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Las diagrammes suivants illustrent la mdthode. 1 2 3 32X t t 3 4 5 6 ■gr^rtiiirni iirriiimiw McGill ...Si^irgerv EMBRACING THE Full Surgical Course of Lectures. iltoiitrral : Trinted bv JOHN I.OVRLL & ifOX. 1898 'fwi^i^^^mm ■'i— >— hMMBIM^ IIIIIBII' lillUM I II I PRKP^ACK. 4 By the kind permission of Dr. Roddick the following notes, which are practically a reproduction of the course on Surgery, have been published. For a number of years both the Junior and Final men have wished to carry away with them for future reference the modes of treatment and technique of their own Professor. In these pages we have attempted to set down these prin- ciples in concise form. We desire to thank Dr. Roddick for his permission and the interest he has shown in the publication, also Drs. Armstrong, Garrovv and Bradley. Montreal, October, i D. M. L. A. T. M. 898. CONTENTS. r Section I. — Contusions, Kcehynioses, H;tmatomn, Wounds Aseplic Techni(iue, Rabies, Erysipelas, Ceiliililis, Burns and Scalds, Injuries to Arteries and N'eiiis, H;x:morrliage, Ha^mo- phylia, AnLnitism, Diseases of Veins, Gunshot Wounds, Shock, 'J'racheotomy, Intubation I'ages 1-45 Skction II. — Inllamuiation, Abscess, Sinus and Fistula, Ulcera- tion, Gangrene Pages 45 66 Se::tion III. — Wound Diphtheria, Syphilis, Chancroid, Anthrax, Glanders, Actinomycoses Pages 66-88 Section IV. — Intestinal Ohstruciion, Coloio;ny, Hernia, Abdom- inal Injuries Pages 88- too Section V, — Diseases of Rectum, Hemorrhoids, Pruritis Ani, Ischio Rectal Abscess Pages loc-i 10 ION VI.— Fractures, Dislocations, Diseases of Bones, Caries, Necrosis, Inflammatory Diseases of Joints Pages no 172 Section VII. — Injuries and Diseases of Genito-Urinary Tract, Gonorrhoea, Stricture, Diseases of Prostate, Urethral Fever, Diseases of Bladder and Kidney, Operations in Urinary Calculi Pages 172-209 Section VIII. — Gastric Surgery, Diseases of Testicle, Liver and Gall Bladder, Appendicitis, Diseases of Breast, Diseases of Tongue .. .Pages 209-237 Section IX. — Bacteria of Surgery, Skin Grafting, Addenda.. Pages 237-247 » •■"■ IIJBIIIlt ^ ' ^.- SURGERY. CONTUSIONS. A contusion is a suhcutanmus laceration, the skin surface remaining- unbroken — skin bcinfi;- elastic r.'ul tough, often re- mains intact with extensive suhcntaneou.' ^lisorganization. Causes : — Blows from blunt objects, sciueezes, indirect blows from falls on feet or hands; conipres.^ion always essen- tial to produce contusion. Contusions may occur in any gr.iiie from slight bruise to greatest disorganization of soft and hard parts. As a rule the connective tissue and vessels suffer most, but muscles, veins, arteries and lymphatics may be lacer- ated, also bones injured. ( )ne of Hie most serious results is extravasaticju of blood. In smaller injuries only discoloration and swelling. EcciivMosis: — Discolouration underlying tissues with various changes as in black eye. In serious injury and larger extravasation may have a doughy feeling, or where the parts are lax may have a bag of blood with fluctuation — when this latter is well defined it is called a Hematoma. In all cases of blood effusion, whether great or small, the blood is generally absorbed. If air enters may have suppura- tion, and haematoma converted into an abscess. Sometimes blood in hsematoma remains long in fluid state, well defined cyst walls forming. Liquid contained dark and of the con- sistence of treacle. Again walls may become thoroughly or- ganized and colour changed to that of straw forming a true cyst. Extravasation if great may cause fatal syncope, or tension may retard circulation with development of gangrene in the part thus affected. When contusion occurs immediately over or ill !■■ Kw iiiiMM y£ vw:^Wi.M!mim'3Kima SURGERY i involves ar. internal organ, it is serious; thus hemorrhage into the abdorr.'nal cavity may prove rapidly fatal. Diagnosis and Symptoms : — The history is of great import- ance. Pain is usually absent except where great tension — if seen late, diagnosis may be difficult. Ecchymosis may be so great that gangrene is simulated, blebs being formed. In contusion always a local temp, of 2 or 3 deg., and a gen- eral increase of the body temp. In gangrene part shows a temp, below normal, or below that of the corresponding part on the opposite side from that affected. (In all gangrene ex- cept inflannuatory the body temp, is normal or subnormal.) In a case of pressure contusion may have the two condi- tions of contusion and gangrene at the same time. Ha^ma- toma may be diagnosed by aspirating. Treatment: — Arrest hemorrhage by external application of cold, subsequently heat. Observe care that the cold applica- tion does not lower the •vitality of the part too much, especially where there is pressure. After hemorrhage is arrested, hot applications are in order; these applications will relieve the feeling of tension and the pain, and promote the absorption of effusion more rapidly than the cold. Spirits and cold water, acetate of lead and spts. to the part leaving exposed to evaporate; all may be tried or each. If hemorrhage persists in spite of cold pack or lotion, use pressure on the artery with tourniquet above the contusion, also elastic pressure with cotton wool under bandages. Hgsmatoma should never be opened so long as not inter- fering with the functions of the part and there is any chance of its being absorbed. Where absorption is not going on aspiration may be practiced. The needle should First be passed through the sound tissue, which will close immediately on withdrawal, and prevent the entrance of air and microbes. If this is of no avail, then open, wash out thoroughly, and leave to heal by granulation from the bottom. If inflammation, local temp., swelling and red- ness, hematoma should then be opened without delay. Contusion, no matter how severe, if there is no opening, the prognosis is favourable. «R..WEiMW»nia mmmmmwimmmwmmK/9mK!p:m^^^K?e^>0j3m:^ i i ' SURGERY WOUNDS. A wound Is a solution of continuity (/". ('., a breach) in any part of the body suddenly made by anything that cuts or tears, dividing or penetrating the skin, \'arietics of \\'ounds: — Incised, Laccraiod, Contused, Punc- tured, Poisoned and Gun-sliot. Incised Wouxds: — Those made by a sharp instrument, as knife or sword, may be simple, implicating only the integu- ment, or deeper structures, or complicated with damaged nerves or vessels, or a cavity opened. Phenomena: — i. Pain. 2. Hemorrhage. 3. Laceration of edges. The iiUensily of ])ain depending upon the nerve supply to the part; the hemorrhage depending upon the vascularity and the size of the wound; the separation upon the amount of ten- sion, or ck'.sticity of the skin, on the direction of the incision, contraction of the muscles, etc. dapiug is always bad win re there is nuich efifusion. CoxTi'SED Axi) Laci'.ratt:]):— These arc wounds attended by more or less tearing about t'le edges or sides, and present every possible variety from an open bruise to the separation of an extremity, machinery, accidents, bites of animals, blunt objects as stones, and oil gun-shot injuries. Characters: — Lips are irregidar and torn, ecchymose, not necessarily gaping, very little hemorrhage, dull aching pain; there is always a distinct layer of tissue which must be thrown off before union can take place, so that suppuration is here the rule; the slough may be imperceptible but it is always present. Remote dangers of this form are i. Shock, 2. Secondary hemorrhage. 3. Sloughing. 4. Infective inflanmiation. 5. Gangrene. Punctured Wounds: — From a needle to a bayonet. In wound with a bhmt instrument have usually a contusion. In punctured wounds hard to estimate the damage done from external appearance may wound some of the deep arteries, nerves, organs, etc., and, owing to the small opening, escape "•^ SURGERY V1 III of effusion is prevented, hence often have swelHng-. tension, deep inflammation, hemorrhage, su])piiration, etc., false an- eurism. Ffeaiinj:'' of Wounds:—!. Healing by ist Intention. 2. llcaling by 2nd Intention. a. (jranulation. h. L'nion 01 granulation. 3. lilood clot. 4. Scabbing. IIeai.ixg t,v First Ix'ii:.\tiox: — This is the simplest me- thod of healing. Instrument in passing through the tissues sets up an inflammatory condition in the microscopic layer of tissues so cut through; then follows inflanmiation, in- creased flow to the part, stasis, effusion of liquor sanguinis, and white blood cells, glazing of the surface with lymph. Then if the surfaces are brought into accurate apjiosition, and other untoward conditions are absent, this lymph will glue the sides of the cut together, and healing will conunence at once. Healing may be retarded by too vigorous sponging, too large blood clots or the use of too strong chemical solutions in washing. In the young, wounds will heal by first intention in 2 or 3 days, in adult it may take a week or 10 days. Healing by first intention is unaccom]:)anied by constitu- tional disturbances. In a large wc^und may have a raise of temp, of 1, 2, or 3 deg., at the end of 24 hrs. (aseptic fever) little or no swelling near wound and no pain. Hi-:.\Li.\G BY Granulations: — Here the edges of the wound are not brought together, i. Either they will not come to- gether. 2. That on account of the condition of the wound, it would be bad practice to bring them together, or 3. Fail- ure of attempt to heal by first intention. Constitutional Symptoms: — Temperature, wound thickened — Necrotic spots on the free surfaces. Healing: — Instead of lymph glaze seen in ist Intention, have here an appearance of granulation loops; these granula- tions pile up until the wound fills; they become organized, fibrous tissue appearing, and the wound drawn together, in this way size of sore is soon gradually diminished. In this form of healing always have an extensive cicatrix. Scar at first red becomes white, losing vascularity. .. .this whiteness !?«»., .»r*«'Mr.aM£».a 3i /^ .mmmm K itmmm m/ ^ mmmm mmmF^ig^.mmsmamm. If li '•i HI';! 141 m f^ iiU • KiM!«tiia»«9 SURGERY is due to the compression of the vessels and their disappear- ance. Union of Gkaxulations: — Granulations on tlio sides o\v- ini;- to the failure of union by 1st intention brought top^ether, and healing' takes place — scar is usually small — here granula- tions on hides not the bottom of the wound. Healing p.y Blood Clot: — This only possible where an antisejMic scries of precautions taken, where the wound is aseptic. I'nknown before the days of antiseptic surj^fcry. Where the wound is not bron£;-ht together it fills with blood clot, lymph being- poured otU ujion the surface of the wound, between the sides of the wound and the clot; if rest main- tained, and wound aseptic, leucocytes enter the clot and .ab- sorb the red cor])uscles, later plasma cells enter, and orq-aniza- tion of the clot takes place — not limited to open wounds, therefore in all wounds the spaces become filled with bloo Wi ^ | Nli fe B B) 'ii | WW*i« sLj{at:i{y 13 ERYSIPELAS. An acute, diffuse, iufcctive intlamniatiou, caused by micro- coccus. alTectinL;- chietly iho skin, or subcutaneous tissues, or both, uuicous, sub-nuicous, and even serous membranes. Causes: — PKF.nisrosTXG AXD Excttixg: — I Ciironic Alcoholism. 2. Brif^^ht's Disease. 3. Diabetes. 4. (lout. 5. ]\Ialij;nant disease. 6 Over-crowding- and ne,q;lect of Hygiene. 7. (lan- grenous inllamma'.ion. 8. Anything that lowers the vitality of the tissues or prevents the excretion of waste. One attack predisposes to another, and the tendency may be hereditary. AcTu.AL Cause: — Streptococcus Erysipelatous. A coccus found chiefly in the capillary lymphatics of the skin, also foimd in the blood capillaries of the neighl)ourliood. Cocci are more apparent always at the borders of the patch, cannot be readily demonstrated from the older portions of the patch. They are found in the hair follicles, hence the loss of hair. Never occurs idiopathically, must be some opening of en- trance; when no abrasion, then it is thought that the infection is internal. Infections conveyed by instruments, etc., and probably also by the air. Water and X'accine virus also a media of propogation ; also sponges, hands, and irritants, etc. Phy- sician attending case of Erysipelas should never attend con- finement case. There is some peculiar relation between Erysipelas and Puerperal fever. The new born infant fre- quently contracts Erysipelas from puerperal mother. Old wounds, ulcers of lupoid and malignant character are awaken- ed sometimes by erysipelas from a chronic to an acute form. This fact made use of by Surgeons in the treatment of malig- nant growths Carcinoma and Sarcoma with aj^parent success. P. M. Appearances: — Similar to that of other forms of septic poisoning, the blood fluid staining the heart and ve>- .sels. The Wdnevs and liver show signs of inflammation, also all serous membranes, resulting sometimes in purulent ef- fusion. The redness of the skin disappears after death. Spleen is soft and diffluent. Ii!l I III I • 14 SURGERY Varietiks: — i. Cutaneous. 2. Ccllulo-Cutancous or Phlcg- nionoiis. 3. Cellulitic. a. Ivrratic — ra])i(lly waiuleriiipf. b. Metastatic — in several places at once. c. Puerperal. lx\y;in- ninii" in tlie yenital orjjans of Iviui-'-in women. (/. Mucous — throat and Gen.