Elements of Surgery

by Robert Liston

After removal of the mamma for carcinoma, in favourable circumstances, some patients remain healthy. Those practitioners who do not recognise the malignant disease, and operate for every tumour, and at all ages, have boasted of great success. But it is not so with those of mature experience. The disposition to malignant action often remains latent for many months, sometimes for many years, and at length becomes fully developed. The disease may return in the skin; the cicatrix hardens, ulceration occurs, and makes progress. Or tubercles form in the cellular tissue, enlarge, and involve the skin. Or the glands become tender and swell; and the swelling is often unattended with uneasiness. Œdema of the hand and forearm, to a great extent, may have existed for a considerable time, and on examination extensive glandular tumours are detected in the axilla and above the clavicle. These, perhaps, ulcerate; or cough and hectic cut off the patient. In short, permanent riddance from mammary carcinoma is scarcely to be expected by operation, or any other means.

Neither are operations for medullary and bloody tumours of the mamma more successful in their results; though I have certainly witnessed permanent cures under unpromising circumstances,—when the tumours were large, of long duration, and even ulcerated.

AFFECTIONS OF THE CHEST.

Inflammation of the pectoral serous tissue would come to be considered more properly in a work exclusively on the practice of physic; but the affection not unfrequently occurs in consequence of wounds or other external injuries, and its terminations must be shortly noticed.

Effusion of serum may take place into the cavities, attended with subsidence of the symptoms of pleuritis. In such circumstances, the lung collapses, either entirely, or still admits a small quantity of air; and, if the collection lodge for a considerable time, that side of the chest enlarges. When the cavity is not quite full, the fluid is heard to be troubled, and on motion of the trunk a sound of splashing is perceived. Part of the cavity may be occupied with air which has escaped from an opening in the lung; or halitus may be extricated from the accumulated secretion. There are other signs, sufficiently distinct, imparting a knowledge of such effusion. The previous history of the case leads to a shrewd suspicion. The chest is unnaturally immovable, as well as enlarged; the intercostal spaces are widened, and ultimately protuberant; there is dulness on percussion, and no respiratory murmur perceptible in those parts where there is fluid; the sounds are natural in that part of the lung which is permeable to air, and distended.

Suppuration often is the result of the incited action; and purulent matter forms in the cavity of the pleura, generally without breach of surface. The membrane is covered with lymph, more or less extensively organised. Empyema is established. Suppuration may take place in the substance of the lungs, and from ulceration the matter may escape, in small quantity at a time, into the bronchial tubes, giving relief to the patient; or it may be poured in profusely and suddenly, so as to cause instant suffocation; or it may work its way into the cavity of the pleura, and occupy the same place as if it had been secreted by that membrane. Or, again, if the lung adhere to the costal pleura, the matter may approach the surface of the body, by the aid of interstitial absorption of the intervening parts, and the collection may then be opened, like a common superficial abscess, by division of the integuments only.

