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Table of Contents
Part I Human Organization
1. Organization of the Body
2. Chemistry of Life
3. Cell Structure and Function
4. Body Tissues and Membranes
Part II Support, Movement, and Protection
5. The Integumentary System
6. The Skeletal System
7. The Muscular System
Part III Integration and Coordination
8. The Nervous System
9. The Sensory System
10. The Endocrine System
Part IV Maintenance of the Body
11. Blood
12. The Circulatory System
13. The Lymphatic System and Body Defense
14. The Respiratory System
15. The Digestive System
16. The Urinary System and Excretion
Part V Reproduction and Development
17. The Reproductive System
18. Human Development and Birth
19. Human Genetics
Appendix A Reference Figures: The Human Organism
Appendix B Understanding Medical Terminology
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Fig. 519
 Incision for resection of thorax. (Bergmann.)

Fig. 520

Trap-door thoracotomy. (Lejars.)

The original Estlander operation has been modified by Schede,

and as now practised is made by a long incision passing obliquely
across the lateral aspect of the chest, from the origin of the
pectoralis major, at the level of the axilla, to the tenth rib in the
posterior axillary line, and then ascending to a point between the
spine and the scapula. The large flap thus outlined is made to
envelop all the tissues outside the ribs. The ribs thus exposed are
resected from the tubercles forward to their insertion into the costal
cartilages. The large area of the chest wall thus exposed is then
removed with the underlying pleura, and all hemorrhage checked.
This flap includes the periosteum, the intercostal muscles, the ribs,
and the pleura, and thoroughly uncovers the entire abscess cavity. It
makes a formidable procedure, but is more often life-saving than the
reverse. Over the opening the skin flap may be later drawn down
and tacked in place at points sufficiently near to each other to
properly hold it in place (Figs. 519 and 520).
This procedure may be modified to suit the indications of any
given case, and simply includes what may be done in extreme
cases. The surgeon who thus for the first time uncovers such a
cavity will be surprised at its interior appearance, and at the shreds
of tissue and debris which hang from its walls. The measure thus
described provides for collapse of the chest wall. Fowler and others
have shown, however, that even now the principal obstacle to
expansion of the lung is not removed, and have suggested what
Fowler has aptly described as decortication of the lung—namely, a
removal of its thickened pleura by a process of dissection and
stripping, which may be made partial or complete, as circumstances
permit. In some respects this adds to the gravity of the case and will
perhaps better be done at a second operation. Should it, however,
be justified by the condition of the patient it is best done in
connection with the resection of the chest wall.
When decortication cannot be practised Fowler has advised that a
series of incisions be made, and that by thus gridironing the
thickened membrane it may be weakened or caused to lose its
inelasticity and thus a mild degree of similar effect secured. Fig. 521
illustrates the end result of such an extensive thoracoplasty.
Fig. 521
 End result of an extensive thoracoplasty. (Park.)

Pneumotomy.—This is a term applied to an attack upon the lung

itself, it having been exposed by a thoracotomy. It is
necessary in cases of gangrene, abscess, hydatid cyst, and
occasionally in large bronchiectatic cavities. It is not ordinarily a
difficult procedure when the lung has attached itself to the chest wall
in the course of the disease process. Here the lesion having been
located a part of one or more ribs is removed, as may be needed,
thus exposing the lung surface, the cavity is then opened either with
a knife or by dilatation with the blades of a forceps, or preferably with
the thermocautery blade, by which hemorrhage is better controlled
and possibilities of absorption reduced. If such a cavity can be
located it may be opened with a large trocar and cannula, which
should be introduced with great care, lest it be thrust too far, the
method by incision being therefore preferable. If after opening the
chest the lung be found non-adherent, it depends on the character of
the lesion whether adhesion should be provoked or the cavity itself
attacked. In the former case adhesions may be produced by stitching
the exposed lung surface to the margins of the wound, and waiting
for sufficient exudate to be poured out to ensure that the pleural
cavity has been hermetically sealed. The same result may be
obtained more crudely by packing gauze around the opening.
In case of urgency it would probably be best to attach the lung to
the chest wall with sutures and secure it there. This is a
comparatively safe method in dealing with hydatid cysts, and will
give a fair measure of success in many other instances. The
suppurating or gangrenous cavity being opened its contents should
be removed, dead or sloughing tissue excised, and the cavity then
packed for drainage purposes, the external wound being kept open
until it can be safely allowed to close.
Pneumonectomy, that is, removal of a portion of the lung
substance, may be done with comparative safety upon animals, but
rarely upon human patients. It is occasionally required in connection
with the removal of malignant tumors of the chest wall, to which the
lung has affixed itself. In exceedingly rare instances it may be
justified for localized tumors of the lung itself. It would be equally
valuable for circumscribed, primary tuberculosis of the lung, were it
possible to recognize this in time. This an Italian surgeon once
thought that he had done, in the case of his fiancée, and proceeded
to resect the upper lobe of one of her lungs. His lack of success
quickly led to his own suicide a few days later.
The lung is exceedingly vascular and at the same time bears
sutures well. The suturing, however, should be accurate in order to
prevent secondary hemorrhage and favor the process of repair.
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.
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.
 Finally the axilla is Fig. 522
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.
Congenital diaphragmatic hernia, with other
congenital defects. Wood Museum. (Dennis.)
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.
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.