-Urin'y tract, newlv born. c. Neonatorum in infants CuTANKous Erysipelas: — i. Erysipelas IMi^rans, or Am- bulans, wiien wandering from one part of the body to another (also termed Erratic) Sim])le cutaneous form attacks chietly the liead and face (facial), originating from a scratch, sore in the nose or mouth, has a stage of incubation varying from 8 to 12 hours, some- times 2 days, sometimes uncertain. Symptoms: — Invariably ushered in by a chill, except in the old; ra])id rise of Temp. 103-4-5 deg., generally falls towards morning and rises towards evening. With chill the T. and R. arc stimulai'.'d; vomiting and convulsions in children, fre- ciuently cpistr.xis, tongue coated, pain in the back, headache, constipation, and general depression, pains in the joints and limbs. Temp, in favourable cases will fall to 100 or loi, and will remain there, and in three or four days will disappear, re- turning at times with the appearance of new patches. Temp, falling to subnormal is dangerous. In severe forms have marked general symptoms. Jaundice, Albuminuria and Diarrhoea, frecpient pulse, fever, and gen- eral Typhoid symptoms. Delirium frecjuent. Meningitis, Pericardiitis or Pneumonia may occur as complications. Local Symptoms: — If wound present, found dry and glazed, unhealthy looking, swollen and reddened appearance, granulations fallen, get early a layer of ashen looking lymph, or diptheritic-looking membrane on the wound. W'ithin 24 hours afteir the rigor, blush appears at the point of inoculation, spreading edge, zig-zag outline, hot feeling, border w^ell defined ; later the skin is of a dusky or yellowish red hue, which does not disappear on pressure; later tliere is oedema and slight evidence of pit- ting on pressure, face bums and smarts, and marginal out- w 'B! V '0. I • Ifis I ft! «fe! '' " ■* "' ^^' ' SSSB 8VRni:i{Y 15 line elevated. Tn lax parts, as tlic eyelids, penis or scmtum, the swelling- is j^aeat ; eyes may elose in a few hours. In the palm of the hand there is little sign of swelling. 1st. there is a hnrning sensation, skin shiny, and soon vesicles appear, which may be very minute, even microscopic. Dlebs appear of considerable size, having at first a clear fluid, which later becnmes turbid fmni the presence of pus. dry up and form scabs. The neighbouring lymphatics are tendi'r. swollen and intlamed, red lines marking their course. When the spreading ceases, the redness gradually disappears, skin wriidrog". is serious; way have seri- ous septic inoculation, pyaemia; may go from the face to the larynx. In the new-born Infant it is serious. It occurs during the first 15 days, usually at the navel, spreads and is invariably fatal, child dying of ex'^austion in 3 to 5 days; Phlebitis sometimes occurs; this is grave in old people. Tki:.\t.mi:xt of Cl't.wf.ois \'.mui:tv:- I'reventalive: When erysipelas is epidemic, take care to ventilate the wards, de- stroy soiled clolh'.ng, and take care 01 the hands, instruments, and sponges ; ;/nould use disinfectants about the room; lead nitrate is good ; destroy all cloths. Broiiilne and loolic i-ioo cautiously. 2. If disease spreatlinj;- and cannot he checked, inject pure Carbolic a couple of tlrops at sexcral places, just at the inar<:;;in of thepatch; or paitU a strouj;- solu- tion of Silver Xit. i dr. to the oz. an inch from the horiler, and a secoiul riny; a half an inch from this. Silver N'it. sets up an intlamniation as deep as the lympha- tics; h'ucocytes are thrown out and attack the cocci, and in this way arrest of the spreadintj oi the disease is affected. 3. Collotlion is useful if painteil in a rin^', the rini; con- tracts, iiccludes the lymphatics ami limits the spread of the ilisease. .}. Ichthyol and Lanoline applieil on liiu and ruhheil into the iKirt and changed three times ilaily. Ichthyol, Collodion and Iodoform each 10 per cent., or Ichtln'ol varnish: Ichthyol and Starch aa 40, Water jo. Hefore ai^plxini;- wash with wa- ter, Suhhmate i-itxxi a.m. and i>.m. 5. (iuaii'col painti'd on the surface is useful, iMie-ludl to two draclmis. 6. Zinc C)xide and Starch with q-rs. XX to the Oz of Aris- tol, as a duslini;' jiowder to he ruhbetl in. 7. It a limb atTccted, elevate. S. Slight jiressure i;ives comfort. t). W hen tension is extreme ma [umcture 'he patch with a narrow tenotomy knife. 10. In Children Kre(,>lin wash is useful. I 1. In fauces Silver Xit., one drachm to the (>/., is the i)est application, followed hy one ai>plication of horacic acid and glyceirine, hot appli-ations to the neck. 12. Scalp, or menin_<;Mis. ap{)ly c*)ld ai)pheations. 13. Larynx steam iiduders, scarihcation, ami iodine spray. Ckllulo CrT.wicots Iun-.siin:LAs: — Related closely to cut- aneous form, wliich latter may nm into Cellulo Cut., here the subcutaneous tissue is always affected; generally follows a wound; may arise in scratch or acne spots ; follows opera- tions on bones, and after stone operations of the old lateral foi m where much tearing v. done. Symptoms: — Both Local and General are more marked than in the Cutaneous form. 2 in 1^ ( 18 SUROERY Local: — Oedema and swelling more apparent, redness dull- er, and not so sharply-defined, zig-zag margin not apparent, surface is purple and later marbled, owing to the pressure affecting the circulation of the skin. Bullae are large and usually contain bloody fluid. Pain soon becomes throbbing. Infiltration is deeper, and on section get a wash-leather ap- pearance. Su])'l. lymphatics are soon obscured by the swell- ing; when incised the tissues are found infiltrated with fluid and gelatinous, or " wet washed-leather appearance," Fascia not usually affected. Constitutional Symptoms : — Resemble those of the cutan- eous form, only more severe, rigors and delirimn pronounced, formation o^ pus with breaking down of the tissues, and gen- eral typhoid ; ^ ins. L'sually Asii . form, death from Pneumonia, Se])ti- caemia, Meningitis; those suffering from Rright's disease rare- ly recover. Diagnosis from Ordinary Inflammation : — The surface involved is very large, no tendency to point, rapid course, grave constitutional symptoms, phlebitis, here feel a distinct cord. Angioleucitis confined to the lymphatics and veins; glands enlarged. Trcatinnit: — Same course at the outset as in the cutaneous form. Calomel and Salines; patient put on a liquid diet; Fe: Stimulants, especially old people, and, where the circulation, is feeble, vjuinine or Quin and Fe. Cf.llulo Cutaneous Erysipelas: — Local Treatment: — Thomughly cleanse the wound and api^ly hot antiseptic fo- mentations, Ph. and Oj). half ati oz. of each to the pint, with one oz. of Alcohol. Collotic and antiseptic precautions have diminished the death rate greatly. lUnMis of the 4th degree are most serious on accoimt of the danger of deformity. Treatment: — To prevent death from collapse and to alle- viate pain, give stimulants by the mouth or rectum, com- bined with opium, I^iaridy 2-3-oz. If heart failure Inject Liq. Strych. and Ether. Children bear opium well in these cases. In Extensive and Superficial burns inmierse the body in a wami water bath with Soda Bicarb., removes pain and depressii'»n. When reaction sets in remove the stimulants gradually. Watch for complications (if reaction great, local blood-letting is beneficial, exceptional). Give wine and broth. ; Local Treatment: — Charred or burnt clothing should be cut ^ofif. Exclude cold, protect raw surfaces from injury.- ■■ ■ I -. In burn of the 1st degree, where no breach of continuitv,' re- lieve the pain by immersing in saturated solution of Soda Bi- carb.; then dust oil flour dried in oven mitil brown; Zinc i->ow- der; Fuller's earth; and cover with cotton wool to, ejcoltide ffi 1 PF I, SURGERY 23 the air. Cold applications, weak Cocaine especially 'od, Castor oil. Burns of the 2nd degree: — P-.inctufe the blistei '■' painful, never remove cuticle. It is uctter not to puncture if pain not too great, and can be left intact. Olive, Almond Oil or \^aseline applied on lint and bandaged on, sooihes. Make aseptic by 1-200 Carbolic, or Boracic Acid, and Thy- mol: Carron Oil is good: better is Olive Oil and Lime \vat(?r, as likely to be purer, put on lint, etc. Cover all with oiled silk and bandage. Burns of the 3rd and 4th Degree; — Cleanse by flushing with Carbolic 1-200 or Sublimate 1-6000, weaker for children; preferable to either is a saturated solution of Boracic acid, Salicylic Acid, Aristol and Eucalyptus, then Carron Oil until pain has abated; or an Antiseptic dressing, Gauze with Bor- acic /Vcid, Aristol, etc., this latter being much to be preferred over Iodoform in children especially. Change the dressings as seldom as possible, especiallv the first, which should be left or, 4-5 days. In place of Carron Oil may use Chalk, Ung. Plunib. Co., I'ng. Zinci, Cng Resinae. Extensive burns treat by total inmiersion, to prevent sepsis, add to the water Boracic Ac. Temp, of the water that which most comfortable to patient. When slougl'. separates and granulation advanced dress with Bot-acic Acid., Aristol, and cover with oil silk: cniploy as little pressure as possible. Keep down exuberant granulations with Silver Nit. Skin-graft: — Look out for contraction, apply splints early, carry dressings well down 1: 2twecn the fingers, passive move- ments. Old cicatrices may be corrected b\ rubber bands and splints. ■ Burns and Scalds of the Mouth in cliildren: — Earynx and Pharynx may he primarily involved, or secondary to burns of mouth: may have spasm of the Glot is and Oedema. Ajiply ice, leeches, and give large doses of Calomel. Opium may be indicated. Multiple puncture of the oedematous parts may be necessar)', or even tracheotomy. f:-.. 24 SUIiOl^RT INJURIES TO ARTERIES AND VEINS. Arteriks: — The Int. Coat of Artery is not of much sur- gical importance, excc-pt that it is so closely allied to the Media that, when tlie Media is injured,. the Int;ni.\ invariably participates. Media is muscular, the fibres circular, does not collapse on transverr^e section. \'eins collapse, except those of the Liver, The Muscular coat equalizes the pressure of the blood on the walls. When this coat breaks down we have Aneurism. An- eurism is caused by over extension, heavy traction; Legfation ruptures the Intima and Media. Adz'entitia: — Vascular, has Nerve supply. Is of pi'reat sur- gical importance. Surgeons injure this coat as little as pos- sible, as it impairs the other two coats; the vessel lies in cel- lular tissue; this should be disturbed as little as possible. Dis- turbance brings on cellulitis, involving the Adventitia second- arily. How may Arteries be injured ? They may be Contused, Punctured, Lacerated, Incised. Contusion: — A bruise, suffering along with other tissues. May be slight and unattended by co^isecpience; may cause clot with occlusion of vessel. If clot occurs suddenly may have gangrene. If dotting slow, collateral circulation will be established. Lacekatkd: — i. Partial rupture. 2. Complete rupture. Partial: — Where the Internal and Middle coats only have given way, not serious. Complete: — Entirely torn across, may or may not be seri- ous hemorrhage, the External and Middle coats curl up and the External and Cellular sheath twist and turn over the ves- sel so that hemorrhage is rare. This may take place in reduction of old dislocations. Punctured: — Where Arteries punctured, hemorrhage is the rule except where so fine as to be closed by the elastic coats. May have fine punctures without hemorrhage, but there is danger of ulcerition at the point of puncture, with -^^- >^.' >y.yj |>'i «w ^ ..*t»y.p. I 1,1 mm rrvim mm SURGERY 2fi secondary or late hemorrhage. Where wound parallel to the axis of vessel, less lia])le to bleed; oblique wounds, especially if against the current, may be ver\' serious, and get consider- able hemorrhage. Clot is very small in punctures, extending outwards into the cellular tissue. In excitement, etc., clot may be displaced, and secondary or late bleeding may occur. Incised Injury to Artery:- Most frerjuent : Excessive bleeding, but, if wound long, there is little bleeding conipanv tively. Oblique wound more likely to gajic. Transverse inci- sion gives great Idecding with large gaping wfuind. Non- penetrating Incised: — The outer and middle coats only are severed. Inner remaining, have for a short time a hernia like swelling, and protusion of the Intima; this soon ruptures and hemorrhage is extensive. I'lunt instruments may rujiture the Intima and Middle Coat. Veins: — Thin, collapsible. Middle coat comparatively weak, this accounts for \'aricose veins. Injuries same as Arteries. Dangers of hemorrhage less than in Arteries, can easily stop the bleeding by external pressure. \'eins are more liable to become inflamed. Treatment of wounded Veins: — Not necessary or advisable to ligature a whole ve'n; apply a lateral ligature if possible, esjiecially in the case of a main \'ein. The blood pressure is slight, and slight pressure will relieve hemorrhage. The most serious comi)lication is the entr.\nce of air. Injection: — Experiment shows in animals that slow injec- tion is not followed by any serious results if the amount is limited. Sudden injection, however, is very dangerous. If care taken not to hold veins open, air will not be sucked in. In canalization of the \'eins, collapse does not occur where following conditions (collapse of the veins). Where thick- ening of the Vein. Infiltration of the surrounding tissues. Adhesion to the fascia. "The dangerous area" is the term ap- plied to the region of the great \^cins at the root of the Neck. Results of sudden entrance of air: — Instant paralysis and ; I n 26 SUnuERY sudden death. Rt. \'entricle and Pul. Artery full of frothy fluid. Left X'entriclc is empty. Patient dies of syncope. A small anioimt of air is dissolved in the blood and elimin- ated by the lungs. Symptoms OF the extraxcr of air: — Tlisshii:^. suckincf, p^urq;ling or laujii^hinj:!;' sound, followed by the exuee. 2. Limited. The free is the connnon method: 6-8 turns. The inner coats rui)ture and curl up inside, the, outer coat protects the opening and extrusion of plug. Torsion is the rapid method; it re(iuires no assistance, and no foreign body is introduced into the wouml. Atheromatous Arteries should not be twisted. V'essel should be pulled out, and care taken that forceps do not enter the artery and thus damage further instead of closing. Do a limited torsion, artery being held by second pair of forceps little higher up. Ligature: — In 1552, Ambrose Parre, a French Surgeon advocated the ligaturd. Ligature as now employed is the best and the safest me- thod, used also to occlude the artery in its continuity. Ligature tied with moderate force, then the inner and middle coats are divided cleanly, and the outer coat alone remains strangled within the noose. In large arteries, the snap of the Media and Intima is quite apparent. The inner cx- /ith -ry, in S- Dn, of :u- ■"e. lio II- II- al J r «l i HVUCF.in' 29 Cd.'its turn up inside, siijiix)rt tlio clot aud .'ict as a hulTir. Di- vision of the coats is not necessary for the fornialion ot per- manent clot. This tnethod i said to be atteiuled by no risk of outer coal, under lij;ature, and thus pnxluce secondary heniorrhajjc. In cases where the coats are not severed, lij^^'iture is sonie- tinies forced l)efi>re the pulse wave, and may slip over the end of the artery. DitVuult to gauge the force recjuircd to ligature without rupturing the coats. Division of the cc^its is still thought the best practice. Tn large vessels two ligatures proximal \ incli to i inch above the excision, and only tight enough to occlude the lumen, thus forming a buffer for the second and tighter ligature at the point of excision. Ligature may l)e absorbed, t'ncapsidated. or cisl off. (lut I'ud animal ligatures are absorbed. Silk worm gut en- capsiUaied. In septic woinids, ends of the vessels with ligatures slough off. Surgeon's knot, two turns, preferred to reef kiu)t. Une turn sufficient for small arteries. Ri-:.vcTi()NAKv ou IxiKKMKDiAKV 1 1 i'..