avoided; and by the permanent application of an ammoniacal or of a
gum and mercurial plaster, absorption of the fluid may in general
be procured—the swelling disappearing as gradually as it arose. If
the collection is large and obstinate, repeated blistering may be
had recourse to; and if that fail, a seton may be passed through the
cavity. But the last-mentioned practice is sometimes followed by more
action than is desirable, inflammation of the surrounding cellular
tissue supervening, and abscesses forming, perhaps extensive. When the
collection is purulent, a free opening is to be made into the bursa,
and the case treated in other respects as a common abscess. If indolent
swelling of the cellular tissue, and spongy thickening of the synovial
surface of the bursa, remain after incision, the application of the
caustic potass may be required. In extensive and acute inflammation
spreading to the surrounding parts, free incisions are often necessary,
along with proper constitutional treatment, in order to prevent
destruction of the cellular tissue and skin.
_Venesection_, at the bend of the arm, is too often resorted to by
thoughtless or ill-educated practitioners, to the detriment of the
patient; as after accidents before reaction has occurred, in local
pains not inflammatory, &c. It is very often had recourse to by those
who have no correct ideas of the actions of the animal economy, who
have not within their heads a peg to hang an idea upon; or, if they
have, they are too lazy to think and to combine their ideas, so as
to come to a proper conclusion regarding what is the most proper and
judicious course to be pursued in any one case. They follow a routine,
and bleeding is too generally the commencement of it.
But venesection is absolutely required in many cases, and must often
be the principal dependence of the surgeon for removing or preventing
evil consequences. After injuries, when the circulation has been
restored, particularly when parts important to life are involved—in
the first stage of inflammatory attacks, with violent constitutional
disturbance—in inflammatory affection of vital or important organs—in
these, bleeding is employed to an extent sufficient to control the
action. But, even in such circumstances, the practitioner must be
cautious not to push depletion too far, but to stop short at the proper
time, so that the life of the patient may not be endangered, nor his
health impaired, more by the treatment than by the disease.
[Illustration]
Venesection is usually practised on either the basilic or the cephalic
vein, or else on the median basilic or the median cephalic. The vein is
made to rise by obstructing the return of the blood by a ligature on
the arm, applied not so tight as to prevent the flow in the arterial
branches. A vessel removed from the inner side of the tendon of the
biceps,—that is to say, not over or near the brachial artery,—is to be
preferred. But sometimes none sufficiently large or distinct can be
perceived unless in that situation, and then great caution is necessary
in making the puncture; the patient’s arm must be held very steady,
and care taken that the instrument does not transfix the vein. The
branch chosen should also be fixed; one which rolls under the finger
is pierced with difficulty. The vessel is secured by the thumb of one
hand placed immediately below the point to be punctured, whilst the
lancet is held loosely betwixt the thumb and forefinger of the other;
and the surgeon should by practice acquire the use of either hand for
this and other minor operations, being thereby saved much trouble and
awkwardness. The right hand is used for the right arm of the patient,
the left for the left. The lancet should be in very good order, not
too spear-pointed, fine, and with a keen edge. The blade, placed at
right angles with the handle, and held lightly, as above mentioned, is
entered perpendicularly to the vessel. The puncture is made deep enough
to penetrate the vein, and then the edge is carried forward more than
the point, that the opening in the integuments may be more free than
that in the vein. The most convenient line of incision is obliquely
across. The pressure of the thumb is relaxed whenever a utensil is
conveniently placed for the reception of the blood; and the arm is
kept in the same position as during incision, that the openings in the
integument and vein may correspond. Unless this be attended to, the
skin will overlap the puncture in the vessel, and thus the stream will
be completely obstructed, or at least the blood will not come away so
smartly as at first. The blood may also cease to flow quickly from
over-tightness of the ligature, and from threatening of syncope; in
the former case the ligature is adjusted, in the latter the patient
is placed in the recumbent position. When the superficial veins are
emptied, the blood flowing by those deep-seated is to be directed to
the wound by muscular action; with this view the patient is made to
grasp the lancet-case, or any other solid body, in his hand, and turn
it round. If the opening in the integument is too small, the flow
gradually diminishes, and at length stops, in consequence of blood
being insinuated into the cellular tissue, coagulating, and so forming
what is termed a thrombus, which plugs the wound. When a sufficient
quantity has been obtained, the ligature on the arm is removed, and
pressure made below the wound. The integuments around are washed and
dried; and two or three small compresses of lint placed on the opening,
one above the other, are retained by a riband or narrow bandage,
applied in the form of the figure 8; the bandage should be so tight as
to prevent the escape of blood, without arresting the flow towards the
heart. The arm should be disused for a few hours; and after twenty-four
or thirty-six hours, the bandage may be removed, when the opening will
usually be found closed.
