The operation as thus described has been extended by Halsted to a degree which requires often much more work, and which has furnished even better results, since he includes in it, if necessary, the removal of both pectoral muscles, and even the division of the clavicle for better exposure of the axillary and lower cervical regions, and the more thorough extirpation of involved lymphatics. In other cases he makes a vertical incision along the posterior margin of the sternomastoid, exposing the junction of the internal jugular and subclavian veins, and removes the supraclavicular fat by a downward dissection and the infraclavicular fat by a dissection from below. This is facilitated by elevating the shoulder, by which the clavicle can be removed one inch or more from the first rib.
[Figs. 527] and [528] illustrate the incision recommended by Halsted and the general method of attack.
Throughout these operations the primary question is removal of disease, the matter of subsequent closure of the wound being a secondary consideration. Nevertheless the extirpation being completed, there arises the question of how best to close the extensive defect thus created. This will depend on its size and upon the amount of loose skin in the vicinity furnished by the patient’s general physique. With emaciated patients, whose skin is tightly drawn, it is not easy to furnish flaps, whereas in those who are fatty, with flabby flesh and skin, it is easy to rearrange the latter. Beck has suggested to make quadrilateral instead of elliptical incisions, leaving a square defect, which can then be closed by sliding flaps from two directions. The names of Warren and Meyer are also connected with elaborately described plastic operations. Years before any of these were published the writer was doing similar sliding of flaps, but never endeavoring to make them conform to a single pattern, raising semilunar flaps, or those of any other shape, as might best fill the demand, and taking them from that portion of the thorax, side, or even the abdomen, which would seem best to furnish them. There is, therefore, no one method to be especially recommended, for every operator of good judgment will be able to secure sufficient integument from some surrounding location, so that it is rarely necessary to leave such a wound uncovered. In those cases which require an amount of dissection not permitting this it is a question if operation be advisable. Nevertheless should it happen that for some reason a sufficient skin covering is not thus easily available, Thiersch skin grafts may be applied to any uncovered area at the time of terminating the operation or later, and may be nearly always relied upon for their destined purpose.
At least one opening should be made in the lateral flap in such a location as to drain the axillary cavity when the patient is lying upon her back, and through this a drainage tube of sufficient size should be inserted. This should rarely be left more than forty-eight hours. Inasmuch as there will sometimes be considerable tension upon flaps a certain number of strong and reliable sutures (silkworm or thread) should be used, to prevent parting of the wound margins, while long retention sutures may be inserted if required. The balance of the suturing may easily be done with catgut. The intent should be to leave no dead spaces. Any isolated mass of fat which stands out by itself after the dissection is complete should be pared down to the common level, in order that it may not perish from ill-nutrition, nor disturb the general level of the adjoining surfaces. It is rarely necessary to keep patients in bed more than two or three days after even extensive operations of this kind, but it is necessary to ensure that equable pressure be made with the dressings, and that the entire arm be bound to the side and immobilized in such a way that the patient cannot move it nor disturb the dressing.
CHAPTER XLV.
THE ABDOMEN AND ABDOMINAL VISCERA.
GENERAL CONSIDERATIONS AND CONDITIONS.
That large portion of the human body which with its contents we term the abdomen was for a long time terra incognita to the surgeon. Despite the sporadic success of such men as McDowell and others there was felt, until the latter part of the last century, a universal and well-merited fear of intrusion upon the peritoneal cavity, because of the tremendous probabilities of infection and fatal peritonitis. Until the memorable researches of Lister and the introduction of an antiseptic, later of an aseptic technique, there was, therefore, the best of reason for regarding the abdominal cavity as a sanctum to be entered only when dire necessity required. In spite of the complexity of its anatomical arrangements, as well as the peculiar and widespread ramifications and connections of its vessels and its sympathetic and spinal nerves, with the almost innumerable complications thus permitted and favored, and the resulting uncertainty of symptoms and distant disturbances of function, the abdominal cavity became, first, a favorite seat for laboratory study and experiment, and then a fascinating field for surgical endeavor. Today this region is invaded by the surgeon in a manner and with a freedom which would have been criminal and unjustifiable when the writer of these pages was a student; and yet, while we have in the main lost our fear of the peritoneum and our dread of peritonitis, we nevertheless see the latter occur now and again, as it were as a punishment for forgetfulness or inattention, the patient unfortunately paying the penalty for the errors of which he is not guilty. Abdominal surgery has now become a specialty which has attracted too many of those not thoroughly fitted by training and by experience. One hears today of many, the older practitioners especially, insisting that the abdomen is too often opened; perhaps it would be more just to say that it is opened by too many. By this expression is meant simply that enthusiasm has not always been tempered by discretion, and that this is a department of surgery which has been too enthusiastically cultivated by men who have not waited to ripen their judgment or perfect their methods. My own feeling is that not merely large observation should be regarded as an essential preliminary for such work, but extensive experimentation in a surgical laboratory; while even here the tyro has to learn, perhaps by severe experience, that not all human beings can recover after manipulations which some of the lower animals bear with apparent impunity. Previous experience as assistant to a skilled operator is of the greatest value.
While uttering this caution we must, at the same time, candidly acknowledge that accurate diagnosis of deeply seated lesions is by no means always possible, and that the tendency, especially among the practitioners of internal medicine, has been, and often is, to waste valuable time in the application of methods of physical diagnosis, all of which are valuable, many extremely ingenious, and yet which prove insufficient or misleading. To give but one illustration—cancer of the stomach, for instance, is a disease absolutely without a special symptomatology. If we are to wait for the development of a recognizable tumor or other features which are unmistakably significant, we wait until the period for successful surgical attack has nearly or quite elapsed. Thus rather than permit months of valuable time to be wasted, it seems to the modern surgeon far more humane to make an early exploration, in order that he may attack the disease while it has involved but a minimum of tissue.
The general practitioner has seen himself robbed, as it were, of one part of the body after another, by the application of this general principle, until there has developed a feeling of irritation or one even more pronounced, in certain cases, of rebellion, as it were, against the cession of this territory to the surgeon; but this is wrong, and such feeling should not exist. Rather should there take place the heartiest coöperation between physician and surgeon, while the operative procedures directed toward the early recognition of these more or less vague conditions should be regarded more kindly and the procedures themselves regarded rather in the light of operative therapeutics. A recognition, then, of the limitations of physical diagnosis, combined with an earnest desire to do the greatest good to the patient at the earliest possible time, when cheerfully combined, and practised by those of ripened experience and cultivated skill, will redound to the greatest credit of all concerned and afford the greatest prolongation of human life. It is to be hoped that the day when the physician shall charge the surgeon with killing his patient, and the surgeon shall have it in his power to retort that the patient did not reach him until he was almost dead for lack of surgery, may soon pass away.
Diagnosis of abdominal diseases requires, first of all, a comprehensive knowledge of anatomy and physiology, as well as familiarity with all the methods of biochemical and mechanical research, on which large volumes have been written, along with a peculiar tact which in some individuals amounts to a gift, and includes the cultivation alike of the senses of touch and sight, and the power of analytical reasoning.