\!()R Kii.vc.i: : — Within 24 hours and before the i)crmancnt process advanced beyond the first stage. Cause: — Recovery from shock, increased heart action, and displacement of coagulum. Struggling of i)atient. Imper- fect ligaturing, or ligatures softening too (juickly Clot displaced in punctured artery thnnigh rapid estab- lishment of the collateral circtdation. Treatment: — Elevation, pressure, ice, tournicpiet over main artery. If troublesome, open the wound and remove the clots; slight oozing may be relieved by jjressure. L'se Tour- nicjuet over Main artery instead of b'smarch. Secondary Hemorrhage: — No form so insidious, difficult to arrest or so extensive; conies on any time after 24 hours. Comparatively rare in antiseptic surgery. Causes: — Faulty ligaturing. Proximity of a large branch, which comes into operation on establishment of collateral 15 I 30 itlliCiKKY circulation. Septic infection. Arteritis occurs in later stages of healing- as late as the second and third week. Constitutional conditions: Haemophilia, Chronic Penal Disease, Diabetes. Breach is at first minute, may have clotting again, and stoppage with disintegration of the clot, and renewal of tlie hemorrhage. Treatment: — In late case, leave tourniquet in situ. Instr'::t attendant- in digital prcs:'ure; if these fail, and renewed he- morrhage, open the wound and ligature. If vessel will not bear ligature, (ir if parenchymatous oozing, use actual cautery. By including the surrounding tissues in ligature, pressure on the artery is released, and henlOrr^",^e is arrested. AvKLiNo's DiuixT Tkaxsfusion Apparatl'.'^ : — Mediate transfusion is now practiced ; blood received into .-i wiilo- mouthed earthen vessel, set in a vessel of water Temp. 105; blood defibrina*ed, filtered through muslin. Inject intt^ arm, leg or vein in the dorsum of the foot; the latter situation is preferred on account of the distance from centre of circula- tion. Injection sliould be made slowly and evenly; take every precaution against air and set cic matter. Saline injections give such good results that other nuthods arc seldom emjiloyed, the advantages being its simplicity, heedom from danger of embolism, the difficulty of getting bloou overcome. Teaspoonfnl of salt to a pint of boiled A(|. or Sodium Chlor., 50 grs. — Soda Carb. or Bicarb., 2ogrs. — Pot. Chlor., 3 grs. — Sodium Sulph., 25 grs. — I'liosph. Soda, 2 grs. — I pt. of distilled wat;;r. Solution of Temp. 100 deg. XX-XXX oz. should be in- troduced, depending ui>on the amount lost. Use little force. Injection often followed by a short rise of Temp. Where the loss is not great, or in an emergency, great benefit is derived by injecting oz. 8-!o into the deep cellular tissue of the buttock or side of the chest. Also beneficial to inject Saline solutiop into the rectum, say 2 pints, tci^lespoonful or two to the pint according to cir- cumstances If peritoneal cavity open, fill the cavity with normal salin-j solution. . ■ » 1 ll>ir «i i m i M WWiiw— I— MMMIH J , ■• ,^^ -;; ^- rr" m ' te * ■"'WW* ftfrnmrnw^tf^mmf^frnf' SUHGERY 31 IIaemoi'Iiii-Ia: — Bleeder's disease, subjects of this are liable to severe hemorrhage on slight injury. Slight bruising may bring on extensive extravasation. It may occur spontane- ously. Hereditary: — Propagated through females, most comniDn in Germany. Jewish families are especially atTected. There is nothing in the subjicls' gcUL-ral hraitli i >r oi»iidili(Mi \n point to the disease. Even the tirst menstruation or some unimportant surgical operation has proved fatal. Character of the bleeding: Of a capillary or oozing nature. If si)ontancnusly. usually in the form of e])istaxis. bleeding from the gums, externally into scalp, oi into the joints. The disease is fre(|uently acc()m})anied or associated with rheumaiism. Knees most connnonly affected. Xo al)ni)rmal- ity of the vascular system, tht- patlvology is obscurt.'. usually die young, not in infancy. 50 per cent, do not reach the 7th year. May recover from the first lileeding ntver to bleed again; seemingly the first bleeding having changed the char- acter of the blood. Treatment: — Xo remedies serviceable, (icncrally occiu's in members of bleeding families. Cold baths; Sea bathing; avoid stimulants and danger of injury ; avoid any oper- ation ; Transfusion of little service ; the wound in the vein may cause more hemorrhage than the origin.il wound. Press.trc, Styptics, Perchlor. of Fe. carefully used. Ice water continually a])plietl. Pressure of Main vessel bv a tourni(|uet. Hot water 115 degrees instead of the hotter wa- ter n ( rdinary hemorrhages, 1 iX degrees. Aneurism: — A circumscril)ed j)ulsating tumour, contain- ing blood ancf blood clot, and conununicating with the cavity of Artery, i. Traumatic. 2. Spontaneous, or Idiopathic. Traimiatic follows injury or ligature of artery, or puncture, with the formation of a sac. 2. Spontaneous. — (a) True. {b) False. True: — That in which the blood is included in a sack com- posed of one or more arterial coats. In early stage have all the coats present; later one or two of the three coats disappear. (&) False Spontaneous Aneurism: — One in which all the 32 suiwEuy t < I coats liave j^iven away, or disappeared by absorption, con- densed tissue covering tlie rupture. I'Drnis: — i. Sacculated, where pouch developed from one side of an artery; openins^ to sac may be exceedingly sm.dl. 2. Fusiform: — All the coats on all sides e(]ually extended. 3. Dissectinj^ Aneurism. — L'sually results from early rup- ture of an atheromatous patch, ihe blood running between the coats of the artery and bulging on the outer side. ComponeiU parts: — Sack and contents. The contents vary with the stage of the disease; blood in greater proportion in the early stage; later fibrin in greater proportion. I'ibrin in laid down in laminae; this is called Active Clot. The red anil softer layers in the centre are called Passive Clot. Spontaneous or Idiopathic Aneurism Causes: — i. Pre- disposing and 2. Exciting. Predisposing Causes: — i. Syphilis. 2. Gout. 3. Alco- holism. 4. X'ascular strain. 5. Chronic Jindarteritis, espe- cially that fcjrm accompanying renal disease. 6. Age, most fre(|uently found between the ages of 30, 40 and 45. Theu- are oidy some 15 cases iOi)orted under twenty years; more fre- ([uent in men, northern climates. Exciting Causes: — I. Sudden mental emotion. 2. Violent exertion. 3. Strains and blows. 4. Cirowths. Symptoms: — When first noticed" it is soft, elastic circum- scribed, pulsating tumour in the course of the large arteries. If lluid contents, it can be emptied by pressure. May be hard by deposition of cU)t and cannot be emptied, or it may hii hard like a gro.vth. Pressure above removes pulsation. Pres- sure below increases the tumor. It is expansile when soft, but when fibrin deposited the expansile property diminishes. Bruit is heard double in the sacculated form. A thrill is communicated to the hand. Pulse below the aneurism is weaker than the opposite side. Pressure Sym])toms: — Pain, sharp, lancinating or boring oedema, absorption of bone, stretching and expansion of the nerves. Interference with the function of the part. Diagnosis: — Ff not consolidated, easy of diagnosis. If consolidated, sometimes confounded with rheumatism and 7, u il I f SiliUHHY .13 f ncuralp^ia, owinp; to the pressure pain. Fluid tumours, cysts, hursat.', liyciatid tumours, and chronic abcesses, especially in the groin and axilla, may be mistaken for aneurism. Soft sarcoma, pulsating tumours of bones, etc., also mistaken for aneurism. The history, situation in the course of an artery, bruit, ex- pansile pulsation, disappearance of tumour when pressure ap- plied centrally, and rapid return, the dilYerence in pulse on two sides when in the extremity, all these should be diagnostic. Termin.\ti()N.s: — i. Death. 2. Spontaneous Cure. Spontaneous Cure: — (a) May be occluded by formation and organization of clot with passage of the blood stream. {b) V'e>sel may be occluded by disi)lacement of the clot. (V) Me- chanical j)ressure of tumor occluding vessel. (J) Inflamma- tion, causing coagulation in the sac. Death: — (a) Rupture. (/') Pressure (asphyxia), (c) Sup- puration. ((/) bursting into serous cavity or iiitesline. {c\ Interference with the function of important organs. (/") Sup- puration in the cellular tissue around sac, resulting in he- morrhage, (i;) Ajtoplexy from clot, (/i) Gangrene. Trcattncnt: — Medical treatment, includes diateiic measures, rest in bed, proper diet (dry) and alterative drugs: 10-12 oz. of dry and 6-8 oz. of Litpiid diet, Tot. lixlide grs. X t. i. d., this lowers the blood pressure and relieves the pain. if necessary to withdraw Iodine, supply Lead acetate, Er- gotine and Iron. In some cases of plethoric people Aconite or a short course of Belladonna indicated. Digitalis is CONTR.\-INDICATED. Surgical Treatment: — A variety of ways. i. Pressure; this may be applied directly or indirectly. Direct Pressure is seldom practiced now, owing to the risk of inflammation, apart frcMii a soft pad and flannel bandage during preparatory treatment. Indirect Pressure: — Digital, Esmarch's bandage, Instru- mental pressure, and flexion. Digital Pressure practicable only in Hospitals, relays of students; this is the safest and best method, pressure should be tricnl first; less pain, venijus circulation not interfered with, and no damage to the tissue. 8 •■^ 84 si:i{ai:h'Y f \, r f- I Pressure of thumb, or first two fingers; changes sliould be made carefully; a sand bag hanging from the ceiling pressing upon the thumb or fingers is of great assistance. Read's method : — kai)id tncthod : — Esmiiirch bandage, rapid stagnation, red clot formed, patient under morphia or an anaesthetic, bandaging from the end of the extremity, tight lielovv, lightly over the aneurism or aneurismal sac, and tighter again alxjve. A broad band sliould be placed at ihe upper end; this treatment is continued for from one to one and a lialf hours, and on rmioval of the haiidai;!.' appl\ Sig- norini's tonrni(|uet above the aneurism to prevent displace- ment of the clot. This contimied on for 48 hours. Dangers of this bandage are dangrene, rupture of the Sac and permanent Xerve lesions, also the occurrence of aneur- isms elsewhere on account of the increased arterial strain. InstrumeiUal Pressure: — Hart's rourni(|uet or Compress is the best form, the pressure is continued 5-6 days or until testing shows the formation of a clot. Fle.xion: — Knee and elbow with pad. supplemented with digital pressure. Other Methods: — I. Manipulation. 2. Introduction of for- eign bodies, i. e., Iron wire. Cat-gut, llorsehair, iiiiroduced into the sac through a trochar. ■>,. Injection of coagulae. 4. Fc. Chlor. Necessary to employ pressure both above and below. 5 Acu-puncture; introducing a long needle into the most pn^minent part t)f the sac, and ])assetl until it impinges upon the sac in numerous places; this with every antiseptic precaution. 6. Calvanic puncture: — Two fine steel needles introduced i inch apart; hard clot forms on the positive ])olo and soft clot on the negative; operation has to be repeated. 7. Ligature: — I. Method of Antyllus: Ligature above and below, now only practiced in traumatic fckrnis; fre(|uently fol- lowed by secondary hemorrhage on account of the ligatures being too near the sac, where the arterial walls are also weak. n. Anel used only one ligature on the heart side, but liga- turetl too close to the sac, and secondary hemorrhages occur- red here also. in. Hunter profiting by the experience of the two others ligatured well up on the healthy airtery, and had great success. f I III n r I »Di| ll» SUROFRY 35 I\ . I'.ras'lor apjilii-d ligature at tho luriplKiy of tlu- >a'-. In aru'urisins of tlie Carotid (.btaincti clot in aneurism, but fri'(|iu'iitly had niptuniif^' of the* sac. \'. Wanlroi), cervical aneurism lij^atnrod, also both carotids in first part and tlie Subclavian in tin.- third part, also placcil fieri] iherally. Dan^aTs: — ("latij^rcne. probably as safe as pressure, with antisiptic precautions. S. Teinpirary Lit^aturi':— Av'ute-pressure — nee the lutima, it always prnduco con- ^,'ulation or thromliosis. I. Simi)le riilehitis. non-suppurative or plastic. II. J^nppurative or SejUic. Simple riastic riilehit':, tif tlie vein is usually attended by an effusion of plast c Iv mpli. ;ind usually ends in n.'^i 'huii m. l''orms: — 1. Traimatic. II. I'liKbiiis by extension. 111. (iouty. y\''. I(li( jiathic. The idioi)athic form f(dlows Tv- phoid. I'ti-ine .".nd I'uerperal I'hlebuis. Symptoms: — A firm knotted cord in the situation of the ^ ein ; llie viin is tendei-; if supirticial li;ive a reddened line. some oedema and slight febrile disturbance. In ^outy subjects the pain is very great, and there is a great temlency to recur. In any form the pain lessens with the pouruig oiU of the lymph, veins, however, becoming more hard and cord like. Trivtnii-til: — I. Of simple Plastic IMilebitis. Howels emptied with Calomel and salts, light diet. No alcohol, especially in gouty forms. Drugs. .Mkalies. Potash salts, and if gi>uty Lithia and I'ot. Iodide. Local Treat.: — Kept in beil part raised on pillows, and evenly supported; all rough handling, massage, sudden move- ment to l)e avoided. Dry heat indicated. Later stages with chronic hard oedema, treatment changed to massage, douches, etc. IL Of Suppurating or Spreading Phlebitis. — The plastic form from irritation or lowered condition of the system may ])ecome suppurative. A spreading suppuration of the Vein and sur- rounding tissue. Puriform softening of thrombus. Infec- tion tends to spread to surrounding tissue, with abcess forma- t ■ m ^ wammt 5isl 1 1 '^ I sii{(ii:i{Y :;7 tion. S.'ptic emboli may become detached aiul carried into the circulation with resultmg Septicaemia ar.d Pyaemia. Symptoms:- -Tlu' cord-like charactc.