Besides puncture of the humoral artery, or of its branches, other
unpleasant circumstances may follow this little operation. The
thrombus—a small bloody tumour from infiltration into the cellular
tissue around the opening in the vein—proves troublesome, as already
remarked, by preventing the flow, and may render a fresh opening
necessary, either in the same arm or in the other. Afterwards it
generally disappears gradually by absorption; or the opening in the
integuments may not close, and the coagulum be separated and discharged
after some days.
Inflammation and abscess round the opening sometimes supervenes. It
is treated by fomentation, poultice, and rest, and the matter must
be evacuated by free incision. Inflammation of the surface, with
diffuse infiltration into the cellular tissue, is also met with after
venesection; the treatment of such an affection is the same as when it
occurs in other situations and circumstances.
The symptoms and consequences of inflammation of the vein have been
already detailed. The affection is attended with great pain, and with
swelling from effusion into the cellular tissue around the course of
the vessel; the integuments are inflamed and tense; sero-purulent
secretion soon takes place in the infiltrated cellular tissue, both
deep and subcutaneous, followed by sloughing, and separation of
the skin from its subjacent connexions; even death of the muscular
structure sometimes ensues—the pectoral muscles have been found black
and soft. The local treatment must be active. Incisions are made early
into tense parts to prevent internal mischief; and if the vein in the
neighbourhood of the wound be filled with pus, it should be laid open
freely. The evacuation of the matter affords great relief; afterwards
bread poultices or water-dressings are to be applied to the wounds,
the other parts should be assiduously fomented, and attention given to
the position of the limb. The bowels are to be attended to, and the
secretions promoted by mercurials with stimulants, as camphor with
calomel, or the hydrargyrum cum creta. When the tongue gets moist at
the edges, tonics and stimulants of a more permanent and powerful
action are necessary.
I have not witnessed any bad effects of venesection attributable to
puncture of the tendon or fascia, or to partial division of twigs of
the cutaneous nerves. In spasmodic or painful affections arising from
the latter cause, slight extension of the incision is recommended, so
as to divide entirely the injured branch.
Inflammatory tumour of the _Mamma_ occurs generally during
lactation;[44] and is attributable to injury, perhaps slight, during
the then excited state of the secreting vessels—to sudden exposure to
cold—to interruption to the flow of the secretion. It occurs, however,
independently of this state—sometimes at the age of puberty, during
the development of the gland—or at other periods of life, either
spontaneously, or in consequence of external violence. The last class
of cases are usually more severe than those first alluded to;
some are more indolent than others; almost all are preceded by
shivering. There is swelling of the part, a sensation of weight in
it, and dull pain; then throbbing heat, and increase of suffering.
The surface is inflamed, and the nipple concealed by the tumescence.
The milk cannot be withdrawn. Fever attends, more or less violent.
Such tumours seldom if ever subside or are resolved; suppuration takes
place, and the matter generally comes to the surface at more than one
point. This abscess originates in the substance of the gland; but
collections occasionally form in the cellular tissue beneath the mamma,
either spontaneously, as in bad constitutions, or in consequence of
injury. In either case, and particularly in the latter, the swelling is
great, and the suppuration extensive; troublesome and tedious sinuses
remain unless early and free openings are made.
Leeching is of little use in mammary swelling during lactation; cold
and evaporating lotions seem to do harm by producing determination
from the surface to the deeper parts. The gland is to be kept as free
from secretion as possible, and supported by a handkerchief tied
round the neck; moderate diet should be enjoined, and laxatives given
occasionally. Fomentations are beneficial at first, but are superseded
by poultice when matter appears to have formed and to be making its
way to the surface. Two or more openings are generally necessary, to
afford free outlet to the matter; indeed, an incision is indicated
wherever the integuments are elevated, thin, and shining. Afterwards
poulticing is continued for some days, and succeeded by other suitable
applications. The discharge seldom ceases, so long as the secretion of
milk is encouraged.
Adolescent males are sometimes affected by troublesome fulness and
uneasiness of the mammillæ. Little or no treatment is required, the
inconvenience subsiding gradually and spontaneously.
Indolent enlargements of the mammary gland occur, though rarely. They
sometimes attain an immense size; and are often attributable to the
menstrual discharge having been inopportunely arrested. Such tumours
have, from their great bulk, required extirpation.
