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.