A Manual of the Operations of Surgery, Joseph Bell [suggested reading .txt] 📗
- Author: Joseph Bell
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Excision of Mamma.—When the whole breast is to be removed, two incisions, inclosing an elliptical portion of skin along with the nipple, must be made in the direction of the fibres of the pectoralis muscle. The distance between the incisions at their broadest must depend upon the nature of the disease for which the operation is performed, and the extent to which the skin is involved; in every case the whole nipple should be removed. The incisions should, if possible, be parallel with the fibres of the pectoralis major, and extend across the full diameter of the breast. During the operation the arm should be extended so as to stretch both skin and muscle. The lower flap should be first raised and dissected downwards, with care that the cuts are made in the subcutaneous fat, and wide of the disease; the upper flap is then thrown open, and the edge of the gland raised, so that the fibres of the pectoralis are exposed below it. These should be cleanly dissected, so as to insure removal of the whole gland.
Any bleeding during the operation can easily be checked by the fingers of an assistant, and if the arteries entering the gland from the axilla be divided last, they can be at once secured. If there are many bleeding points, the application of cold for a few hours before the wound is finally closed is a wise precaution.
The requisite stitches may be inserted while the patient is under chloroform, but not tightened. The arm should then be brought down to the side, and a folded towel laid over the wound after it is finally closed. Great benefit results from the free use of drainage-tubes in most cases; for this purpose a dependent opening in the lower flap is often made.
Surgeons now operate even when the axillary glands are diseased, and by a very free dissection and removal, even in hopeless-looking cases, life may be prolonged. To insure the removal of the lymphatic vessels as well as the glands, it is best not to separate the breast at its axillary margin, but keep it attached by the tail of lymphatics surrounded by fat, which will lead up to the glands. Section of the great pectoral muscle will aid the dissection.
When the tumour is very large, and the skin has been much stretched and undermined, more complicated incisions may be necessary; these must be governed a good deal by the presence and positions of adhesions or ulcerations of the skin. The best direction, when the surgeon has his choice, that these incisions can take, is that of radii from the nipple, bisecting the flaps made by the original elliptical incision.
N.B.—In operating for malignant disease, the one paramount consideration is that all the disease be excised, however curious, inconvenient, or awkward, even insufficient, the flaps may look. Partial excisions are worse than useless.
Paracentesis Thoracis, for the relief of pleurisy, acute and chronic, and empyema, is an operation of extreme simplicity.
The proper selection of cases, the settling of the suitable position for the tapping, and the choosing of the suitable time for it, are more difficult, and not within the scope of the present work. On these subjects much information may be obtained from the papers of Dr. Bowditch of Boston, of Dr. Hughes and Mr. Cock,[139] and an exceedingly interesting and valuable paper by Dr. Warburton Begbie.[140]
Where is it to be performed? Not above the sixth rib, else the opening is not sufficiently dependent; very rarely below the eighth on the right side, and the ninth on the left. The intercostal space generally bulges outwards if fluid is present, and this bulging acts as an aid to diagnosis. As the intercostal artery lies under the lower edge of the upper rib in each space, the trocar should be entered not higher than the middle of the space; and because the artery is largest near the spine, and also the space is there deeply covered with muscle, the tapping should never be behind the angle of the rib. In most of the manuals we are told to select a spot midway between the sternum and spine for the puncture; but Bowditch, Cock, and Begbie, who have had large experience, prefer, and I believe rightly, a position considerably behind this, an inch or two below the angle of the scapula, between the seventh and eighth, or between the eighth and ninth ribs.
The operation may be performed with a simple trocar and canula, round, about an eighth of an inch in diameter, and at least two inches in length. The point must be sharp, and it must be pushed in with considerable quickness, so as to penetrate, not merely push forwards, the pleura, which may be tough, and thicker than usual. Once the skin is pierced, the instrument must be directed obliquely upwards, so as to make the opening and position of the trocar dependent. When the trocar is withdrawn the fluid may be allowed to flow so long as it keeps in a full equable stream; whenever it becomes jerky and spasmodic, the canula should be removed before the sucking noise of air entering the chest is heard.
In more chronic cases, where the quantity of fluid is large, and especially if it is thick and curdy, the exhausting syringe of Mr. Bowditch is an improvement on the simple trocar and canula.