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.
 C H A P T E R X L I V.
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.
Hemorrhages from the breast sometimes take place idiopathically,
at others as vicarious efforts at menstruation. There is a peculiar
sympathy between the pelvic organs of women and the mammary
glands, and the latter evince this in more than one way, becoming
sometimes extremely tender or swollen at the menstrual period, or at
other times peculiarly sensitive or even neuralgic, while at times
congestion will proceed to the point of hemorrhage. These conditions
do not require particular attention, but are not to be confused with a
bloody discharge that may occur later in life, in connection with
certain forms of malignant disease occurring in the interior of the
breast.
There exist the widest differences in development of the breasts in
different individuals. The term “breast” is used intentionally, since the
difference is not so much in the actual glandular development as in
the surrounding connective tissue and fat. Thus a plump breast may
contain very little more secreting structure than one apparently ill-
developed. Nowhere outside the uterus save in the breast do such
compensatory changes take place under the stimulus of pregnancy.
In fact, a mammary gland in preparation for lactation is a
physiological adenoma. At conclusion of lactation there is absorption
and atrophy from disuse, usually not to the original degree, although
in some instances the fatty tissue disappears irregularly and leaves
the breasts in quite different shape from their originals. In this way
the breasts may become exceedingly pendulous, so much so as to
lead to pain and soreness from traction, and to call for their support.
Idiopathic hypertrophy of one or both breasts is a rare deformity,
occurring usually in the young, sometimes in girls, involving them to
an indefinite degree, but in some producing enormous overgrowth,
with corresponding deformity. For such hypertrophy no known cause
has been assigned. Fig. 524 illustrates an instance of this character
in a young girl, occurring under the observation of my colleague, Dr.
Bebee.

INJURIES TO THE BREAST.

These consist largely of contusions to which, from their positions,
the breasts are peculiarly exposed, and these may be followed by
hemorrhage, by extensive ecchymosis, or by any of the
consequences of infection. They may also be followed by more or
less permanent induration. The fact that in the course of time certain
 Fig. 524 contusions of the
breast are followed by
development of
cancer is
incontestable,
although the relation
which may exist
between the accident
and the neoplasm
has not yet been
made clear. The
breasts are also
subject to the same
possibilities of injury
as other parts of the
thorax, which has
been considered in
the previous chapter.
The nipples are more
often injured by
efforts of the nursing
infant, or by the
friction of ill-fitting
stays or rough
clothing, than in any
other way. These
injuries, at first of a
minor character, are
not infrequently
followed by serious
results, erysipelas,
septic infection, or
tuberculosis being
conveyed through
Idiopathic hypertrophy of breasts in a girl of sixteen.
trifling abrasions thus
(Bebee.)
inflicted.
 The nipple of a nursing woman once excoriated, or its surface
broken, is kept constantly liable to maceration and surface infection.
In this way a trifling lesion may result in a linear ulcer known as a
fissure (“cracked nipple”), or in a more extensive involvement. These
fissured nipples are very erethistic, and great pain is caused by each
attempt at nursing. On this, account the mother postpones the act as
long as possible, and until her breast has become overdistended, the
result being injury to the breast itself, with a greater possibility of
infection and of subsequent abscess formation.
The slightest excoriation of the nipple, under any circumstances,
should lead to the adoption of every precaution for its cleansing and
protection. Both before and after nursing it should be carefully
washed, while, after removal of the child from the breast, it should be
carefully dried and dusted with dry boric acid or a similar antiseptic.
Any abrasion which fails to heal should be treated with silver nitrate.
More pronounced abrasions and ulcers should be cocainized, then
cauterized, and afterward treated as above. Finally in extreme cases
it may be necessary to discontinue nursing and allow the breast to
dry. If this policy be adopted it should be applied to both breasts, for
such is the sympathy between them that the use of one gland seems
to stimulate the other. The local use of such preparations as
belladonna ointment, etc., is to be avoided. Pressure, rest, and the
care above described afford more relief.
Paget’s disease of the nipple implies an eczematous condition,
first described by Paget as a precursor of many cancers. It is a more
or less chronic affection, involves the nipple and the areola, is quite
intractable to treatment, gives more or less discomfort, and is to be
dreaded when noted. It seems to sustain about the same relation to
later cancerous involvement as does leukoplakia in the mouth and
on the tongue.
There is no reason why any person may not have an attack of
eczema about the nipple, but cases in which the condition is
persistent and obstinate, and especially in which the underlying
tissues gradually become infiltrated or indurated, should be viewed
with suspicion, and should be treated by eradication of the area
involved, even though this may require extirpation of the nipple or of
the entire breast. When the condition is developed no ordinary
treatment will suffice, although a fair trial might be given to the
cathode rays.

