OPERATIONS ON THORAX.
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.
FOOTNOTES:
[139] Both in _Guy's Hospital Reports_, second series, vol. ii.
[140] _Edinburgh Medical Journal_ for June 1866.