- seen at tirst disap- pears; veins become soft, inflammatioa of the surrounding parts. Qnis-tituiional disturbances marked, rigors, hiffh Temp., and all the other symptoms of abcess formation. Further, may hav.' delirium, etc. Trcalmciit: — Locally through asepsis. l^)ultices will soothe, abcesses freely opcne'i. also the vein below and al)v)ve. Thrombus flushed with sublimate and stuffed witli gauze. If \ii)pcr limit of Thrombus can be found, cut down, and ligature i-..:" above. (Juinin*-. ci>iui-iitrated foods and stimulants indicated. \'\K'i(osF. \'i:iN>^: — \ permaticnt dilitation of the veins \vi»h tliii-kening f>f the walls, caused perhaps by over-exertioii of the part, with driving of blood to the superficial veins. X'cins are lengthened, dilated, tortuous, especially the outer coats thickened. 1"lif Inter and liUra Muscular vein> ma\ be af- fected, but never the deep veinf>. Conunon in woiutii, especially those who have been preg- nant, caused by prolonged constipation. Complications: — Hemorrhage, idceration, thrombosis, and apt to be followed by inllammation. chronic cc/ema, later chronic iiuluration of the skin. Treatment: — Palliative, or Radical. I Palliative, by ;ipplication of carefully applied bandage, rubber bandage, el.'<.tic stocking, no long walks, stimul;U;ng diet, when- hemiinluigc r;ii>^e tlu' p;irt. II. Curative, or K.idical treatment. Tlircc (3) modes: — I. Acupressure, bougie upon vein ami figure of eight thread, adhesive inllammation, several neetlles reipiired, left in a week or more. 2. Ligature, Silk f>r ChroTuic cat-gut. excise the vein between the ligatures, ^l^. I-lxcision, expose a long por- tioti of the vein or varicose mass, ligature al)ovc and below, dissect from its bed, and ligature the branches. 38 tiVuai:i{Y »f i CL'XSIIOT WiU'N'DS. W'licn extensive comprise all cliaraeters of lacerated and contused wounds and hums. They almost always suppurate. X'arieties : — i. Mere contusion, with possihly sid)cutaiuous fracture called wind contusion, and due to a s])ent hall, or a hall strikiu}^^ ohli(|uely. or on some hard suhst.'incc, hone or sunuthinj^ in the pocket. 2. I'.all causes jjutter or furrow, or hrush hurn, possihly a little skiji overhan^MU).,'. 3. r>ullrt forms a tuhular wound, lodj^ing in the soft parts; possihly may rehound from the hone. .4. Ihdli't lod^'i's in a cavity. 5. 1'erforatuij.j^ (moist common and imi)ortant). t >peniii.Lj of eiurance usually less in size than huUet, owinfjf to the skin heinjjf stretched hefore hrokcn, with edj.je inverted, ;md, if from a short distance, hlackenereij.jn htnlies. Symptoms :— i. Shock. 2. I'ain; may le very sli}.jht ,is seen in excitejnent of action, or ver\ intense, and prohahly r'ferred to dilTerent rejjion, where nerve trunks are alTecte I. .V I'aralyiis; from concussion of larp[e nerves. 4. llemoirha^e: — ('ictierally slijjht at the time The larj^je ■-■iiii»i »w >ii m ii r' iii i ^^ i ffr .g*fiijRo^>wyi^ ^M^MB^''; II ^ '"^woMMiMnllHIH srRrrliaf,^c is apt to occur in 10-15 'lays frmn sloiii^h- inp, if artery lias been hiinit at the time. 5. Sepsis. 'l\'tainis. Hospital or otiier }^^'ln^ae^e. Trcatiiu'iit of (iuiishot Wounds in (iciuTul: — I. Pro- mote react ii 111 from shock. 2. Arrest the hemorrhage. 3. Kemove forei^'-ii bodies. 4. Treat the heiiioirhatie; if venous raise the limi); pressiwo by bandage, [f arte'ial in limb. t(nirni(|uet, or Siianish wind- lass, or rubber banilaj.jt'. h'lexinj^; the limb, with a conipress behind, if in th'.' popliteal space, axilla, etc. If can't contr )1 the wound hemorrhatje, by ciuitrolliiif,' circulation, tliiii pluij with j.;aux.e or aseptic fm^'irs. 5. I-lxplore the wound while numbmss persists, with body and clothes in position occupied at the time of wounding (to show if foreiK'n bodies likely present .uid to relieve volvular action), usintj aseptic tuij.,^er where possible, enlar^'im; the ori- fice to ver ami remove foreij^n substances; sometimes a probe is necessary, ordinary silvc-r probe, straight, or verte- brated or uujulazed porcelaintipped probe, winch last will show the mark of the Kad if it touches the bullet. The only fall, icy is that the bullet ma\- have left some lead on ilie bo.ie, and passei'i on. X'arion.s I'K'Ctric ;iirr;m.L;fnients also. (1. Remove the bullet by ordinary dressing forceps if su- perficial, the open spoon, if the track is wide. If proper asep- tic apparatus is not at hand, better to have wound uncovered and exposed to the air than use banda,<.,u's that are jiot aseptic. Kemove as soon as fjossible all foreii.;n bodies ; irrit^ate, loosely pack with Iodoform pauze, antisep. dres'p;. With primary occlusion, if Imllet has l)eewheri'. save tliat here the ends projecting tlirough the skin sh.)uld he returned, not sawn oiT at oner, or one is apt to havi' necrosis, osteo-myehtis and intiamniatory affection genemlly. (iunshtit wounds nf the lu-a' he used for enlarging the wound for ex- ploration, removal of foreign hodies, drpressed hone, rtc, or wlu-re an\ pressure symi)toms are present. If don't fuul htilU't at once clcatise thoroughly, shave off the hair, occlude the wonnd, and dress with a little Iodoform and Boracic. (lunshot wotuuls of the chest are :— i. Non-penetrating ; unimportant, unless they failure a rih or injure the pleura. 2. Penetrating, which are exceedingly dangerous, giving rise to shock, collapse from hemorrhage, dy.-^pnoea, haemo and pniumo-ihorax, haemoptysis, and emphysem;i, i.iier m.iy have pneumoin.i. sloughing or gangrene of the lungs. Hae- morrhage may he froni the intercostal or mannnarv ar- teries, or from the Imigs; hlood from the hmg is frothy. h.mphysema is caused hy the air heing pumped on expira- tion intt) the tissues at the side; exit heiuy; pi evented hy the tissues already swelled v ith ;ur. . Sloughing of the lung may occur. (langrene of the lung only when wound very extensive. Prognosis :— \ery grave, hut not ahsolutely h(»j>eless, 'IrCiititu'iit: — Arrest the hemorrhage. If collapse does not threaten tltatli, let it alone to give hlooil)lc ar- tcrii's. iO stop iiUcT.KSial iK'niorrliaj^c- i)a>s j^auzo into wonnd with a prohi'. and stulT tlu- Itai^ so fornif;- the che>t. If latter has to be done, tlu'u may look for bullet. Air in tissues is i.;;en- erally .ibsoibed in J .^ days, if not punctured. (iim^-hot wotnuUin tlie Abdomen: Aery danjj^erous. owin^ to piissibli- injurv ti I abclouiin.d vi^cei-a; :'lioci>; and collapse are marked. lnjin\v to the stoui.ich is markid b\ haematemesis and oiizin^- of fooil through tin- wound. Injury to tlu spleen or liver ni.'irkeil by I'xtreme heiuorrha^*-. Injiuy to the In- testine is m.'irked b\ food and nas escapin^^. Injury to ilu> Kidneys is less serious, as it is extra-pcritoncal. iV'trn^iou of ;ib(lominal contents is rare. TrC(itiitciit:—]-.\v\\ dtn-iiic shock, explore with tlu- rm!4;er. If tliere is hemorrhaj;e y nnminf;; coils alonj,' or m- jectinj.,'- Iiydroj^^en j,^as per rectum, which escapes by the wound. I lemorrhaj.je from the I.iver is vers serious, can be treated only li\' spdiij^'e pressure or car.tery. liemorrhaj^e from the Spleen c.ui bi- tri'alei] I»y spoujre l>ressure or excision. 1 leniorrhatfe from the kidm-ys can casilv be stopped by sponj^e pressiue. I lemorrhaj,^' from tlu- .Stomach or Intestine — ligature as usual; excision of a small pieci- is j.joo.v;/.7,'l- the 6th (lay, from a small ovcrlookcil iiitL-rstitia! wouiul thcro may be oozinj,' and tluii pcrittjiiitis. Repairs of W'imiuls : — Is by outpoiiriiiy; of lym[)li. the orpaiiizalioii ami formation of which forms a permanent bond of union. Xew tissue always forms between divided surfaces. (1) I'nion by first intention, or primary union occurs where divided surfaces are brought to>4:etlK-r, and left umlislurbed, and exudation is very sli^iu; no su])puration. (2) I'nion by Jnd IntiMition- Iutc union differs fri>ni prim- ary only in the anu)unt i>f lymph thrown out. and thr si/e of the fib Me librmous wed^e hetwcen the opposinjjf surfaces, ilic loss of tissue is such that the opposin^f surfaces cannot be brouj.jht to^^ether, the edj^'es will not meet; exiulation takes place as before, 'j'here should be 110 more intlammation or suppura- tion here than there is in primarx' union; presence of blood, if aseptic, >houlil be no hinijr.itice to ln'.iliiiLj, but rather serves as ;i scafYoldinj^ to sup])on tlu' exudation. Too lar}^e a clot will, however, by tension cause inl];iniinati(jn and sometimes suppuration; nniove it and look for union between the two granulation surfaces, e. jlt. : (3) I'liioii by 3rd decree or intention. This occurs often in snr..((.r\ where there h;i^ bi'eii secondary hemnrrhaj^e, and we are oblitjcd !>• tear wound open to stop it. (4) Ilealin<4 umler scab- (scab is a hardeiie(l layer of ef- fusi'd blood and dust and lymph); this may sometimes be en- couraj^ed. Lymph at the base of scab forms a protective base or layer to the wound. I\e]iair of wnuutls is often interrupteil bv intercurreiU coni- plicatinus, siin])le or septic intl.'immation, erysipelas, wound diphtheri.'i or };-anj;"rene. SHOCK. Shock is a severe impression made upon the nerve centres, car.sin^- j.'cneral lowering- of vitality. It may vary from ])ass- in^' disturbance of emoiious to profound depression and death. In severe injuries it is often hard to separate the ef- fects of shock from those of hemorrhajje, and still more dif- ficult when to these the effect of the anaesthetic is added. Wi WIin ■Mmm ,% ^^. O^. \t>^\<6. V <^ A c^l IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1.8 t 1^ Photographic Sciences Corporation A ^L--; S' -€?, / f/i J MAIN STREET WEBSTER, N.Y. 14580 (716) 873-4503 ^ /<' 4? Mj (/j 4> m !•< I ! i ii TOt i 'j;ui'.umLum« SURGKh'Y 4n 1 ■; r L h The only chang'e in {■'.tti. when deatli from sliock is distention of the abdomiiii.! veins. Causes of Shtjck : — AHlioug-h all injuries produce a cer- tain amount of shock, certain classes of injury and injuries in various rcp^ions are es'^ecially liable to cause shock. Women, bedridden persons, phlegmatic persons, very young or very old pcsons arc lial)le to shock; but opium eaters are less liable, because in them the nervous system is dulled. Symptoms of Shock : — There are two^ varieties of shock, (a) Extreme depression. (/') Great excitement. The first form, that of depression, is much the commoner. The patient lies semi-conscious with the extremities cold, face deadly pale, expressionless, pulse feeble and fluttering, e} es half closed and glazed, Resj). shallow. Temp. subnorm.:il, vomiting, (especially if the injury is about the head), sphinc- ters are often relaxed. Patient may succumb or gradually enter the stage of reaction. The seccMid form — great excitement is much rarer and met only in military practice. Here the sufferer — though not ne- cessarily a stifferer — cries or screams. As before Temp, sub- normal, cold perspiration, relaxation of the sphincters, may sink into the stage of depression or delirium may ensue, al- most innnediately causing rapid collapse. Reaction from shock: — Pulse becomes slower, fluttering ceases, colour of the lips returns, pulse becomes normal in a few hours, or if the reaction is too great get fever, great men- tal excitement, and traumatic delirium, or there may be fluc- tuations, relapses alternating with improvement. Shock following operation is in)w less conmion on account of the precautions taken to prevent it. For this confine the patient to bed 1-2-3 days before operation, regulate the diet and the bowels; during the operation keep the body covered, warm with hot water bottles or hot sand bags, or hot water table with water icx) c\e^. Faren. circulating beneath. If shock occurs during operation, bring it to a close as soon as possible, or discontinue for a time; arrest all hemorrhage. I'reatment of Shock : — Slight cases may recjuire covering the body and the application of heat, mustard plaster, massage I «;. -w^ 44 SURGERY I ! over the heart, lowerin.c: the head and stimulants (liypoderniic by the nioutli or enema). Severe cases similar precautions, stimulate mure freely, lirand}- a drachm everv 5 min. until pulse affected. If hypodermically, Alcohol. Ammonia, Kther (if not already anaesthetfzed). Tr. of Di.critalis 15 min. every 15 to 20 minutes for four doses with probably onedumdredth of a ,q-rain of Atropine (only twice). If hemorrha>;e uncontrollable, transfusi()n of blood, or saline solution. K^ise and banda^q'e limbs, to g"ive as much blood as i^ossible to the central nervous system and heart. If no hemorrhai^e and the superficial veins and heart are distended, bleedint;' from the external jugular may be advis- able; such cases are rare, [-dectricitv is of some use in such cases. TRACHEOTOMY AND INTUBATION. Tracheotomy may be done : — i. Above the fsthmus of the Thyroid. 2. Just below the Isthmus. 3. Well below the Isthnms. ( )perate his^'h up if the Q])struclion is merely in the larynx. Conditions which may require tracheotomy arc: — i. Acute Oedema. 2. I>enit;-n Neoplasm. 3. Croup. 4. Diphtheria. 5. i\Ialif;nant disease. 6. Syi)hilitic and I'uberc. Stenosis. The best form of tracheotomy tube is the "lobster tail" pilot. Chloroform should be used as ah anaesthetic, and the operation done in the first stage. High operation : — Having shoulders raised, locate the cricoid, and incise exactly in the middle line to the episternal notch, divide the episternal and deep fascia on a director from below upwards, hook up the trachea and open it from below upwards. In rapid tracheotomy the incision is to be made directly down to the trachea. All vessels should be secured before opening the trachea. If blood gets in suck it out. In Laryngotomy : — Incision is made into the cricoid or rather crico-thyroid membrane, by knife held transversely. After operation, prop the patient up in bed, except in diph- theria, where there is danger of syncope. Patient generally falls into a long refreshing sleep; on awakening give beef tea, etc., enjoining very careful swallowing. ^Hfmmmm In I H Wli'i'i'.ii 'II ruiu.ani.iiijii.mwi» suj{(ii:ry Dangers of Tracheotomy : — i. Syncope; especially in the old. 2. Broncho-pneumonia, especially in diphthe i (within 4 days). 