Volume 1

Text-book of surgery for practitioners and students / by American authors ; edited by William W. Keen and J. William White.

Date:: 1893

Credit: Text-book of surgery for practitioners and students / by American authors ; edited by William W. Keen and J. William White. Source: Wellcome Collection.

686/694 page 626

$abscess in the neck, burrowing down behind the deep cervical fascia, or upon tubercular trouble either in the neck or within the thorax. The traumatic variety may follow contusions, but has been most common after fractures of the sternum or gunshot wounds. Such abscesses are characterized by a sense of weight in this region, by pain on coughing, drinking, sneezing, etc., by a sense of being out of breath, by more or less oedema over the sternum, and by the constitutional signs of the presence of pus. When these signs are present the proper course will be to trephine the sternum, to explore care- fully with the hollow needle, and, if pus be found, to open, wash out, and drain the cavity. SUEGICAL AFFECTIONS OF THE DIAPHRAGM. This muscle constitutes the natural septum between the thorax and abdo- men, and has fixed attachments to the spine and to the lower portion of the thoracic wall. It is capable of considerable displacement upward and down- ward ; in forced expiration it rises to the right third cartilage, and in forced inspiration descends to the right fifth intercostal space. On the left side it is one or two ribs lower. In cases of enormous abdominal distention it has been found as high as the second rib, and in cases of enormous pleural effusion as low as the false ribs. It, however, never loses its convexity. Most of its upper surface is covered by pleura, and most of its lower surface by peritoneum ; these two membranes therefore come into very close relation here. Still, there is a small surface where the liver comes into actual contact with it, and at this point a ball penetrating from behind at about the tenth dorsal vertebra might enter the liver without wounding the peritoneum. Congenital Defects.—The sternal portion of this muscle is sometimes wanting, and absence of other portions is occasionally seen, a case being on record of a child which lived ten days in whom the left half was entirely want- ing. Through such openings the abdominal viscera, most commonly the stomach, may protrude into the thorax, constituting a diaphragmatic hernia {q.v.). Various muscular additions have also been observed, but these anom- alies are rare. Paralysis.—Paralysis of the diaphragm may occur in the course of pleurisy, diphtheria, disease of the spinal cord, or lead-poisoning; or it may be hysterical, or due to injury of one or both phrenic nerves, or to the destruc- tion of their roots in rapidly ascending degeneration from injury to the cord in cases of fracture or dislocation of the spine. It may be unilateral or bilateral, and complete or partial. It is characterized by difficulty in breath- ing, the abdomen sinking during inspiration and becoming fuller in expiration, thus reversing the natural order. All efforts which require fixation or con- traction of the diaphragm, such as coughing, talking, etc., are made difficult or impossible. The prognosis must depend upon the cause, and treatment must be directed to the removal of the same. In idiopathic or non-surgical cases the faradic current, with one pole applied over the phrenic nerve in the neck, the other over the diaphragm, is said to have given good results. Hernia.—See Hernia. Wounds.—Wounds of the diaphragm are inseparable from those of the abdomen or chest, and are of importance according as the viscera on either side of it have been injured. It is occasionally torn by the jagged end of a fractured rib. Perforating wounds of the diaphragm, however, are not neces- sarily fatal, and many patients have recovered whoj^v^been shot in such a way #'LCc%v LIBRARY$

Text-book of surgery for practitioners and students / by American authors ; edited by William W. Keen and J. William White.

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