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.