3. Secondary liemorrhage. 4. (leneral en 'i\senia; this latter ma^- occur from too small an opening or an open- ing to one side. 5. Blocking of canula. 6. Ulceration of trachea. 7. Cervical Cellulitis. Remove tube for short periods of time to be sure that pa- tient can do without it before permanently dispensing with it. Intubation : — Child is wrapped tight in blanket, tube is in- troduced (after gagging) by an introducer, which relaxes the tube; after it has entered the larynx ])ut thread on the car. Breathing innnediately becomes slow and tubular. Cyanosis ])asses off and (juiet sleep comes on. If this does not occur, either the tube is in the oesophagus, as is shown by its being gradually swallowed, or it has been plugged with exudate, when it nuist be removed, cleaned, and re-introduced. Indications iov InlubatiDii : — Marked d}-spnoea, witli fall- ing in of supraclavicular spaces and cyanosis. Lung slKnild be auscultated. 1st, to see if breathing is cciual on both sides. If membrane has reached into the bronchi, then intubation will do no good. Patient should be fed from a feeding bottle with head well lowered, as danger of food getting into the tube is great. Removal of the tube : — Leave it in 7 days in child under 2. If onset is gradual, 2 days may be sufficient. As to which operation is the best, opinions are evenly divided, and re- sults the same. Intubate always in children under 3 and a half years and in the poor. Tracheotomy in children over 5 years, and in the rich. ', IXFLAMMATIOX. Inflanmiation is the reaction of living tissue to injur\', and is the result of damage, provided such damage is not suf- ficient to cause dea.li of the part, and is followed by char- acteristic changes in the stirrounding blood vessels and con- nective tissues. Acute Inflammation: — Causes: — (Never Idiopathic.) 46 SURGERY i F'rLnlisposini^: — Any circumstance inipairinc;- tlie ncncral hcahli, nr rondcrins:: the tissues less resistent as food, climate, occupation, aj^e and temperament. I )elermininLi- Causes: — ( N'ever constitutional ). ((/) Mechanical: — i. N'ioK-nce. 2. Wounds. 3. I'racture and 1 )isl<)cati(in. 4 l'"oreii;n bodies. 5. Compression. (Z') Chemical:- — i. 11 eat or Cold. 2. Irritants. 3. Microbes ^C^enerally (tjonococci. etc.). Inflammation is: — I. Simple, where we have only the non- patholo,y;ical form; sli.cfht irritation. II. Infective, produced by pyoj^enic organisms. Symptoms : — (Celsus" classitication). Rubor. Tr.mor, Calor. Dolor, also los^ of function and im- paired nutrition. Rubor: — Ilrilliant in acute, livid in the chronic form. The part is far j^one if colour is not jireseut after pressure. If the coUnu- is not red, corpuscles have been driven out. or are decomposed. Tumor: — Due mainly to increased exudation from vessels, consisting of leucocytes, and serum (containing fibrin), caus- ing swelling of the connective tissue, more marked when the conn, tissues are lax, but jiitting occurs even in inflam- mation of the bone. This swelling usually subsides, but may partially ])ersist. Calor: — Always, unless stasis is early, or intlamiuation is very chronic. The Temi>. of the ])art is nearly as high as the internal body temperature, owing to the increased supply of arterial blood. Dolor: — Due to (a) Pressure on the ner\'e endings from in- creased tension, (b) Irritation of Ptomaines. It is worse early, before the tissues have stretched, and most intense throbbing, where room for expansion is lacking. It is increased by dependence of the part. It is burning if skin is involved or mortification is setting in. Pain is referred often to distant parts through nen^ous con- nection (knee in hip disease, penis in bladder). Impairment of Function : — Seen in inflammation of the glands, deep inflammation of the eye, muscles, joints, bladder. ..::.ism» Bp i ll l J I ll i piw sui{fii:iiY 47 Modificcl Nutritioti : — Hypertrophy ami Atrophy following Tiiflaniiiiation fsocn in hone"). II. Constitutional Symptoms :--All masscil undrr one word — I'evcT. a. ( ifiicral Temp, raised r de^^ or nioro. /'. Pulse and rcsp. ([uickened. c. Appetite impaired. n only in supi)urative arthritis and pneu- monia. 4. Cold and llcat: — Cold is-, a powerful agent in C(3ntrolling inllanunation, but it needs caution, for it constricts the ves- sels, tliminishes the action of the leucocytes and the general vitality. It is of most use as a preventive, unless continuous cold will increase inflammation by reaction. Ice bag, cold irrigator; or by capillary attraction with candle wick, lead or alcohol, added to the irrigator, intensities the cold. Heat: — i'"omentationis, Douches (Antiseptic), hot water bag. These stimulate the leucocytes, dilate the vessels, di- minish tension, and promote resolution, and, if condition too far advanced, these encourage suppuration. 5. Counter Irritation: — Plasters, linaments and cautery, used mainly in chronic forms. 6. Astringents for mucous membranes. B. Constitutional Treatment: — i. Diet; milk oz. 2-4 per hour, peptonized it necessary. Beef tea (not if diarrhoea pre- sent). Chicken broth (add starch if much diarrhoea). Jellies. If rejected, peptonized enemata oz. 2-3 q. 3 hour with Tinct. mi<^4V»lfWHRP"l ii 3 It 5'f- ! : II sf i ri -## 'mmmMt wi tf ii i wumw i jij f:(URaKRY 49 il'l Upii if necessary. Wash bowel beforehand. Alcohol with caution. Better without in early stages. Indicated by deli- riuni, oz. 3-4 per diem; half a pint of wine per diem. For thirst, barley, toast, rice water, acid drinks. 2. h'ever — nuinine, g-rs. 5 q., C hour. If hii;h fever, grs. X. b. i. d., or even grs. XX t. i. d.; don't use pills. Ouinine is very good in genito-urinary inilammation. If Ouinine fails, try Salicylic acid, Antipj^rine, Aconite and Antimony. 3. I'ain: — Opimn. 4. Stimulants: — Alcohol; Amnion. Carb., grs. W, spt. of Ammon. Aromat., Aether. 5. Purgatives — CaU)mel. grs. 3 to 5, with \'-X grs. Soda llicarb., followed by a warm Seidlitz, or Sulph. of Magnes. Oz. 1. (Drachm, i, every hour in peritoneal intlannnation.j CfIR( )XIC IXFLAMMATU )X. May follow acute form, often recurrent. \'ery connnon after (a) Syphilis, {b) Tuberculosis, (c) Rheumatism, and ((/) Gout. Symptoms: — The sanie as Acute, but less severe. 1. Pain, neuralgic or boring. 2. Swelling very marked, causing degenerations (joint af- fections, etc.). T.'V(7;;;;t'/;/;— Remove exciting cause. Constitutional Treatment : — Mercury, Colchicum, Acid Salicyl., attend to nutrition, the bowels, uric acid tendency. Therefore, recommend the change of air and climate, the use of baths, woolen clothing, tonir Syr. Fer. lod. Local Treatment:— Determined by the condition of the par< ; warmth is generally better ; often, i. Alternate heat and cold are better. 2. Friction and message. 3. Counicr irriiation, vesicants, stinndating liniments, cautery lightly (every week. 8 to 10 spots), setons. 4. Alterative Ointments. Hg. or K. L with pressure or Scott's Ung. Ammoniacum and mercury ointment on sheepskin. 5. Astringents. Modes of termination of Inflammation: — i. Resolution. 2. ,.)i .*':i 1^ f^' J! ; -h :r : oO iiVRGEUT Suppuration. 3. L'lccration. 4. Gano^rcne. 5. Hyperplasia. 1. Resolution: — The symptoms gradually subside, and we have a comjjlete return to normal in a few hours, or before the end of many days. If complete there is no alteration in the tissues. 2. Sui)puration: — This is the common termination to in- fective inllanm-.ation caused l)y: — (a) Staphylococcus. {b) Streptococcus. In chronic abscesses they do not occur; they proljably die out. Xon-Ilacterial Suppuration may be produced by sterihzed cultures or turpentine, mercury, castor oil. puriloid material, but never met with clinically. Abscesses: — Circumscribed collections of pus usually caused by staphylococcus. This is: — i. Acute or hot. 2. Chronic or cold. Acute Abscess : — Symptoms. Local Symptoms:— (A) All ordinary sym])toms intensified. (B) Skin shiny, soon adheres to the lower tissues; oedema follows: it is tlusky especially at one point where we have bulging- and peelings ofif of the skin (the abscess is pointing), the skin l)reaks. and pus is evacuated. (C) Fluctuation. Sensation imparted upon manipulation — ■ oedema same. Palpation of the buttock or across the ham- string muscles will produce the same sensation, but we will not g-et it in the long axis. (D) Certain tissues greatly resist the progress of abscess through them, as in psoas abscess; abscess points towards the skin instead of towards the internal cavity. Constitutional Symptoms: — (a) Rigors or shivering fits, or convulsions or vomitings, when pus beg^ins to form. Small frequent pulse, frecjuent respiration. Face pinched. Pallor marked. Temp. 105 to 106 in one hour (in the old there is sometimes only a very slight chill). (b) After this may have a most profuse perspiration. Temp, falls, and get relief. Diagnosis: — From i. Aneurism. 2. Hernia.- 3. Rapid Malignant Tumor. 4. Extravasations of blood. Chronic Abscess : — Generally tubercular, btvt sometimes sy- ■plasia. lul we before tioii in to in- ^. {b) lie out. •rilized iterial, caused )nic or isified. edema ' have iting), tion — hani- e will l)scess :1s the its, or iched. le old Fenip. Rapid es sy- I .1 I' III •^ir if \ 1 1 1 i i '> 5'* i , \ ^ ? J t ; : ! '1 a 1 1: 1 1 « ''*mjsmi>> SURGERY r.i philitic. Formation is slow, especially those connected with bones, joints, glands, kidneys and bladder. The only marked symptom is the swclHni;". Pecnliarilics : — i. iViidency to form a pyogenic membrane. 2. Huge curdy masses. 3. Cavity tends ti> divide into chambers. Constitutional synii)toms vcr\- slight, emaciation. Residual Abscess: — One which had existed years before, and again at^pears. Metastatic— Sec(~)ndary. Lymphatic — In lymi)hatic glands, rucrperal — ryaemic, in the puerperal peri.)d. Emphysematous — Rectal. Chronic abscesses may become acute from the entrance of pyaemic cocci. Diagnosis: — From (i) b'alty tumor. (2) llydatid and sim- l)le cysts. (3) Rapid malignant growths. (4) .'^erous accu- mulation. (5) Enlarged bursae. (6) Mernia. (7) Aneurism. l'"atty Tumors:— I. Xo history of vertebral disease. 2. So inllannnatory sym]noms. 3. Lobulation, and woolly feel. b'enioral Hernia from Psoas abscess: — i. Neck inside femor- al vessels. 2. Sudden, painful, reducible in different way from abscess. 3. Imi^ulse transmitted on coughing. 4. Note re- sonant. 5. Reappears suddenly on rising. Aneurism: — i. Lateral expansic:)n; lifting fe ''ng. 2. Dif- ferent bruit. 3. Stopping circulation, one can press blood from aneurism, and it returns immediately. Use hypodermic when in doubt. Prognosis: — Depends u]>on the size, situation, cause and constitution, serious in Tubercular form. Acute abscesses of the bone may prove fatal. Treatment of Acute Abscesses : — Best way is to open where it is pointing. If not pointing, open where there is oedema, or skin is adherent, cutting in the direction of the fold of the skin, or of the vessels; if deep, dissecting carefully with scalpel. Keep abscess aseptic; don't squeeze blood into abscess. Hilton's niethoil: — \\'here not well assisted, scratch through the deep fascia with director, then tear open. If cavity large, wash with hot Boracic. If small, ditto Phenol 1-80; Sublimate 1-5000; Iodoform, tube, dry dressing. Ifr I 11 ;1 ! fi2 SURGERY Treatment of Chronic Abscess: — Evacuation is necessary where there is any constitutional disturbance. Aspirator is the safest with dehcate persons. Introchice aseptic needle a short way from the top of the pus to gx't healthy edj^'cs. Inject into the cheesy remainder oz. 11 of Iodoform I'.mulsion, for- nudae for same beinq-: — lodof., 5. Glycer., 30. Water, 100. Incisions are to be made with aseptic ])recautions; in the most dependent parts, larg'e enouj^h to admit one to two fini^ers. Larg-e spoon to scrape away the pyogenic mem- brane. Where the abscess is large or in a young' child do not remove the pus too rapidly for fear of synco])e; more ]iressure is necessary than in the acute form. Irrigate, after scraping, with hot water, at least 120 deg-rees. Can ])aint abscess cavity with a 5 i)er cent. Ether solution of Iodoform, or Emulsion of Iodoform, 10 ])ts. to a little less Cilyceriue or Iodoform Dr. i to the oz. oi Almond ( )il. Hectic Fever: — Also called "Suppurative fever (Chronic)." This is a fever recurring where long standing suppuration ex- ists; in this the temp, varies from the normal in the morning to 102 degrees or more at night. It especially follows in- fection of a chronic abscess. Symptoms: — A bright flush on one or b(ith cheeks. Head- ache, restlessness, discomfort, chilliness, thirst, hot skin. ])ro- fuse persi)iration, 1 r p.m. to 1 a.m., followed by sleep and comfort. Later in the disease have a small frecpient pulse. Patient anaemic. Failure of the strength and appetite, diarr- hoea, and red cracked tong'ue. Treat incut: — i. Improve the drainage. 2. Wash out with Hydr. Perox. i or 2 drs. to the Pt. of Aq., or Zinc Chlor. grs. X-XX to the oz. of Aqua. 3. Improve the diet. Sti- mulants. 4. Atropine for sweating. 5. Quinine and Fe. 6. Bismuth for Diarrhoea, grs. X-XX t. i. d. Lardaceous or Amyloid Deg^eneration . — This is occa- sionally met with. The liver, kidney, spleen are enlarged; diarrhoea. May be benefited by keeping cavity aseptic. Prognosis : — Grave, sometimes recovery. wmtm jjHiEt^K^J' — ** """ ssary s the short nject , for- loo. I the two icm- not sure )in.o-, 1 of less :c)." cx- liiipf in- ■ad- iro- uid rr- ith or. Iti- 6. 