For some days or even weeks the patient must be fed through an elastic catheter introduced through the nose and retained, or by an ordinary stomach-tube through the mouth. In introducing the latter there is always a risk of opening the wound. No special sutures for the wound in the oesophagus are required, nor is it advisable too closely to sew up the external wound.

FOOTNOTES:

[127] _Lecons sur la Tracheotomie_, p. 10.

[128] Rough diagram of larynx and trachea:--A, crico-thyroid s.p.a.ce, _laryngotomy_; B B, dotted outline of thyroid isthmus and lobes, defines the upper and lower positions for _tracheotomy_; C, thyroid--D, cricoid cartilages; E, dotted outline of thymus gland in child of two years; F F, outline of clavicles and jugular fossa.

[129] _Surgical Observations_, p. 335. See also Harrison _On the Arteries_, vol. i. p. 16.

[130] _Lecons sur la Tracheotomie_, p. 9.

[131] _Lectures on Surgery_, 3d ed., vol. ii. p. 900.

[132] _Clinical Surgery in India_ (1866), p. 143.

[133] Mr. John Wood, _Path. Soc. Trans._, vol. xi. p. 20.

[134] South's _Chelius_, vol. ii. p. 400; and case recorded by Spence, in _Ed. Med. Journal_, for August 1862.

[135] _Med. Chir. Transactions of London_, 1872.

[136] _British Med. Journal_ (Nos. 643, 644), 1873.

[137] Gross's _Surgery_, 6th ed., vol. ii. p. 342.

[138] _Guy's Hospital Reports_ for 1858.

CHAPTER X.

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 a.s.sistant, 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 st.i.tches 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. c.o.c.k,[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 s.p.a.ce 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 s.p.a.ce, the trocar should be entered not higher than the middle of the s.p.a.ce; and because the artery is largest near the spine, and also the s.p.a.ce 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, c.o.c.k, 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 quant.i.ty 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-c.o.c.k 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 a.s.sistant, by means of a strong cross handle; the first stop-c.o.c.k is then opened, and the syringe worked slowly till it is filled with fluid through the trocar, the other delivery stop-c.o.c.k being closed. The first is then closed, and the second opened; the syringe is then emptied through the second into a basin. By a repet.i.tion 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.

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 p.u.b.es, 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 pa.s.s 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 a.s.sistant should stand at each side to make gradual pressure by pulling on the ends of the bandage, thus a.s.sisting 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.