It consists of a powerful syringe, which fits accurately to the trocar with which the puncture is made. There is a stop-cock between the trocar and syringe, and another at right angles to the syringe. The trocar being introduced, it is held firmly in position by an assistant, by means of a strong cross handle; the first stop-cock is then opened, and the syringe worked slowly till it is filled with fluid through the trocar, the other delivery stop-cock being closed. The first is then closed, and the second opened; the syringe is then emptied through the second into a basin. By a repetition of this process, the fluid can be removed at pleasure, without any risk of the entrance of air.
Dieulafoy's aspirateur, which the author has now used in a very large number of cases, will be found the best method yet devised of safely removing the fluid in cases of serous effusion. But in severe cases of empyema the pus is sure to be reproduced in the great majority, and then a free incision, with strict antiseptic precautions, will be needed, and subsequent free drainage.
The author has used with great benefit silver tubes, like long narrow trachea-tubes, with broad shields, to insure free drain.
CHAPTER XI. OPERATIONS ON ABDOMEN.Paracentesis Abdominis.—To withdraw fluid from the abdominal cavity is an exceedingly simple operation in itself, though certain precautions are necessary to render it safe.
Trocar.—The usual instrument used to be a simple round canula with a trocar, the point of which should be very sharp, and in the shape of a three-sided pyramid. It should be about three inches in length, and a quarter of an inch in diameter. It may for convenience have an india-rubber tube fixed to its side or end, for the purpose of conveying the fluid to the pail or basin, but any other additions or alterations have not been improvements. Lately surgeons have been diminishing the size of the tube so as to withdraw the fluid more slowly, and taking many precautions to insure the wound being kept aseptic.
Where to tap.—In the linea alba, midway between the umbilicus and pubes, or rather nearer the umbilicus. Here, there are no muscles nor vessels, the opening is a dependent one, and the bladder is quite out of the way of injury.
N.B.—It is a wise precaution, in every case where there is a possibility of doubt as to the state of the bladder, to pass a catheter. I have myself known at least one case in which a surgeon was asked to tap an over-distended bladder, as a case of ascites.
The Operation.—As there is great risk of syncope coming on during the operation, from the sudden relief to the pressure on the organs, a broad flannel bandage should be applied to the belly, the ends of which are split into three at each side, and crossed and interlaced behind. An assistant should stand at each side to make gradual pressure by pulling on the ends of the bandage, thus assisting the flow, and maintaining the pressure. A hole should be cut in the bandage at the spot where the puncture is to be made, and the trocar inserted by one firm push, without any preliminary incision, unless the patient is inordinately fat. As the trocar is withdrawn, the canula should be pushed still further in. The surgeon should be ready at once to close the canula with his thumb, if the flow begins to cease, lest air should be admitted. If the flow ceases from any cause before all the fluid seems to be evacuated, the trocar should not be re-introduced, lest the intestines be wounded, but a blunt-headed perforated instrument fitting the canula should be inserted.
When all the fluid that can be easily obtained is evacuated, the canula may be withdrawn, and a pad of lint secured over the wound by strapping.
Gastrotomy.—Cutting into the stomach for the extraction of a foreign body has now been performed at least ten times, and all but one recovered. A typical example is that by Dr. Bell of Davenport, who removed a bar of lead one pound in weight and ten inches in length, by an incision four inches in length from the umbilicus to the false ribs. The opening into the stomach was as small as possible, and required no sutures.
Gastrostomy has within the last few years been practised very frequently. Gross has collected 79 cases, 57 of which were for carcinoma of œsophagus, all of which died within a few weeks, except eight who survived for periods varying from three to seven months. The results in cases of cicatricial and syphilitic strictures are more favourable.—Howse's method seems the best, consisting of two stages.
1. A curved incision is made through the parietes parallel with, and a finger-breadth below, the lower margin of chest wall on left side, the peritoneum should be opened at the linea semilunaris, the stomach sought for, and then attached to the abdominal wall by an outer ring of sutures and to the edge of the wound by an inner ring. It should then be dressed with carbolised lint and supported by a bandage.
2. A small opening should be made four or five days after the first stage and the patient should be fed through this opening.
For full details, see Mr. Durham's paper in vol. i. of Holmes's Surgery, edition of 1883, pp. 801-4.
Gastrectomy.—Excision of whole or part of the stomach is one of the latest developments of operative daring, first done as a regular operation by Pean in 1879, it has now been repeated sixteen times; four cases have survived the operation for more than ten days. The chief points to be attended to are prevention of death from shock and hæmorrhage, and very careful stitching up of the wound. Considering the difficulty of the diagnosis, the danger of the operation, and the almost certain recurrence of the disease, the propriety of such operation seems very doubtful.
Ovariotomy.—For the pathology of ovarian disease we must refer to
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