1^ t ': M I ft « >iW!.l!ilili, i JH I lia>i!i?! W «! M ! MMt>' g~rril)le deformities. An ulcer is always a source of danger, phlebitis and peripiilehitis, may become infected and lead to a pyaemia or septicaemia. It may be the focus fcjr infection of erysipelas, Diagnosis. — Includes the condition and cause. Tn study- ing the features, consider base, edgi-, surrmmding tissues, character of discharge and character of pain present. Base may be shallow or deep; sm'ooth or granular, sloughy, eroded, indurated and bmnid down tn iKcp struct nres. fungat- ing. Character of healthy growth on tloor of ulcer — bright red in color; small in size and uniform; neither painfid nor tender, and discharge consists of a huidahlc form of pus. Small scattered irregular granulations are i\\w to venotis con- gestion. When sodden with serum may be oedemalous, flabby, soft, often bUnding easily. The edge may be slough)-, irregularly eroded, sheKing or undermined, characteristic of tuberculous ulcer, or may be sloughed out, characteristic of l'a(|ue!iu's cautery or nitric acid. The edge is characterized by three zones. 1. A narrow inner one. bright red tinge due to granulations. II. Middle zone. ]^urplish hue. IT I. An opalescent or milk white zone of almost complete ci)itheliation. A rounded, thickened, adherent i:(\^c indicates an ulcer of long standing. An infiltrated Ci(\gc is seen in syphilis, lupous and epithelioma. A spreading uker will usually have eroded edges. Inver- sion of Q(.\^c of ulcer characteristic of malignant disease. Surrounding tissue may be (piite healthy, often the result of Paquelin's cautery, but same characteristic is well marked in syphilitic ulceration of upper jiortion of leg. Surrounding tissues may be inflamed, red, swollen, oedematous, painful, tender, characteristic of inflamed ulcer. Surrounding tissue beside edge of ulcer may be indurated and infdtrated if long standing. Surrounding epithelium may be much thickened from piling up of epithelial scales, or in varicose veins sur- rounding tissue may be cold and livid. I I « i •H f >.l. iril 'iff if; ,«r 6t; SURGERY r iM The discharge may be laudable pus, or may be abundant and thin as in icterus, irritating surrountHng structures. In scurvy may be hemorrhagic, llubo may be infective. I'ain may be nil, as in healthy healing ulcer; may be smarting, tingling and burning, as in intlamed ulcer; may come in paroxysms and be 'ra>] 11 i ; SURCIERY 57 S If f .: ! ■ is macerated, owing to tissue being infiltrated witli serum. The source may be the simple giving way of a vein. VI. Callous or Indolent Ulcer. — Is particularly liable to be a terminal condition of neglected ulcers, apt to arise in varicose legs in old people with diminished reparative power, especi- ally when this leads to cutting ofif of arterial blood supply. Surtrounding structures always thickened and oedematous, base depressed and fixed; nearly always pale; no granulations; discharge always thin, never pusy. Edge thickened, usuallv rounded, not sliar])]y cut, usually .-hite, and from its look is devoid of intlannnation. It is simply a sore in a stationary condition. The situation is the lower 3rd of leg and the victims poor people. MI. Haemonrhagic ulcer is exceedingly rare, associated with scurvy, lulges and base are swollen, reddened and cov- ered with clotted blood. NTH. riceration due to pressure or tf) deficient enervation. Pressure ulcers are ])articulaHy liable to occur in the foot by development of callous on big or little toes. This callosity mav go oil develo])ing for weeks or months, llien intlannnation takes place; the inllanied ])roduct collects between luvrny epithelium and rete nuicosum and burroughs its way through. Char- acter — a layer of horny epitheliinu with cavity in centre; base of ulcer usually covered with fungus, granular and bleeding rcathly. (Iranulations always become necrotic and have a bad smell. Bed-sores. — Due to continual pressure over bony areas. They are formed by a giving way of a jiortion of tissues, caused bv the cutting off of the Idood supply, diminished vital- ity of tissues as in typhoid fever, etc. They are re^illy pres- sure ulcers. Perforating ulcer of foot is closely related to above. It begins as a horny layer in same situation, rarely extends in circumference. It involves tendons, fascia, ligaments, ioints and bones. It begins exactly as preceding by a funnel shaped cavity and a piling u]) of epithelium. Two horny surfaces will not unite. It is frec(uently associated with tabes dorsa- lis and peripheral neuritis. There is a condition of local anaesthesia. j ; ] -' ;i! If * Ill 'I 1 < i I n 58 SURGERY i '>^i Pliagcdenio nicer is caused by the ])rcscnce of micro-or- ganisms, as the venereal sores on drunkards; but is extremely rare due to aseptic surgery. It is a variety of gangrene, al- though the process is a truly ulcerative one. The base of nicer is covered by a pulpy greyish green false membrane, beneath which a rapidly melting of tissue takes place. Sur. rounding tissues necrotic looking, dusky; not nuich swelling, because tissues seem incapable of reaction to injury; otVensive odor. Condition always gra 'c because nui}- extend with frightful rapidity. Coiuiiiioii of JicaiiiiiJ.—i. Base nnst lie on a level with sur- rounding tissues. -'. ^largins of ulc m-s must be moveable. 3. Whole sore must lie capable of contracting as well as margins. 4. Granulation must have a healthy a])pearance. Trcatiiu'iif of Ulcers. — Find otit and remove cause. Im- prove conditions of base so as to favor granulations. If it is a healthy healing ulcer, all we have to do is to protect from injury, keep aseptic, and at rest; cover with oil silk and gauze on outside. If granulations under this become fungous then use astringents and ]>ressure. Rest in bed and splints of the utmost importance. If due to venous obstruction, put patient to bed, apply splints to leg and then elevate. May use Martin's r{d)ber bandage. Asep- sis same as for operation. Scrape with s])oon. If nuich dis- charge, dress frequently. Once a condition of healthy tdcer is obtained, treat as above. Oedematous ulcers require to be treated with caustic or curette. If a sloughing ulcer. ]-)rovide for removal of slough by hot antiseptic fomentation, not strong, bi-chloride. i-io.ooo or Thiersch's solution. Irritable ulcers nnist have base destroyed by cattstic, cau- tery, or sharp curette, thus killing the nerve. After this treat in ordinary way. Weak C leers. — Particularly after burns. When ulcer is over joint it is sometimes necessary to excise the joint. Varicose ulcers treat on general principles. Callous ulcers may recpiire blistering, or pressure by rubber bandage. In order to relieve tension, may be necessary to make multiple parallel incisions through base. »T I IvfMlJIl ^wauLjT ^VRGERT 59 Perforating ulcer must have callosity removed and then treat base. Phagedenic ulceration, a microbic infection: destroy all infected tissue by cauterization. Pac|uelin's or Thermal ( 'au- tery. Then ap])ly moist dressings, Thiersch or bi-chloride, i-i,ooo. To stinndate ulcers. — Sulphate of copper, grs. i-x to tlK oz. Sulphate of Zinc, grs. i-x to the oz. Nitrate of silver, grs. i-\ to the oz. Chloral Hydrate, grs. yi x to the oz. Always begin with a weak solution and increase. Resin ointment. — Resin and yellow wax; Balsam l^'eru. Can- tharides. Iodine (str.), Ferri Wa. Tart. — Red wash. li GANGRENE. Death of the part en masse. Mortification or Sphacelation, or -longhing of the soft parts, necrosis of the hard tissues (sphacelus is complete mortification of the parts, generally preceded by gangrene, the incomplete stage). It differs from ulceration in that the dead portions are visible. It is: — (i) ^Slixed when ist rnoist and then dry. (2) Primary, when death of the part occurs directly as from a severe burn. (3) Secondary when death of the part follows acute inflam- mation. (4) Idiopathic, when causes not known. (5) Thrombic or Embolic. (6) Constitutional, when due to constitutional causes as diabetes. (7) Pressure when du.e to long constriction of the part. Three Great Divisions: — ^loist. I. Inllammatory — this char- acteristic. 2. Traumatic. 3. Diabetic. 4. Hospital. 5. Pure- ly local: — {(;) Cancrum oris. (/)) Noma vulvae, (c) Carbuncle. (d) Decubitus, (c) Phagedena. Dry:-— [. Em]:)olic or from ligature. 2. .Senile (character- istic form). 3. Raynaud's symmetrical. 4. Ergot. 5. Frost bite (may be mixed). Septic Forms Proper : — i. Inflammatory. 2. Traumatic. : I 't ; Hi % ,1 w4 m' m .11 60 l^URGERY ili;' 3. HoF,)ital. 4. Local forms: — (a) Cancruni oris, (b) Xtv.na ^^llvae. ((•) Carbuncle. ( three weeks to reach the hone, and three to four mouths to ulcerate throus^h it. If no opera- tion. stump> heal like a chronic ulcer. I'oustitutional Sym])toms of all hdnus of ( u'uiiL;"reue : — These vary with the extent, always more marked earl}' while lymph barrier still w'ak. [. ( Ireat depression; face dull and anxious. 2. Pulse cpiick aud compressihle. 3. 'J'emi). liii;!! at times, occasionally a chill. 4. Skin moist and claum\ ; tougue brown. 5. (ireat thirst and muscular prostration. 0. I'robabl}- albuminuria. 7. Often diarrhoea. 8. Alutlerint;- de- lirium, aud typhoidal state latterly. ]u dry gau,i;rene the symptoms are less marked. ()rdinary treatment of gangrene in general : — 1. \'en- nu- tritious food, often in small amounts. 2. Stimulants early if pulse feeble. 3. Opium almost always, or, if it disagrees, give Chloral; Hyoscyamus; Cannabis Indica; Sulphonal. 4. Keep tlie bowels regular. Local treatment: — i. Warmth to the i)art by absorbent cot- ton and tiannel bandage. 2. Slightly raise and flex the limb; friction. 3. Antiseptic measures from the outset; Phenol 1-80; Sublimate, i-iooo; Salicylic acid ; Boracic ; Permang. K. ; paint with Halsam Tolu; charct)al, yeast, and linseed poul- tice, made with Phenol, 1-40 to 1-80. 4. Let the sloughing parts separate as they will. 5. Treat stump as an ulcer. Treatment of special forms of Moist Gangrene: — i. Inflam- matory. This is due either to pressure of inflammatory ex- udate and consequent thrombosis, or perhaps due to the irri- tant that caused the inflammation. It is almost always sep- tic. Some forms of inflammation such as carbuncle always cause gangrene. Use general treatment until the form be- comes plain. I Hi 1^ ^\m 62 suiidEiiY I 2. 'I'lauMiatio. (Iciicrally caused l)y severe criishiiiij, frac- ture and niaceratitju of larjj^e vessels; there may also be iu- flaniinaiiou. (A) Local: — (ienerally from crushing", soft parts beiiijj; great- ly torn. It (lone by a wheel or other blunt thins;, the skin may not be .g'reatly injured. If skin is broken, intlanunation is generally innnediate. If skin is unbroken, we have exten- sive exudation of blood, destroyinj^ the i)art by j)ressure and blanching; the limb, which is also vqry cold, tense and pulse- less: loss of sensibility — colour changes. I'l- to this point, relief of the tension will often, at least ])ar- tially save the limb. Line of demarcation appears generally just above the injury. The constitutional disturbance is slight. (I)) Sf^rcaiiiiii^: — If tension be long- continued, the intlam- mation ijroduced spreading- into the lym])h si)aces causes deep- seated intlanunation. This occurs generally in the feeble ; mortification may not a])pear foir two or three days, and th.en may be above the seat of injury. It tends to spread to the trunk, preceded by discolouration and oedema, etc. Have high tension of the skin. Rajiid pulse and res]). Temp. 104- 105. sometimes typhoidal condition. Treatment of the local traumatic form : — Amj^utate if the patient can stand it; if not, apply general measures, and wait for line of demarcation, it may. however, chang-e to the spreading; form. Treatment of tlie Spreading- Form: — Often extremely dif- ficult. In a few strong- subjects, often may be able to ampu- tate. If so, operate high up. As a rule we can only apply general measures and await the f nd. 3. Hospital Gangrene: — This is a rapidly spreading inflam- mation, accompanied by extensive sloughing (localized gan- grene), which has now practically disappeared from civilization. The streptococcus causing it is from sepsis in treating the wound. The edges of the wound become oedematous and gradually melt away. Wound takes on sloughing action. Have thin, greenish or bloody discharge and verv' nasty odour. Large part becomes gangrenous, and sloughs off, leaving gaping ulcers in which hemorrhage occurs. B J'SWK.I i aU M c- i . |, i ,' i i i \ I ■• >* ' m ' i ;4m tikimummimm t nmm ' i.-fH i«»'i"' ii, J" f.mv:"»» v,n"«'.in'i"»s!';,»i)w?''< w»«i»i>i '"w.wvii ivw'H,w.' i^UUCFJiY 03 ( 'oiistittitii >nal svini)tiiiiis an' niarki'il, i^H'iU'raiK- txpi'iiidal. 'rrcatnioiU : — i. Strict isolatiun, l)urnin!4' ot' hul rlmhcs, (Ircssin.n's, rtr. J. (autrri/.r tlu' sloiu;!) with \i;. .\r. and solid /itu" ( lildf. ("anti'r\'. Itroiniiu'. and repeat if lU'crssarv. 3. Tlu'ii rhaiTiial. linsiH'd. ami IMu'iml piMiltici'>, I In imitie si>hitiiiii, I'lii. IV'nnaiij^'. 4. .\s it iinprnvt's llMrariraiid IdiId- fiinii. 5 if a linil). iri'ij^aU' for hours ; i^ccp it in aiui^r|)tic sohnioi. for lon<;- periods of time. C). .\inpntation is orra- sionally neressarx , aflrr hne has fornied, where invoKentent is j^reat. or wliere we have lu'niorrhaqes 4. i)iahetir ( lant;rene: ■ Ma\' oceur in the K\i;s of an\onc ha\inL;' diahett's, bnt es|)eeian\- in those w hi > have wi'ak iieart, or are old. It frei|uenlly begins in a hiel) under the foot nr t)iu' toe (sometimes 1 m the s^'enitals. ])nttoek or c\e). and perhaps from sliyiit injury. ( »i- perforatini.;- nicer. Treatment: — ( ieneral niea>nres and wait for the line of de- marcation was the old rule, and then an'putati', Inn l\nni and 'Li^aturt'. Patient coni]ilains of sudden and sev/re jiain and tenderness at the seat of embolism, at which jioiut i)nlsation ceases, ];art below d.ry, cold, blancheil, shrivilled skin. Treatment :—()rdinar\- nn'asures: keep warm; runputate immediatelv just above tlu' ])oint of constriction and obstruc- tion. 2. Senile (Jan,L;rene: — Typical dry qanrrrene. It always be- !.;ins in the le.qs, results from atheroma, and consecpient ck-t fiirmalion and embolus may come from the heart. ("icnerally bej^ins as a black spot oti one side of the toe or foot, often bc.q'ins as a slu.qi^ish int1annnati(jn after sli.q'ht in- jury; i)aiu often intense, Temp, often hardly raised, spirits low, muttering delirium, line of demarcation appears slowly. Treatment: — General treatment always opium and alcohol (generally liy]XMlermic with atropine), and keep limb warm. " 'i ■' :!l I ' * 5 I! m « CA SURGERY Amputate without \vaiting' for the line of demarcation, slightly lower than in diabetic form. (Hutchison says lower third of thii^h, not St) hiijh as Kuster). It tends to become moist as it extends upwards into the calf. 3. Raynaud's or Symmetrical dan.q'rene: — This is a vaso- motor neurosis in children and youui:^ adults, and is synnnc- trical (.e^enerally the fint^-ers, toes or ears). Exists i^a-nerally for months, with local intermittent cold and nund)nc'ss. 