Elements of Surgery. Robert Liston

the old. I must say that I am unacquainted with any remedies capable of performing the above indication. The removal of a swelled gland may occasionally be accelerated by such means when stationary, or on the decline, and before cheesy tubercular unorganized matter is infiltrated into its texture; but to trifle so with a new and independent growth is altogether absurd. The knife only is to be depended on.

      Many of the tumours first described have no malignant disposition originally, and only require surgical interference when they produce deformity or inconvenience from their bulk. Yet even these ought not to be allowed to attain any great size, however indolent they may appear at first, and however little pain they may produce; for there is always a danger of their assuming a malignant tendency, or forming connections with important parts, so as to render their removal either altogether impracticable, or at least attended with much difficulty. Tumours of every kind, when seated near important organs, must be early removed. Glandular tumours, however, even when of great size and long continuance, are not to be rashly interfered with, when they arise from irritation in the neighbourhood.

      Those in which it is feared that malignant action has commenced cannot be trifled with; and the only means which afford a chance of the patient’s being effectually delivered from them is an operation. With a view to their complete extirpation, the external incisions ought always to be free, so as to admit of the after-dissection being easily and rapidly performed: they ought also to be made in the direction of the muscular fibres, whether these lie above or beneath the tumour. In this way the margins of the wound are easily brought into apposition, and there retained; whereas, if the fibres be divided transversely, the wound will gape, and union by the first intention be rendered absolutely impossible. If there is no reason to suppose that the tumour is malignant, little or no integument ought to be removed, unless the growth is of a large size; but, when malignity is dreaded, all the discoloured, tense, and adherent integument, all that is permeated by dilated and tortuous vessels, ought to be taken away, and the incisions made at a distance from the disease. In all cases they ought to commence at the point where the principal vessels enter; these are thus divided at the outset, can be readily secured by ligature, or by the fingers of an assistant, and the dissection is proceeded in without risk or interruption from farther hemorrhage. If the opposite course be pursued, the vessels will be divided two or more times during the operation, and thus the performance of it will either be delayed by the application of numerous ligatures, or will be attended with a considerable loss of blood. After the tumour has been exposed it ought to be principally detached in one direction, as in this way its removal will be sooner accomplished, and not first cut on one side and then on another. If malignant, great care should be taken that all the diseased mass be removed, for a minute portion remaining will form a nucleus in which similar diseased actions are certain to arise; in most instances, it will be prudent not only to remove the parts actually diseased, but those also which are in immediate connection with the tumour, though at the time they appear healthy. All important parts must be carefully avoided. After removal of the mass, and the complete cessation of bleeding, the edges of the wound must be approximated, so as to favour union by the first intention; if this fail, granulation must be promoted, and the wound dressed according to the particular circumstances of the case. All operations on malignant tumours, in their advanced stages, are unwarrantable; they are necessarily painful and severe, and cruel because unavailing; they often, indeed, expedite the dissolution of the patient. If the integuments over the tumour have ulcerated, and if the lymphatics in the neighbourhood are diseased, the disease if removed will certainly be reproduced, and the succeeding tumour will be still more malignant. The operation ought, if at all, to be performed when the disease is in its incipient state, for then only can success be expected.

      Exostoses need not to be interfered with, unless they are the source of much inconvenience, either from their size and form, or from their having been detached, and lodged amongst the adjacent soft parts. If loose, they can be removed in the same way as any other extraneous body; if firm, their attachment must be divided by a saw, or by cutting pliers, close to the bone from which they spring. Sometimes, as in the scapula or other flat bone, a portion of the original bony tissue can be cut out along with the new growth, and this renders the chance of any return of disease much less likely.

      Osteo-sarcomatous tumours are to be taken away, along with the part of the bone in which they are imbedded, and, if possible, before the integuments have ulcerated. The incisions must be made, and the bone sawn, at a healthy part. The removal of the entire bone in which the disease has commenced, when practicable, will afford a still better chance of immunity from farther disease.

      In spina ventosa more is seldom required than to lay open the cavity, give vent to the matter, and then treat the case on the same principles as in abscess of the soft parts. The cellular tumours, partly cartilaginous, partly osseous, ought not to be permitted to remain; the operation can generally be done without much difficulty; and thus the danger of their degenerating avoided. Frequently, however, a considerable part of the bone must be removed along with the tumour, since the neighbouring tissue is generally softened, and intimately adherent to the diseased part, which it somewhat resembles in structure.

      In general, regular dissection is unnecessary in the removal of encysted tumours. An incision is made, or an elliptical portion cut out; the contents escape, and the cysts, being then laid hold of by dissecting forceps, is readily separated. In some situations, as on the eyelids, under the tongue, or amongst tendons, the sac, which is thin, is not so easy of extraction; it is then inseparable, either naturally, or from previous inflammation. Caustic is used with safety to destroy those parts which cannot be detached, and for this purpose the potass is to be preferred. When, however, the tumour is large, a part of the integuments covering it must be removed, otherwise a large cavity will be left, in which pus might accumulate. In this case, the base of the tumour is to be surrounded by two elliptical incisions, and the cyst dissected out entire, leaving only integument sufficient to cover the exposed surface. In the smaller tumours, it is vain to attempt regular dissection; a portion of the cyst will be left, and the disease reproduced: whereas, by using the potass, the operation is much more speedy, and always successful. The making a minute aperture, and squeezing out the contents, is at best but a palliative measure, and is often followed by severe constitutional disturbance.

OF WOUNDS.

       Table of Contents

      These vary in extent and nature. The instrument by which they are inflicted, the violence attending the injury, and the nature and importance of the parts divided, or in the neighbourhood of the wound, must all be attended to, for, from an accurate knowledge of these circumstances, the treatment of the case comes to be conducted accordingly. Wounds are divided into incised, punctured, bruised, and lacerated; that is, into such as are inflicted by a sharp-edged, sharp-pointed, or an obtuse body. In the first kind, there is greater or less effusion of blood, according to the size and number of the vessels divided. Some extend but a little way beyond the subcutaneous cellular tissue, and are consequently attended with but slight bleeding; others penetrate to a greater depth, and occasion hemorrhage from a large vessel, or other alarming symptoms, by having reached some important organ; others, though not of so great a depth as the former, may still, on account of their mere extent, be accompanied with very considerable loss of blood from a number of small branches. It is seldom that fatal effects immediately follow external wounds; but they may and do occur when bloodvessels of the first class only are cut. They are most likely to prove suddenly fatal when the arteries are only partially divided, and when the large veins accompanying them are also involved. When the artery is cut through, its extremities retract, effusion takes place into the sheath and compresses the orifice; the formation of a coagulum within the vessel is thus promoted, and the hemorrhage arrested. But, when a portion only of the circumference is divided, the blood continues to flow through the aperture and onwards, as if into a smaller ramification of itself, no retraction or contraction of the vessel can occur, coagulation is slow, and the bleeding profuse. I have seen a wound of so small a vessel as the internal mammary prove almost instantaneously fatal. Wounds of the large internal vessels for the most part prove immediately fatal; as wounds of the heart, or the large vessels passing to and from its cavities, at the root of the lungs, or at the upper part of the