicious and one

which should be noted if present.

In addition to the local evidences in the breast the _involvement of

the nodes in the axilla_ and of the lymph vessels leading up toward it.

These should be carefully studied, the patient’s arm being held loosely

away from the body, and somewhat to the front, in order to relax the

pectoral muscle. In fleshy subjects it may not be possible to discover

them even if present. The supraclavicular region should also be

examined, and enlargements may be felt here or along the cervical chain.

In addition to the above features others which are more indicative,

because they point to advanced disease, are the appearance in the

skin or just beneath it of shot-like nodules, more or less red, or of

any mass which causes the skin to protrude and to have an unnatural

appearance, usually one of lividity or threatening ulceration. _Pain

is an uncertain and variable feature_, upon which little stress should

be laid. The laity have incorrect notions about the constancy and

significance of pain, and many a woman has deluded herself into the

notion that she had no cancer because her tumor was not painful. _Pain

is sometimes pronounced_ and severe, even radiating down the arm; _at

other times it is absent_ until almost the terminal stage.

_Any tumor in the breast which presents any one of the above

characteristics is to be regarded as at least suspicious, while the

occurrence of two or more of the above features should stamp it as

malignant, and consequently condemn it. This is equally true of the

cancers which rarely appear in the male breast._

Cancer is supposed to be a disease of _middle and usually of advanced

life_. _This, again, is an error._ To be sure, carcinoma is rare below

the age of thirty, and yet one sees it not infrequently in women much

younger than that. One of the saddest cases I have ever known was one

of carcinoma of both breasts in a young mother of twenty-two, advanced

to hopeless condition because her physician had held that it could not

be cancer at her age, and because she had coincided with his belief,

since she had not suffered pain.

The _course of a cancer in the breast_ depends on several factors.

There is a rapidly growing type which tends to kill within a few

months, this occurring usually in younger patients. On the other hand

there is a slowly growing type which may last over a period of years.

This is the so-called _atrophic cancer_, and its slow growth is due

to the perfection of the protection afforded around the cancerous

masses by the density of the stroma. Occurring in a fatty breast it

leads to a diminution of its total mass, even though the cancerous

features themselves be advancing, and this makes it sometimes hard to

convince patients that a breast which is actually diminishing in size

is becoming more and more seriously involved. _Cancer tends ever to

advance, and sometimes_, as it were, _by leaps_, the method of invasion

being usually one of steady progress and infection of the adjoining

tissues; while metastases are to be expected as the case goes on, and

occur sometimes in unexpected forms. Thus in cancer of the breast

there is a well-known metastatic invasion of the bones, even of the

extremities, with the consequent liability to so-called _spontaneous

fracture_. In cases of the latter the former condition should always

be suspected. There is a possibility always of invasion of the sternum

and the ribs by continuity. It has been shown that invasion of the

pectoral muscle, and even of the firm pectoral fascia, was a common

result, and this demonstration has led to the adoption of the more

recent radical methods of removing both of these structures along with

the involved breast. In rare instances both sarcoma and carcinoma

assume the _miliary type_, and evince it by a miliary invasion of the

skin of the thorax which becomes gradually infiltrated, softened, and

perhaps finally ulcerated, the involved skin thus having the aspect of

a corset of diseased tissue, and being spoken of as “jacket cancer” or

“_cancer en cuirasse_.” Such a condition may before the patient’s death

involve the entire circumference of the thorax. Any of these miliary

expressions of malignancy stamp a case with a hopeless aspect. General

miliary carcinosis is also known to occur.

Nearly all cancers grow faster in the young. Other things being equal,

there is a somewhat better prognosis for the condition in elderly

people, and this applies equally to prospect of recurrence after

removal.

In regard to the curability of cancer the reader is again referred to

an earlier chapter on the general subject, but doubtless _there is a

time when if the growth were recognized and thoroughly removed it would

not recur_ and the patient might be cured. This time is, unfortunately,

too often past when the case comes under the observation of one

competent to deal with it. This is due partly to fear and ignorance on

the part of the patient, and unfortunately too often to failure on the

part of some practitioner to appreciate the significance of the early

manifestations, _i. e._, to a failure in early diagnosis.

_Cancer also occasionally occurs in the male breast_, and I have record

of a number of fatal instances of this kind. It is, however, quite

rare. It is usually of the scirrhus type, but may be the result of

epithelioma commencing about the nipple and spreading. It cannot assume

marked size without becoming thoroughly distinctive, and probably

ulcerating, and there should be no difficulty in diagnosis. It demands

the same radical operation as cancer in the female (Fig. 525).

=Treatment.=--In regard to the method of treatment there is but one

which needs to be seriously considered, _all others being fallacious

and irrational. It is by operative removal alone that every hopeful

case should be treated at the earliest possible date._ Patients may

dread the knife and some men may fear to use it. Nevertheless the

above statement holds true. Even then cure is not obtained unless

the knife be used thoroughly. Treatment by plasters is barbarous

and unscientific, as well as uncertain and absolutely unsurgical.

None of the popular remedies is of the slightest value. Treatment

by the Röntgen rays should be reserved for the hopeless cases or

for _postoperative protection_. Eradication is, therefore, the only

scientific surgical relief.

_Any growing tumor in the breast of a woman which cannot be clearly

recognized as perfectly innocent demands operative removal_, and the

operation itself should be made thorough if success is to be attained.

In the presence, then, of lymphatic involvement, of any adhesion or

infiltration of the overlying skin, or of the surrounding textures, or

of retraction of a nipple, or of fixation of the breast upon its base,

operation should be advised without any reference to the question of

pain. Equally important is it to decide _when not to operate_. When the

condition is disseminated, when the presence of cancer in any other

part of the body can be demonstrated, when the lymphatics of the neck

are notably involved, when the arm is already swollen from obstruction

to the return circulation, when the skin presents numerous miliary

nodules, or when from disturbance of the heart or of respiration--_i.

e._, chronic cough--it might appear that there is involvement of the

bronchial nodes, with consequent pneumogastric irritation, then it may

be held that the case is so far advanced that it is useless to subject

the patient to the risk entailed by operation. There are exceptions,

however, even to this statement; such as an evidently hopeless case

that has reached the stage of ulceration, in which discharge is

offensive or hemorrhage recurring, when operation may be done for

temporary and with humane purposes.

[Illustration: FIG. 525

Cancer of male breast. (Buffalo Clinic.)]