MASTITIS.
A true inflammation of the mammary gland may occur at one of
three periods: (1) At birth, when the tiny breasts of the newborn
infant secrete a milk-like fluid, become more or less congested and
tender, and when they are unintelligently treated by massage or
interference of any kind; (2) at puberty, when a perfectly natural
turgescence and congestion occur, which, however, rarely proceed
to suppuration unless infected or unless violence or some indiscreet
treatment have been received; (3) during pregnancy and lactation,
this being the time when mastitis is most common.
Considering that the nipple affords a number of open paths, from
an area which it is difficult to keep clean, extending into the depths of
inflammable tissue, it is strange that infection through the milk ducts
does not occur in most cases. Such a path of infection affords the
explanation for at least a large proportion of mammary abscesses.
Again the presence of excoriations, abrasions of any kind, and
especially of deep fissures which are not easily cleansed, will
account for infection through the lymphatics. In these two ways
nearly all cases of mastitis and of mammary abscess are to be
explained, and both these accidents are likely to occur during
pregnancy and lactation.
The consequence of such infection is mastitis, which begins with
painful induration and local indications of inflammation, but which
may under suitable treatment undergo resolution. This failing, the
infectious process proceeds to suppuration, and the consequence is
a superficial, deep, or retromammary abscess, all but the last named
often in multiple form. The lobular construction of the breast permits
the independent occurrence of distinctive suppuration, occurring
synchronously at several different points, and hence it may be that a
breast is riddled with abscesses, which form successively or almost
simultaneously.
There is a superficial form, which occurs usually near the nipple,
and in which the deeper structure of the breast is scarcely involved.
This comes usually through infection of some surface lesion. Simple
incision is usually sufficient, and the local lesion is thus quickly
terminated. Deep or intramammary abscess, single or multiple, is
always painful, sometimes distressing and occasionally an extremely
serious condition. Occurring in a breast already well developed and
fatty, abscesses may form at such depth as to be recognized with
difficulty. The surgeon infers their existence rather than discovers it.
This is unfortunate, for the longer the delay the greater the local
disturbance, with a tendency to burrowing, and the worse are the
consequences for the patient. It is, therefore, far safer to early note
the minor signs of deep suppuration and to freely incise, than it is to
wait for pus to come toward the surface and give its ordinary surface
indications. The amount of induration, sometimes dense and brawny,
which such conditions will produce within the breast, the size which
the latter may assume, and the consequent suffering to the patient
from neglected conditions of this kind, need to be seen to be fully
appreciated.
Retromammary abscess may be the result of conditions not
primary to the breast itself. Thus the writer has seen spontaneous
perforation of the thoracic wall in a case of empyema, with escape of
pus into the loose cellular tissue behind the breast, and the
consequent protrusion forward of the latter until it presented as an
enormous tumor. Treatment in such cases would mean not alone
evacuation of the retromammary collection, but emptying the pleural
cavity of its accumulated fluid.
An infected breast will produce not only the ordinary local
indications, but will be characterized by extreme tenderness, with
enlargement of the lymph nodes in the axilla and later abscess
formation in this location. In proportion to the amount of pus thus
imprisoned, and the virulence of the infecting organisms,
constitutional symptoms may be mild or extreme.
Nowhere is there greater need for release of an imprisoned
amount of pus than under these circumstances, although the
incisions necessary for the purpose may be sometimes multiple and
deep. Every incision made for evacuation of a mammary abscess
should be placed radially—i. e., in a line radiating from the nipple—in
order that lobules may be incised along their course, and that neither