Surgical excision

“ When the disease implicates internal organs, it is almost always fatal. On external parts the destructive process gradually spreads, and the patient eventually succumbs to superadded septic infection. When, from its situation, the primary focus admits of removal, the prognosis is more favourable.
Treatment.—The surgical treatment is early and free removal of the affected tissues, after which the wound is cauterised by the actual cautery, and sponged over with pure carbolic acid. The cavity is packed with iodoform gauze, no attempt being made to close the wound. ”

“ Should an attack of the external variety of piles not result in absorption, but leave an excrescence, painless but inconvenient, and liable at any time to become inflamed, excision would be in order. Divide the integument by an incision radiating from the anus, separate the skin from the tumor down to its base, and after seizing it with toothed forceps cut it off with scissors curved on the flat. Little flaps or tabs of skin remaining after piles may be snipped off with scissors. It is not well to operate upon external piles unless they obstinately resist all milder treatment. ”

“ It also resembles a lipoma, especially the congenital variety which grows from the periosteum, and the differential diagnosis between these is rarely completed until the swelling is punctured or explored by operation. If treatment is called for, it is carried out on the same lines as for hæmangioma, by means of electrolysis, igni-puncture, or excision. Complete excision is rarely possible because of the want of definition and encapsulation, but it is not necessary for cure, as the parts that remain undergo cicatrisation. ”

“ For the excision it will be found best to use a fine pair of curved eye scissors, beginning the incision by raising the skin at the outer canthus with a fixation forceps or tenaculum.
Another guide to outline the necessary amount of tissue to be removed is to mark the area, prior to operation, with India ink or an indelible pencil. The parts can then be snipped away readily without fear of causing ectropion. There is usually very little bleeding, and in most cases the tissue is exceedingly thin. ”

“ It is only to be avoided by an increase of the staff, which is not likely to be made except on very special occasions.
Other difficulties are purely surgical. First, the difficulty of diagnosing with certainty a perforating lesion. In the presence of the fact that many incomplete lesions follow wounds crossing the intestinal area, and that these give rise to modified symptoms, I believe this determination to be impossible without the aid of an exploratory incision. ”

“ There is no conservative surgery save where the function is conserved. The essential point of the treatment of diaphysial fractures consists in the early operative disinfection, primary or secondary, by an extensive sub-periosteal removal of fragments, based on exact physiological knowledge, and in conformity with the general method of treating wounds by excision. ”

“ To lay open the abdominal cavity from the sternum to the pubes, and rapidly dissect out of this cavity an enormous tumour with a narrow neck, the operator's only embarrassment being the peristaltic movements of the bowels, and his only care being to tie the neck of the tumour firmly with strong string, sew up the wound, and trust to nature, was an operation very easy to perform, and requiring free cutting rather than dexterity, and rashness more than true surgical insight. ”

“ The most effectual remedy is excision, though this can very rarely indeed be had recourse to with safety; for when the disease is extensive, the vessels in its neighbourhood are much enlarged, and their action increased; so that any attempt to remove the tumour by the knife is followed by profuse, and often an uncontrollable, flow of blood. When excision is practicable, it ought to be accomplished by cutting very clear of the disease; the tumour, like every other, must be cut out, not cut into. ”

“ In women the hair in front of the ear, instead of being shaved off, should be combed forward and plastered down with carbolic soap. By doing this the hair can be arranged so as to cover the bald area during convalescence, a matter of great satisfaction to the patient.
Fig. 216. Diagram showing Position of Skin Incisions in Post-aural Operations. 1, For removal of foreign bodies or exostoses, or for excision of a stricture within auditory canal; 2, Usual incision for the mastoid operation; 3, Prolongation of incision upwards for exposure of temporo-sphenoidal lobe ”

“ If interference is needed, it is much more likely to be satisfactory the more chronic the condition has become, since the source of the bleeding may be impossible to discover. I never saw a patient's life endangered by the amount of such hæmorrhage, but if this should seem to be likely, local treatment is of course unavoidable. In several cases quoted below, incision and evacuation were followed by excellent results; in any such operation too much care to ensure asepsis is impossible. ”

“ We operate upon them as upon scrofulous tumours, by incision, dissection, sutures, and the rest of the treatment, only avoiding to wound the membrane, lest its fluid contents be poured out and obstruct the operation, and lest a part of it should be left behind, which often occasions a renewal of the complaint at the wrists, ankles, and the moveable parts about joints, as a scrofulous tumour does in like manner, if the whole or a part of it be left behind. If any such thing be left it will be better not to sew up the wound, but to consume the remainder with septic applications. ”

“ An incision (Vrana) which is wide, extended, equally and evenly divided, should be deemed the best.
Authoritative verses on the subject:—An incision which is wide, extended, well divided, does not involve any vital part, etc. of the patient, and is well-matured as regards time, is the best of its kind* [2] . Courage, light handedness, non-shaking, non-sweating, sharp instruments, self confidence and self command are what should be possessed by a surgeon engaged in opening a boil or an abscess. ”

“ This work is a classic which has been often referred to by eminent men in recent times.
Early in practice he was convinced of the lack of proper treatment for pleuritic effusions, and he watched with deepest regret the death of many a patient from the lack of what he then believed to be the proper surgical procedure in cases of large effusions which gave rise to great dispnea and often death from suffocation. Opening of the chest wall by surgical incision had been occasionally practised at rare intervals in former years, but only in cases of apparent chronic pleurisy. ”

