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.
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.