When the pleura is full, the chest enlarges, the integuments become œdematous; and if, from the preceding and collateral circumstances, no doubt exist of the presence of matter, paracentesis may be performed with a chance of relieving and saving the patient. The patient is placed horizontally, with the shoulders slightly elevated; and the affected side should be as dependent as possible, that he may be readily turned over on his face should the breathing become embarrassed. The position of the diaphragm, in regard to the inner surface of the false and lower true ribs, must be kept in view. When the distention is great, this important muscle is displaced; it is pushed downwards, carrying before it the viscera in the upper part of the abdomen; it is thus removed far from the place at which the incision is usually made. The point of election, as it is called, is between the fifth and sixth ribs, and midway between the sternum and the spine. An incision is made through the integuments, over the upper edge of the sixth rib, an inch and a half in extent; in this situation there is no risk of wounding the intercostal artery. If the operator intend to shut the cavity as soon as the fluid has been discharged, the integuments are drawn upwards previously to making the incision, in order that they may afterwards overlap the wound. A cautious opening is then made through the intercostal muscles, and the pleura punctured. This is immediately followed by forcible ejection of fluid. The wound of the pleura is then enlarged by a probe-pointed knife. The thrust of a trocar, or sharp-pointed bistoury, is here inadmissible, as in some cases the diaphragm, perhaps the liver or stomach, or even the lung, might be wounded. The fluid at first escapes rapidly; afterwards it is ejected chiefly during expiration. After its discharge, a tent is placed in the wound, over which a compress is put, and the chest is firmly bandaged. The closure cannot be maintained safely longer than twenty-four hours; the dressing must be undone, the tent removed, and the matter again allowed to flow. I would certainly not recommend any attempt to heal the wound by the first intention. In consequence of continued closure, the secretion soon becomes very profuse, mixed with blood, and of a putrid nature; irritative fever is established. The treatment principally consists in obtaining gradual, and at the same time free, evacuation of the fluid, restraining the motions of the chest, and supporting the general strength. As the discharge ceases, the lung may in part expand; it may, however, continue collapsed, become consolidated, and the chest fall in. In neglected cases, absorption of the intercostal substance takes place; the integuments bulge outwards, and distinct fluctuation is perceived. The skin has been allowed to become thin, and even to give way, without the nature of the case being known; but this can be the result only of ignorance or of inattention. In such cases, the ribs have been denuded, and become necrosed to a large extent,—the sequestra separating slowly and in fragments; and causing long-continued and wasting discharge. It is plain, therefore, that pointing of the matter should never be waited for. Chronic collections are occasionally met with of some years’ duration, and producing great enlargement of the chest. Surgical interference with such is less likely to prove beneficial than with the acute.

Wounds of the large bloodvessels of the chest, or of the cavities of the heart, are almost immediately fatal. Mere punctures, however, of these parts, have closed for a time, and in some cases even permanently. All wounds of the chest, though not involving bloodvessels of a large size, are productive of severe consequences—effusion of blood or bloody fluids into the cavities, escape of air into the external cellular tissue, collapse of the lung, and inflammation and its results, are always to be dreaded. The danger is not uniformly tantamount to the extent of injury inflicted. Individuals have recovered from extensive wounds causing profuse hemorrhage, and great displacement and laceration of the parts; whilst, from much slighter injuries, untoward and fatal consequences have quickly resulted. Wounds may penetrate the chest, and be continued into the abdomen; the stomach, liver, and intestines—one or all—may be perforated as well as the lung; in such cases the hemorrhage is in general speedily fatal. Injury of the intercostal arteries, and of the mammary and its branches, is attended with serious bleeding. It is easily arrested, however, by pressure. A piece of fine linen is pushed into the wound, followed by charpie, so as to form a small bag within the chest, a little larger than the opening; by pulling this gently outwards and fixing it, efficient pressure is made on the bleeding vessel. At the same time the motions of the chest are to be restrained by bandaging; indeed this is necessary in almost all injuries of that part. When reaction has been established, antiphlogistic treatment must be pursued, and it generally requires to be extremely active. Bloody, serous, or purulent fluids, lodging in the cavity of the pleura, are to be evacuated, if need be, either by incision or by enlargement of the original wound. In the course of the cure hectic usually supervenes to a greater or less degree, and requires the reverse of the previous treatment.

AFFECTIONS OF THE ABDOMEN.

Inflammation of the peritoneum, when idiopathic, is generally treated by the physician. But it occurs in consequence of wound, obstruction from hernia, or affection of the lower bowels. There is a burning heat in the belly; the pain is constant and increasing, much aggravated by the slightest pressure or exertion of the abdominal muscles, and the patient, in consequence, lies with these muscles in a state of relaxation. The pain is of a very different character from that arising from spasm, induced by the irritating nature of the intestinal contents, which supervenes in paroxysms, and is relieved by pressure or by evacuation. In inflammation the countenance is very anxious, and generally pale; the extremities are cold and bathed in perspiration; the patient vomits frequently; and the bowels are generally constipated. The pulse is small, wiry, and rapid.