“ To assure the operator of a thorough dissection he may inject the site with sterile water through the opening made with the knife, squeezing it out before injecting the nose.
If the skin has had to be freed by surgical means the mass injected should be sufficient to overcome the defect almost entirely, to prevent the reformation of the bands of connective tissue which have been severed. ”

“ These points must all be considered, but as a general rule, I would say that such attempts at preservation of the limb are much more justifiable, and longer justifiable in the hip and knee-joints than in the elbow or shoulder; for the results in the lower limb will probably be as good, if the patient survive, if not better, than those obtained by excision, while the danger of the operation is greater ”

“ An assistant should stand at each side to make gradual pressure by pulling on the ends of the bandage, thus assisting 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. ”

“ The accumulation of an excessive amount of inflammatory exudate may endanger the vitality of the tissues by pressing on the blood vessels to such an extent as to cause stasis, and by concentrating the local action of the toxins. Under such conditions the tension should be relieved and the exudate with its contained toxins removed by making an incision into the inflamed tissues, and applying a suction bell. When the exudate has collected in a synovial cavity, such as a joint or bursa, it may be withdrawn by means of a trocar and cannula. ”

“ The little wound being then stretched open between the finger and thumb of the operator, the incision is moistened with the matter, by gently touching it with the flat side of the infested lancet. This operation is generally performed in both arms, and sometimes in two places in one arm, a little distance from each other. For as I have not observed any inconvenience from two or three incisions, I seldom trust to one; that neither I nor my patient may be under any doubt about the success of the operation from its being performed in one place only. ”

“ If he works blindly in a pool of blood he courts disaster.
The hæmorrhage is best prevented by first curetting away any granulation tissue and then packing the cavity firmly with a strip of gauze. If this be not sufficient, it may be again packed with gauze containing adrenalin solution. It will repay the surgeon to have a good assistant to keep the field of operation dry. Troublesome bleeding, coming from a small vessel in the bone, may be arrested by the local application of a small fragment of Horsley’s sterilized wax (see Vol. I, p. 437) . ”

“ The incision should include the skin and subcutaneous tissue. The V-shaped flap is dissected up and the lid liberated from the underlying scar tissue. The incision is then sewn up in the form of a Y (Fig. 155) . Temporary tarsorrhaphy (see p. 266) is always desirable. Subsequent shortening of the lid margin by the Argyll Robertson method is sometimes necessary.
Denonvillier’s operation. This procedure is useful to remedy an ectropion of the outer portion of the lower lid by the transposition of flaps at the outer canthus.
Instruments. Scalpel, dissecting and artery forceps, scissors, sutures. ”

“ Displacement or partial extrusion of the dead bone may cause complications, as when a sequestrum derived from the trigone of the femur perforates the popliteal artery or the cavity of the knee-joint, or a sequestrum of the pelvis perforates the wall of the urinary bladder. ”

“ Thirty years ago, in consequence of the great danger of opening the head, the chest, or the abdomen, or, in fact, of making an incision anywhere about the body, the surgeon never dared to interfere until he was obliged to do so. Hence, not only were many modern operations not even thought of, but in obscure cases we had to wait until time and disease developed symptoms and physical signs such that we were sure of our diagnosis, and then, knowing that death would follow if we did not interfere, we ventured to operate. ”

“ In the mean time for, first, the recognition and, second, the surgical treatment of perforating wounds of the abdominal viscera, American surgeons have won for themselves the greatest credit, and an already long list of successful laparotomies after gunshot wounds of the intestines, with intestinal suture or resection, has shown the very great value of this procedure, even though it has kept some would-be murderers from the gallows. ”

“ When a large old hernia in an adult is the subject of operation, it is thus performed by Mr. Wood:—The pubes being shaved, and the patient put thoroughly under the influence of chloroform, the rupture is reduced, and the operator's forefinger forced up the canal so as to push every morsel of bowel fairly into the abdomen. An assistant then commands the internal ring by pressure, to prevent return of the rupture.
An incision is made in the scrotum over the fundus of the sac, large enough to admit a forefinger and the large needle used in the operation ”

“ When the mucous membrane has been so long exposed as to have lost many of its characters, and to resemble leather in its toughness, excision will be found less painful and much more rapid than ligature.
A longitudinal fold at each side of the anus should be pinched up and excised by a pair of probe-pointed curved scissors. There is always a certain amount of risk of hæmorrhage following such an operation. The risk is lessened and the result improved by stitching up the wound in the mucous membrane before the protruded portion of bowel is returned. ”

“ The incisions necessarily required for this purpose in the thigh are sometimes neglected, or the surgeon refrains from making them from the great thickness of the muscular parts, and from the wound having taken place on the inside, near the great vessels, so as to render incisions of sufficient size or extent in some degree dangerous. The thickness of the muscular parts is not a sufficient reason for avoiding an incision, neither is the vicinity of the great vessels and nerves, although they may not be divided ”

“ The abdomen is opened by the median subumbilical incision; but when the operation is performed for the removal of large tumours it will frequently require extension above the umbilicus. The operator should never allow himself to be embarrassed by a small incision. As soon as the peritoneal cavity is reached, the surgeon introduces his hand and carefully makes out the nature of the case, the presence or otherwise of adhesions, other tumours, and the relation of the fibroid to the uterus, and determines whether it is impacted in the pelvis. ”