'rrcatmciii: — Preventive by electricity, warm massage, al- wa\s wait for ii;e line of demarcation, and for a time remove ])arts by force])s and scissors, poulticing until circulation is better, then am])uu;tc. 4. I'-rgot Gangrene: — Occurs when Ergot has been mixed with the food, and acts as Raynaud's disease, by contracM', n of the vessels, aniesthcsia, tingling pains, cramps in the fir' gers, toes and lind)s. Dry gangrene becoming moist in places. If severe may havi' extension and death in eight (jS) days. In the more chroidc form await tlie line of d'/marca- tion. which is general]}- early, then amputate. 5. brost bite: — Due to cold and feebleness, have first l)lanching, and then erythema, vesication, and possibly gan- grene; more moist if gradually protlucetl. Trcatmcni : — Rub with snow or cold water cloths. Keep in c in). It occurs especially in those liroken down ]>y long disease or intemperance. TrcatDiciif: — Constitutional treatment is very important. Iron is often indicated. Richard gives Potass. 'I'artrate of Iron, gr. X t. i. d., also ]ierhaps ^^lercury between times for 8 to 10 days, or at same time by inunction or injection. Local treatment: — Apply Xitric acid, or Acid Xitrate ot Mercu: . . pure ferric chloride. Richard applied Potassic Tar- trate of Pe, grs. XX to oz. Remove slough, or place part for hours in an antiseptic bath of Phenol. Sublimate and Boracic, to wash off the suppuration as formed. WOUND DIPHTHERL\. Occurs frequently in diphtheria epidemics, in wounds not kept aseptic, especially v»'Ounds about the genito-urin- s i 'A i i i! il ! t III MMM miWERY 67 I.'. ary tract, a^ oirciniK-isioii, urethrotomv aiul vacfinal fis- tula. ( )|)(.Taii()iis arc also frcciuontly followed by wound diphtlu'ria. A toui^li ,i;rey librou.s nicnibrauf appears on the part, which contains, beside the fibrous exudate, gra- nulation cells, micrococci, and the Klebs Loetler bacillus in the j;enuine t\)rm. In ])>eud()-wound diphtheria we have only pyaeniic streptococci. It is very fatal, especially in children, parlicuh'.rly b_\- iiroducin^- sepsis, and so producini;' extensive cellulitis. Trcalmcnl : — If possible tear off the diphtheritic membrane, and apply Silver Xit. to the mranuL'ilin,^- surface; if this not sufficient, ap])ly Xilric Ac. followed 1»\- I'lienol i -S, ( itycerino after, ;ind wash with Corrosive subhniate. I'apoid is excel- lent, and can be more thoroui^hly applied; then dress with Iodoform. Relieve any tension by early incision. Internal: — Improve the general health; give Tine, of I"cr. ]SIur., with I'ot. Chlor. and (,)uinine. 'Vr\- ;nniloxinc. A ii SYPHILIS. Syphilis is a general infective disease, transmitted l)y con- tact and inherited; chronic in its course. Caused by morbid secretion from a previously syphilizcd person. Begins hu'ally, invades the whole organism, especially the connective tissue; produces inflammatory processes of a lov/ grade; gives rise to granulation tissue. Resembles in some respects Leprosy and t'b'c. It diffLM's in having an initial lesion or primary sore. In the early stages there are many points of resemblance to Exanthemata and Diphtheria. Like Exanthemata it originates in a mixed infection,-, fever, with eruptions, constitutional symptoms and period of incuba- tion. Resembles Diphtheria in having a local origin, attack- ing one ]')art; alike alsi:) in ])lan of systemic poison, in ])ro- ducing peripheral paralyses and infectious form of nephritis. Erom analogy, a disease of microbic origin. Klebi;, Lust- garten and others have found in active and early syphilitic lesions, curved "S" shaped bacillus with enlarged ends, bvit their numbers aie small, presence not constant, and attempts to make cultures failed. : ::!^ -rl I I I 08 SURGERY ORKiiN AND History: — In Europe towards the end of the 15th Century ( 1494), a violent outbreak at the siege of Na])les, beHeved at that time to be introduced from America. It probably existed previously to this date in milder fonn. Syi)hilis has grown less virulent within the last 25 years; the treatment is better, and the police regulations unproved. Methods of Propagation: — i. Ac(|uired. beginning in lesion of a local nature. 2. Xo local primary lesion, disease gen- eral; in infant or young. Hereditary. How Contracted: — Cienerally during sexual intercourse, called Intcrgcnital Syj^hilis. Other parts of the body: — Extra-Cienital Syphilis. Extra-Ccnital form coiuractcd: — Through kissing, sore on lips or mucous patch. Child may infect nurse, or nurse may infect child. Midwife in the lower classes may inject the mother *»n nipples in drawing the Ijreast. ThroAigh scratches or bites, .'■nirgeons fre(|uently contract syphilis in operating, and uccoiicluurs in making vaginal examinruions. In tr.t .^.'ng. by using saliva to wet the needle — a dangerous practice. In skin grafting, .'\mong the Jews in circumcision. Further modes of ac(|uiring l^xtra-Cienital form: — \'acci- nation, from soiled scarifier, or hunuinizcd virus, llutclnson investigated one sucli case, and those opposed to vaccination cite this case. Should take care in vaccinating those in a factory; use a spirit lam]). Dentists by unclean instruments. Pipes, cigars, tooth-brushes, drinking utensils, razors, sur- gical instruments, chewing gum. Blood capable of trans- mitting. Normal secretions of Syphilitic subjects do not contain any virus, but may be contaminated with pathological secretions or blood. The saliva is harmless if the mouth is free from lesions, but not otherwise. Semen of a man at any time is not an infective fluid. Women not so infected, but child in directly infected and mother secondarily. Milk of a syphilitic woman does not contain virus, nor does the sweat or urine. Stages: — Not always separated, but means of classifying as follows: — I. Primary. II. Secondary. III. Tertiary. Primary: — i. Incubation. 2. Appearance of initial sore. of of :a. n. s; d. Ill 1- e, I I I ^ !'!'= I! ^asaWMWNliWSH "j i ^m mmm a^-rif,-^ tiVRdFRY 60 Skcondary: — Period of secondary symptoms, and erup- tions, and may occu]\v a year or two. TicuTiAKY: — More remote lesions, p^nmmata. etc. JkHween the latter two staji^es, perfect Iiealt'.i may intervene. Pekioi) ok Ixcrii ation: — Some time intervenes between tile inocnlation, .-ind the appcannu-v of the initi.al sore. \ irtis is deposited upon sduie p.'irt I'f (he hody, the (lenitals or Kxtra- j::enital, and in many eases person is miconscious of it, others a small sore disappearintr in a few days. Incubation may be from lo to 70 days. j;enerally averaj^e between \2 or 15 and After expiration of this time tlie chancre shows it- 21 (lavs. df. ( )i sen. \Juestion is:-- I nnv liMii;- is the poison localized at the seat of iiitH-ulatiiin brfi He entrrint;' the system? probablv verv short time. I'sperially iHcause the se;it of abrasion has in main- in- stances been destroyed or incised immediately after ex- posure, and yet sy]diilis occurred. When period of incub.ation is past, we see a peculiar growth of new tissue, ehronie indamtuatory process, beneath the epi- thelium, hard and indurated, fonm'd by the intiltration of con- nective tissue with S. R. cells, I.-ir^cr ci'lls. mononeuclear ;uid multildcul.'tr cells. This iudiir.'ition ;is ;i rule is m.'irked and decided, but may be nu^lilied by the tissue in which it is formed, mucous membrane differing' from the skin. Indur.'Uion eomes on usually very early: other c.ases of coitrse may be deferred. May be sore for from the loth to the 14th day before the induration is marked. As a rule, i^dy I'nc ch.'inere: few exceptions. Cases have been observed where /TiV sores were observed. Usually where two sores found, one will lose the characteristics of a chancre, the other alone continuintr to bear them. S ITl' 111 male. I'ound on tl le ,i;i;ms penis, prepuee, si :in meatus, immediately within the me;Uus. scrotum and peno- scrotal an^cflc. In female:- T.abia Ma.jora. entrance to vagina, meatus sheath of clitoris, and os uteri. Clinically two forms of sore: — i. Descpiamatory papule. 2. Indurated or PTunterian Chancre. lin 4i: 'm \n im i;ii w I ■■'■A I 70 SUHGERT Desf(uaniatin<:i^ Papule: — This appears as an elevated cop- pei -coloured lianl spot, cov-rcfl wi'li scale?, almost iiivari- al)ly found on the- skin of the penis, in dry places, seldom fdund "iieneath the i)repuce or in or on the ^land; r^radually ex- tends and l)ecomes flatter, indurated, elevated edjj^es. shaq)ly detined ; edt^es ni.iy be one-sixteenth in. ahovi' the surface; one- half an inch wide. If not 'rritated. it remain^ dry. but if ir- ritated, it becomes nmi^t. idcerates and assuiues the second form of the diseased sore. It may be overlooked, as it may cause no inconvenience, p^nudess. and thus may j^et the ex- treme fiirni of the disease. 2. HuxTEKi.w CiiAXCRii.: — OftcH begins as a papule, as a r'de a litde idcer. on the glans Penis, or Qjrona in the fis- sure behind. \'cry soon it assumes a deep unhealthy look. Induration early, marked and extensive; surface is early cup- shaped, r.d.^-cs raised above the surface, cartilaginous feel; lifts aw.iy from the tissues below : painless and discharge slight, always thin, serous discharge; parchment induration. Irritation brings on a pustular di-^charge. Several less Distinctive Forms : — i. Chancrous erosions, looks like an erosion of the epithelial layer, irregular, color dull cc^ppcry rerl. 2. Ilerpetifonu: — \'esicles burst, leaving a chancre, conuuon in herpetic peojde. 3. "Silvery Spot." looks as if part touched vvith Carbolic or Silver .\'it.. in a fe\v days a little ulcer, increases slowly, in- durated. Probably ulceration always due to local irritation. 4. "Mixed Chancre." a species of mixed infection, very puzzling; appears early, chancroidal, generally very virulent, markedly "Ilunterian " on glans penis. 5. Urethral C! ancre: — Inmiediately within the orifice, and may lie seen on opening the lips; tends to extend outwards ; sometimes more deeply seated, discovered by accident with the endoscope, or felt by patient, often treated as gonorrhoea. 6. Chancre of the Scrotum: — Appears often as a primary lesion, virus rubbed off the penis, large, well rounded, some- times ov.' 1. seldom irregular, often saucer-shaped, covered with mcribranous-looking substance ; here get parcluuent- like induraiiou. s : ;.?i srh'Cl'RY /. F.xtra (lOiiital ('hancres : — ricnorally dry. and run a clironio, iiuloloiit and painless course, and last longer than the yenital. (_(/) Anus,-- uuirc truiucuily in wonieu frtiUi the virus triek- ling hehiud. (/') Imu.l,.]-. A|)i)eais as a small sore by the side of the nail. aee(im|iauir(l hy inueh swellint;' — red. |iaintul, tinker bul- bous, resembles a malignant sore. ((■) l.i|i: (Juile eoiiiiuon, usually situated on the viTmillion bordiT, iii\ I il\ rs llie mue. uu'Uib. ami skin ; usualh tissiu'ed, in- (huMtion I'arb ; mav be markid; ma\ br purrb. " 11 niUerian," e>piTially at the an^K- of the mouth. uK-t.'!ati> and sui>pm-ates early. I lie nearest lymphalies arr rarly implieatrd ; maIiL;naut sore takes uiiuuhs. ill) Tongue: I\aren,'';ht also be mistaken for a mrdi;:; nant t;ro\vth, e.arly enl'u-,i,ei-.:eut of the inlands is diat:^iu)stie. ((■) Tonsil: ;^hould be thou^'nt of in treatini; irrei;nlar nl- ceratioiis of the tonsil : .'~^ore iirei^ular. induration m.arked ; sore tna\ be yci\. ( )fteu eoveied b\ a milky or dull brown nienibraue, now and then resemblint; the diphtherilie memb. It is painful, submaxillary, subliiis^ua' and other t^lands en- large. In women, ehaneres oi the gi ' 't.'ils do not slio.v any spe- cific eharaetirs (i'lTering from inosf ii men linluration is less marked, more likely to be suppun. ve • nia> be followed by oedematous spots. C lianere is sonKtum..-' e>tmmonly !• 'wud ou the ( ^s. either lips, and sometimes surromidin.n' the ( >s. Kdges are circular and raised, covered with a greenish nietn brane, causes oedem.i. Indolent, paiidess indurat: n pre- sent, but ditVicuh to m.dxe out, Cchksk: — From 7 to 11 days after the initial sore we get commencing induration of the Lynij)hatics (the glandsi in the immediate neighbom"hood. As a rule one ^laml ■ ' ^e;i first, several inmiediately following. Ihe glands 01 both groins arc implicated. If chronic on one side, the glaiuls of that side are affected first, painless, intensely hard, and feel like beans. Each gland clearly distinguished from neighbors, from the skin ami un- §1 r SURGERY *u ii I derlying parts. No infiltration or doughy feeling. Suppu- ration outside of the disease. At the same time the enlarge- ment of tlie dorsal lymphatics is very marked sometimes. They are felt as hard masses. Treatment: — Chancre: — Recent method not satisfactory. Frequent cleansing with hot water. Hot borated solutions, ano it painful the application of Cocaine. Dusting with Bo- racic, Aristol, Nai)thol, Iodoform. Calomel pure, or with Zinc, is an excellent application. Sublimate oidy recom- mended where ulceration is extensive. iUack wash is good; never use anything irritating. If sluggish may stimulate with Silver Nit. CHANCROID. A local sore, a local contagious ulcer, Un- a long time a sul)- ject of siieculation. Is inllannnatory and destructive, never Icals to Syph. or any form of systemic affection. \'ehicle of contagion: — Virus in form of i)us. Contagic^n is contained in the corj)uscles. Auto-inoculable, distinguishing it from :dl otl'cr sores. As a rule the area of inllannnation is very limited, but oe- '•^-ionally from irritation, becomes very extensive, producing sloughs. Virus said to be destroyed, by drying. Bacterio- logy unsettled. No period of Incubation, the destructive ac- tion of the pus begins at once, as soon as epithelium per- forated. As a rule, 24 hours on the mucous membrane. Skin 2 to 3 days, to 5 days at the outside. In muc. meiub. first signs minute yellow spot, surrounded by a halo of intense redness; if not punctured or ruptured, it j^rows larger until a pustule i^ form- d, breaks, leavinga tv])ical ulc^T. usuall\- round or oval if it (K .