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.