Sarcomatous tumours of various kinds are met with, either in
the cellular tissue under the mamma, or in the substance of the
gland—tumours not of the gland, though in it. Such are generally traced
to injury, as to a bruise by falling against the corner of a table
or chair, an accidental push from the elbow of another, &c. Simple
sarcoma is the most frequent formation; but I have encountered tumours,
thus situated, of a worse nature—reproduced, though freely and fully
removed; in fact, taken away along with the gland and neighbouring
adipose substance.
The gland itself is most frequently affected by carcinoma. Sometimes it
is attacked by, or involved in, medullary sarcoma; and bloody tumours
are also met with. In some cases, the gland is enlarged and softened,
and penetrated by cysts of greater or less size, and more or less
numerous, containing a fluid either serous, albuminous, bloody, or thin
and black.
The appearance and progress of carcinomatous and other tumours have
been already described. The mamma is more frequently the seat of
malignant disease than any other gland; it is frequently excited, and
much exposed to injury. Often the induration following abscess remains
stationary for several years, and at length takes on a new action,
forms morbid deposit, and is of rapid growth. The disease seldom occurs
in young subjects; though I have met with several well-marked cases
under thirty. Before that time of life, the tumour is generally of a
strumous nature, and this should not be confounded with the malignant;
for the one is remediable under the influence of constitutional means,
the other is not. Malignant disease is in most cases developed about
the period when the menstrual discharge ceases; when the discharge is
irregular previously to its entire cessation, the mamma is excited, and
then hardness is perceptible. The disease also forms, though seldom,
long after the “critical period,” but in such cases its progress is
usually slow. It occurs, also, and not unfrequently, in those who have
never had the mamma excited by lactation; the mammilla is also subject
to malignant disease in males advanced in life.
When the malignant nature of the disease is recognised, the tumour
should be extirpated without delay, before it has made much
progress—before it has contracted extensive adhesions, or contaminated
the lymphatics. The circumstances rendering interference unadvisable
have been fully spoken of when treating of tumours generally. If the
patient is a female, the period of the menstrual discharge, if still
regular, must be attended to, and avoided; indeed this maxim should
apply to every operation on the female. The most favourable time for
operating is some days after the cessation. The position of the patient
should be sitting, unless the dissection is expected to be tedious; but
it ought not to be so,—the extirpation of glands, or the detachment of
the tumour from parts to which it may have contracted firm adhesions,
can alone cause delay; and when these circumstances exist, interference
is not allowable. Any warrantable operation on the mamma can be
completed in a very few minutes. Two elliptical incisions are made from
the border of the pectoral muscle, in the direction of the fibres,
embracing the nipple and any portion of the integument which may be
adherent or altered. The surgeon need never hesitate to sacrifice the
nipple, for in this disease it can be of no further use; besides the
malignant action is apt to return in it when saved, it being almost
always adherent to the tumour: it must be removed. The incisions are
made quickly with either a scalpel, or a sharp-pointed and broad
bistoury; the lower should be the first, that the flow of blood may
not interfere with it and obscure its course. This is carried at once
through the skin and subjacent adipose tissue, and then the upper
is made rapidly, to get over the most painful part of the operation
as soon as possible. The dissection is next proceeded in, from the
axillary region forwards, and the tumour detached first on one side,
and then on the other. A few strokes of the knife will separate the
remaining cellular attachments to the fascia of the muscle, or of the
fascia to the muscle. The surface of the wound and of the extirpated
mass should be carefully examined, so that no part may remain whose
structure is altered. The vessels are tied; and after oozing has
ceased, if sufficient integument has been saved, the edges of the wound
are put together and retained. The patient is placed in bed, with the
head raised and the arm slung.
Operation is scarcely justifiable when it is evident that the
absorbents are affected. Yet a small glandular tumour on the border
of the axilla, without any enlargement more deeply seated, may be
removed along with the mamma. With this view, the incisions should
be made so as to include the tumour, and detach it previously to the
mamma being interfered with. But when swelling has taken place deep
in the axilla, it is impossible to ascertain its exact extent, and it
may be considered very certain that a chain of altered and enlarged
glands lie along the course of the axillary vessels. The whole of
such a tumour cannot be taken away, and, in removing even the more
prominent and accessible parts of it, there is great risk of wounding
the axillary vein. This blunder I have seen committed more than once,
and I have also seen the vein, the artery, and the majority of the
nerves, all included in one ligature in order to stop the bleeding. I
need scarcely add that the patients soon perished. When enlarged glands
are perceptible above the clavicle, or in the intercostal spaces, the
practitioner who would advise interference with the original tumour
must be grossly ignorant, or very unprincipled.
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.