TUMOURS. 



The diredtion of the incifion is various with different 

 pradfitioners ; feme making it perpendicular, others tranf- 

 verfe. In general, the fliape of the tumour muft determine 

 which is the beft. In France, it has been faid, that when 

 the incifion follows the fecond direftion, it heals more ex- 

 peditioufly, becaufe the (kin is more extenfible from above 

 downward, than laterally, particularly towards the fternum, 

 and confequently allows the fides of the wound the more 

 readily to be placed in contaft ; and that the aftion of the 

 peftoral mufcle tends to feparate the edges of the wound' 

 when it is perpendicular. On the other hand, it is allowed 

 that the wound, made in the latter manner, is the moft 

 favourable for the cfcape of the difcharge, if fuppuration 

 Ihould occur. See Default par Bichat, torn. ii. p. 312. 



The cut through the flcin (hould always be fomewhat 

 longer than the tumour ; and as it is, perhaps, the moft 

 painful part of the operation, and one attended with no 

 danger whatever, it {hould be executed with the utmoft 

 celerity. Pain is certainly more or lefs to be dreaded, 

 according to its duration. The fear, however, of giving 

 pain, has probabJv led many operators to err, by not making 

 their firft incifion through the integuments large enough, 

 the confequence of which has often been, that there was 

 not room enough to get at the tumour fo as to difleft it 

 out with facility : the patient has been kept nearly an hour 

 in the operating room, inftead of five minutes, and the fur- 



feon cenfured by the fpeftators as awkward and tedious, 

 t is clear, alfo, that, befides the great deal more blood 

 loft from this error than would otherwife happen, the vef- 

 fels being commonly not tied till all the cutting is finifhed, 

 the avoidance of pain, that fear which led to the blunder, 

 is not efFefted, and the patient fuffers much more, and for 

 a much longer time, in confequence of the embarrafTment 

 and obftacles in the way of the whole operation. 



When the difeafe is of a fcirrhous or malignant nature, 

 the (kin covering the tumour (hould at all events be in 

 part removed. All that portion which is difcoloured, 

 puckered, tuberculated, or otherwife altered, (hould be 

 taken away. Some muft alfo be removed, in order to pre- 

 vent a redundance, in all cafes in which the tumour is 

 large. We have faid too, that in cafes of fcirrhus and can- 

 cer of the breaft, the nipple is confidered a dangerous part 

 to be left behind. For the purpofe of removing the necef- 

 fary portion of (kin, the furgeon muft obvioufly purfue a 

 difiTerent mode from that above defcribed ; and inftead of 

 cuic ftraight incifion, he is to make two femicircular ones, 

 one immediately after the other, and which are to meet at 

 their extremities. The fize of thefe wounds muft be de- 

 termined by that of the difeafe to be removed, and by the 

 quantity of (kin which it is deemed prudent to take away ; 

 for the part which is included in the two femicircular cuts, is 

 tliat which is not to be feparated from the upper furface of 

 the fwelling, but taken away with it. The (hape of the two 

 cuts together may approach that either of a circle or oval, 

 as the figure of the tumour itfelf may indicate as moft con- 

 venient. The direftion of the incifions is to be regulated 

 by the fame confideration. 



In the above ways, the firft divifion of the integuments 

 is to be made in removing tumours of every defcription 

 covered with {!<in. The fame principles and prafiice (hould 

 prevail in all thefe operations ; and, whether the fwelling is 

 the mamma, or any other difeafed mafs, whether fituated 

 on the cheft, the back, the head, or extremities, the fame 

 confiderations (hould always guide the operator's hand. 



The incifion or incifions in the (kin having been made, 

 the next objedl is to detach every fide of the tumour from 

 its conneftious, and the feparation of its bafe will then 



be the laft and only thing remaining to be done. Whert 

 the tumour is a fcirrhus, or other malignant difeafe, the 

 operator muft not diffeft clofe to the fwelling, but make 

 his incifions on each fide, at a prudent diftance from it, (o 

 as to be fure to remove with the difeafed mafs, every ato-m 

 of morbid mifchief in its vicinity. But when the tumour 

 is only a mere fatty or other mafs, perfeftly free from ma- 

 lignancy, the cellular bands and velTels forming its connec- 

 tions may be divided clofe to its circumference. It is afto- 

 ni(hing with what eafe if.ity tumours are removed, after the 

 nece(rary divifion is made in the (!<in ; they may almoft be 

 turned out with the fingers, without any cutting at all. 

 When they have been inflamed, however, they are then 

 more adherent to the furrounding parts, J 



Thus we fee, that the firft ftage of the operation of re- * 

 moving a tumour, is the divifion of the Dun ; the fecond„ 

 the feparation of the fwelling from the furrounding parts on 

 every fide ; the third and laft ftage is the divifion of the 

 parts to which its under furface, or bafe, is attached. The 

 latter objeft (hould be accomplilhed by cutting regularly 

 from above downward, till every part is divided. 



It is a common thing to fee many operators conftantly 

 embarralTed and confufed, whenever they have to remove a 

 large tumour, on account of their having no particular 

 method in their proceedings. They firft cut a few fibres 

 on one fide, then on another ; and turning the mafs of dif- 

 eafe now to this fide, now to that, without any fixed defign, 

 they both prolong the operation very tedioufly, and prefent 

 to the byftanders a complete fpecimen of furgical awkward- 

 nefs. On the contrary, when the praftitioner divides the 

 cutting part of the operation into the three methodical 

 ftages above recommended, in each of which there is a 

 diftinift objeft to be fulfilled, he proceeds with a confidence 

 of knoiving what he is about, and foon effefts what is to be 

 done, v/ith equal expedition and adroitnefs. 



Having taken out the tumour, the operator is immediately 

 to tie fucQ large velTels as may be pouring out their blood ; 

 indeed, when the removal of the fweUing will nece(rarily oc- 

 cupy more than three or four minutes, it is better to tie all 

 the large arteries as foon as they are divided, and then 

 proceed with their diffeftion. This was the celebrated De- 

 fault's plan, and it is highly deferving of imitation in this 

 country, not only becaufe many fubjefts cannot afford to 

 lofe much blood, but zJfo becaufe the profufe effufion of 

 this fluid keeps the operator from feeing what parts he is 

 dividing. 



The largeft arteries being tied, the furgeon (hould not be 

 immediately folicitous about tying every bleeding point which 

 may be obferved. Inftead of this, let him employ a little 

 time in examining every part of the furface of the wound, 

 in order to afcertain that no portion of the fwelling, no har- 

 dened lump, nor difeafed fibres remain behind. Even if any 

 part of the furface of the peftoral mufcle (hould prefent a 

 morbid feel or appearance, it muft, on every account, be 

 cut av*ay. Alfo, if any of the axillary glands are difeafed, 

 the operator (hould now proceed to remove them. After 

 the time fpent in fuch meafures, many of the fmall vefiels, 

 which bled juft after the excifion of the fwelling, will now 

 have ftopped, the nec^ty for feveral ligatures will be done 

 away, and of courfe the patient faved a great deal of pain, 

 and more of the wound be likely to heal by the firft 

 intention. 



Some information may be derived, refpediing whether 

 any of the tumour is left behind, by examining its furfaces, 

 when taken out, and obferving whether any part of them 

 is cut off ; for if it is, it may always be found in the cor- 

 refponding part of the wound. 



The 