- lojxs in a fissure; it mav be long. The sores tend to coalesce and form an irregular sore. Edges are always sharply cut, "punched out." edges become imdermined; floor of ulcer is uneven and wor'ii-eaten in appearance, and csilii>n. Leeclu'S. IJol fonu'Hlatii >ii. I f (.-arlw icr. I'-rlladi imia I 'la>!cr. Internally, (iiey pi iwdi-r, (."alcium Sulphide. Injection. lo min. of t'arb(jlic; lo gr. to i ( )z. I sually perforni early exci-Mon ; remove the glands: protect the wound with Zinc Chloride, grs. 1\'. to the oz. SKC( )XI)ARV S^ Til IMS. .\t the expiration of six weeks, or 70 to 90 days, the se- condary stage of S\i)hilis begins. Tile systemic effects vary greatly: in some cases, specially women, great constitutional disturbances. Constitutional I )isturl)ances:— h'ever is not a coimuon feat- lU'e. Tem]). runs fr^im 100 to 104, ComplaiiUs: — Xeuralgic ])ains at night, sciatica in an.aemic ]H'opIe, disturbances of the s\ mpathetic system, cold hands and feet, early anaemia, and impairment of nutrition, loss of ap- petite, condition of ner\>>usness. general langiKM-. (ilands Involved: — I'mtli tlie superticial and dee]) glands are involved. Cervical. .'^u])racl;ivicul;ir and h.pitrochlear, c.'uised by hyperplastic condition, induced by poisun. Later the deep glands are involved; the prevertebral, lumb.'ir, etc. Pains: — Rheumatic pains, pains in the muscles, fascia and joints — the muscles of the extremities are principally involved; pains exaggerated at night: feels in the morning as if beaten. ( >sseous implications, pain in the skull and clavicle, tiliia, ribs and stermun. — ^later swellings with the formation of nodes. R;ire Complications: — Jaundice sometimes occurs, Albu- miimria ;md Clycosuria. Cutaneous F.rup'ions : — i. Syphilides. Syphilodcrnia. 2. Rashes are early symmetrical: the later stages teiul to be- come as> linnet Heal. Characters of Rashes: — i. rolyinoqdiism, i. e.. Papular, i I I SURCKRY 73 Pustular, and S(|uanious; all tho abovi- nia\ exist on tlu- saiiii' paiii'iit at tlu' sauu' tinu-. J. C'i)l(iur (if tlu- rash: — 'I'liis varies from a mixture nf rod, yellow, Itrown and purple; the most characteristic is "copper color," or "raw ham" tint. J!,. Arranp^etnent, or confis^'uration, cither in circles. "S," horseslioe, or serpi,L;inous. 4. Pain or itchiti}^ entirely absent. > Situation: — Everv portion of the hodv mav he the seat. Certain varieties prefer certain ])laces. e. p.. Pustules, the face and scalp Pajniles, the hmw and neck. Scaly, the palms and the soles. N'arieties of Pash : — i. Macular. 2. P.apular, (ti) (\ry ; (/') moist. ,^ Pustular. 4. Ilullus. 5. Tuln-rcnlar. (>. ( ium- matous. W'.sicular syphilide rare ( I lerpetiform). 1. Macular l'!ash : — Koseola or h'rythema are the most conunon. Scattered in spots, of ;i pinkish hue, reseiuMinj:^ closely the rash of measles, generallx' on the fmnt of the trunk, extending' up thi' chest, frt>nt of liinhs, later the tlexor surfaces. The rash may he very slight ai.d sometimes overlooked. The colour varies with the colour of the skin, and disappears on pressure; may he mistaken for heat rash. 2. Papular Kash : — I'sually small, sometimes lariji'e, early covered by scales, papulc)-S(|uamous syi)hilide. They appear later than the last form: may remain a year; usually symme- trical; any ])art of the body ; may be dry hif,^us, Rupia, larj.;e vesicles form from the size of half a ])ea to that of a ten cejit piece; they are first clear, then milky, later pus, and skin bursts; sometimes called rupia ; the oyster-shell variety indicates a bad dose. 5. Tubercul.'ir: — Late; tend very soon to become globular on nares, forehead, penis and buttocks. '■■■i fiiitnFitY 6. r sonasis or h(iuani<>us \'aru't\-: — ScaU-s dirt v. ill- M[ '■' formed, tendcucv to the formation of rin^,'"s, found after pul) .r- ty; otluT often Ijejjins in early life. Syphilitic f'soriasis yields to Mercury; simple psoriasis doi's not. Syphilitic found on palms and soles; Simple is only fomul then- when it lucon:es chronic. It is ^'enerally found on the clhows and knees. If lonm; standinjj^ may take yeais to ciu'e. 7. Piy-meiuary Syphilides: — Occur on the neck, tlu" side of the head and spread; very j)ersistent. S. Puq)uric and IlenKirrhaj^^ic : — F.xceedin^■ly rare. ("(indyloma oriy-inate from a papule; in places where there are opposed surfaces, aii, eyelashes seldom, except from ulceration; patchy form is the most com- mon; patches are irregular; back («f head first, llair looks atropic and dull. General thinning less common ; occurs third month to first year. 1 )i'ig. from other forms: — Alopecia Areata, patches laiger, scalp shiny, hair elsewhere is healthy, common in ch.ldreu; seldom attacks other })arts sinuiltaneously. Senale alopecia extends backwartls. and scalp shiny. Syphilitic form recov- eretl from. \ails: — Two varieties: {a) Onychia, (b) rerionychia. in the tirst. the nail and nail-'-ed are affected. In the second, the condition extends to the surrounding tissues. ( 'cciu's late in secondary syphilis, the second yen*. May have a simple dry conduion, friable, and losing its lustre. ( )iiychia Sicca, transi)arency is gone; only a portion may be invLilved, but there are depressions and fiurL>ws. Another iovm is Hypertrophic Onychia; nails separate, bed covered with granuUu;<)n tissue. Pcrionychia, an ulcerative condition, begins with a papule, or a pustule at the border (jf the nail, creeps under the nail, di.-charges, nail undermined, on removing matrix found un- heahliy; ulcerativ. .\t the same time the disease extends outwards, folhnved by clul)bing of the terminal phalanx, may have the periosteum afTected. Toes less frc(|uently affected. Three (3) forms of Onychia, (i) Simple. (2) Syphilitic. (3) Malignant. Hones : — The skull, face, palate, tibia, sternum, clavicle, ribs, and sometimes the scapula are attacked. One or more may be attacked at once. In the early stage have a periostitis proper. Intense patn, i 78 SURGERY i I especially at ni.i;lu. At one spot ,q;et early exudation, which may under trcalinent he resitjved. 1 f nei; levied j^el a permanent exudation; p;et a permanent node of fibrous tissue; may go further even in the secoml stage. Denuded bone may become necrotic. Most common in skull. Tendency to sclerosis of the bone; the whole shaft may be the scat of this syphilitic sclerosis. Obscure aching pain ; worse at night; not severe. A most extensive necrosis occurs in sclerosed bones; the canals are closed so rapidly that ne- crosis follows, h'ven tiie >«kull is the seat of this condition. Syphilitic caries may follow a node, conunon in the skull, or sternum, or the head of the tibia. Joints : — Rare; sometimes pain, but generally due to perios- titis near by; sometimes synovitis, occasionally gununata in ihe joints. Syjihilis of ]'.ur>ae, Muscles, and Tendons: — Rare in the second stage. Syphilis of the Testicle: — This is common. R])ididvmitis or uniform eidargcment. Testicular sensation is absent, large ovoid, sometimes have hydrocele. Insidious onset. In the tertiary stage get gummata. Epididymitis usually resolves. 'rrcatmciit of sirondary Syphilis: — Rersistent atienl-iin to general health, food, skin, tepid bath with a little salt, tobacco discontinued, alcolio! stopped, except in anaemic subjects. Claret. Sautcrnc. Sea vox age, mouiUains, open air. Constitutional treatment: — Hutchison connnences as soon as chancre diagnosed. l'"rench and .Americans, wlien secondarv symjjtoms develop. h"arly treatment delays the secondary symptom^, but does not modify materially the course of the secondaries. Rut the i)atient at om-e on Mineral acids, \ux \"omi ica, Repsin atK 1 I ron. VA Ue ill t uice a wee .and gen- erally build up for special treatment. Complications : — i. Where ])hagedenic ulcer accompanies the chancre. 2. Where chancre blocks the urethra. 3. Where chancre at the anus interferes with defecation. 4. Where de- glutition and breathing affected, owing to chancre of Tonsil or Throat. In these four cases commence general treatment II < i i:, \\ H I t I ! I I: I si a'(,/;a'V 79 at (HU'i', alsn do so wIiimt \si>li to a\oi'»ition, wliiii- pa- tiiMil kno\v> i'IIohl;!! |o iiisi.si nu iMilv li raliui'iit. MiTiurx is loiura iiitlii-alc(l in lliii^lil's disiMM, aiid in tlu- dis>H>alid ami starvi'd, 1 >r, ii used, imUi- };i"i .u prciMution. \.\- amim* urine liilon- lKi;iniiini;. also hr raroful of idios\ nnasios. (iivt'u I)v iIk- mouth. I'xtcnially l»y inuuotion, tiuui;;alion and I 1 \ i>o. and IvudiTiuii-ally. IntiTnal iiuudirs in ordii- o| \ alur: rroto-i.ididc, ricldin- idr. r.inii id.dr. Tainiatf, I'dne Till, i alonicl, ami ( ira\ powder. 1 lu' I'roid iodide is a i^rncial la\'»iiii'. iluuliistin .L;ivi's the ( lii\ powder i^rs. || i. i. d. In earlv adliiinistraliou it is the hist ; it is also the hest and sal'est in any idiosv iierasy. ratniale pie\entsany tronhles, mie i^astritis and diiiri;"ea, and is thonL;lu to ha\i' a less eniunlative tiMiilenex. \\ ilh pi'oto- iodide he^in with a (|narter of a ^rain pill t. i. il. )). e., soiuetiiues };i't iliaiih.i 'ea in a eouple of da\s, then ledr.e' to t'Ue eii^hth j^rain. > ir, n -^ti >niaeh is tttT.i;ive one pill at hedlinie onl\ fi '!• a few da\s. If anaiinie ,L;i\i' I'dand's m \allel's. rersisieni diatihoea; a (|uailei- of a i^Tain of * 'lunni. .| ,L;rs. of I'ulv. Ipieae. ( 'o. 1 neiease Mri"i-ur\ up to of.s. I | (two) a day, and this (|uautity may even lie dounled. I he tindiiuv I" aeemmilate and suddenly eause salivation should hi' re- meml)ei-((l; if wi' timl the j^nnis letiiU'r or hleediiii^ wlu'u hnished, tlu'u diminish the do>e. Interrupted iiielhiid: louniier's plan. Suspenf one nii'iith, renewal fur si\ w I'eks to t w i» months, i. ill' >w eel li\ a respiii' i if | w . i ( -' i months, eontinued over four i.p \eai"s, l'..\pei ieiiee shows thai this metliiid is defeetne. The imist satistaetory is tlu' eontinuo\is treatment; (> m<>s., 9 iiios.. or a year. IhuiiiL; the treatment keep waian, take hut se;i water h.iths, wiHilcn ujiderelothiiii;. Imiiictioii. .111(1 other oxtcni.'il niethoils, save the stoin.ieh, and Ionics have a imieh better afTeet. < >hjeetio!i is tiiat it is uiieleaul\-. and th;it it re(iuiros time ami skill in it.s einploynicnt; it is the host tnctliod when rapid la ' Is 80 Slh'dHh'Y I!? acfioji is re(|uirc(l. Vuefore nsinjj^, cleati with soap :uid w;itir, followed 1)\ alcoluil; rnl) in vigoronsly. l-eet ,l;oo(1. ;is the socks absorb the liig., and reabsorption taki's place by the foot in the course of walkinj;' about. ."^^ometimes irritation results in eczema, um' dustint; powder of /.inci ( >\. and Starch, or thachms 1\ of Talc, and /n. ( )\. drs. 1\'.; Ac. .Salicyl. j^rs. W'.; \ aseline Alb. o/. 1.. Lis;ird's I)aste. l'"umii;;ition.- t ';ined)otlomi'd chair, cover patient with blanket, hirst i;i\e steam bath 5-10 min. 'Then >ublinu-, L;rs. X.\-X.\.\ of Calomel in porci'lain dish over spirit lamp. I lalt an hour everv four days, then every second, and tinjilly e,ci"y da\ if necessary as in pustular forms. 'This method is rapid anil clean, efticacions, and witli a good nurse great re- sults are obtained. Injection :— Sublimate one-twelfth to a-tenlh gr^. in water Mins. X., or suspended in ( )live ( )il and starch, every three or i'vcr\ other day. Souie prefer (. alomel gr. tin 10 min. of wit- ter and glycerine, repeated every two or three days, 'i'his nietluKl shoulil not be enipK)yed until others tried; liable to produce salivation. Injection^ sometimes followed by boils and abscess; cleanse the jjarts, inject straight into the deep muscles. Salivation: — I'sual signs, treat witli an infusion of slippery elm bark, or linseed tea. borax, chlorate, and glycerine wash, with probably carbolic. Rub the gums with eiiual parts of Tr. of .Myrrh, and Cinchona. ( iood practice is to begin Pot. lodidi at once. For salivation: — llrandy solution, Aix-la-Chapelle. A^. .Mum. I'b. Acetatis a. a oz. one-half. Acpia add oz. ^'I. Sig. : — A drachm in. a timiblerful of wann water. Tn the later secondary stages and the Tertiary the prepa- rations of Iodine are the most useful. In intestinal lesions, Pot. lod. is vor>' useful. '~*— "*— 'Ml I n •J m snf(ii:iiv H Trt-atniciit with K. I. from the bopiniiinp is apt to result in vxtriisivi' t(.rtiariis. nervous iuvolvi'Micnt. K.. Xa., I.i.. Am., ami Sir.. l)Ut K.I. is the l>(.st. ( iivt" in >inii)k' watery M>lutioii>. Start at 5 j;rs.. and iiUTi-asc tlu' ilosr hy otu- ^rain each day up to _'() or 30 j;rs. l.i.d.. well (lilutiil; where >toinach t'ail>. dot-.'t stop, hut 1^(1 li.hk tM >ni;ill di 1*1'. In hr.iin >\pliili> as hiyh as ^^(1(1 to -}oo i^rs. luayhftakrn tlail>. ."^pls. of .\inm< mi. .\ri)- niat. w ith the Iodine will allow of a {.greater amount hiiny takc-u. Complications: — ,\ene, C'ory/'a, L'rtiearia. ( )hstinate Con- stipation. Mixed treatment: — K. I. and \\^., toj^ether or in conihina- tion. liiniodide or Trotdiodide or inunetion and K. I. in- ternally. Treatmem >>{ !^yphilitie Lesions — Syphiladertns : — Vng. with Int. Tiiat. White preeipte jo ijrs. to oz. 1 .oeal appli- cation of the .^uitlimate i-() t^ iimhhi, i-spccially in tlu' S(|ua- mous. Condylomata; wash with suhlimatc. dust with calomel, or calomel and staivli. If irritatiufx use lodofo^rm, lodol. ftc, and an occasi(»nal application of .Silver Xit. X to XX cjr.s. to the o/.., with sometimes an ajiplication of the solid stick, .Syphilis in Mouth : — Mouth wash. I'ot. Chlor., and I'ora- eic .\c., (Juinine, and sometimes .Xitric acid. Alopaecia : — Cut the hair off, wash with tureen soa]), and apply: — Tr, Cantharides, oz. I. Tr. Cajjsici. Tr, Nux \ omii;i ;i.;i.. drs. \' 1 . Ilydrarf.^. iiichlor.. j^^rs. I. l^pts. \ in. I\(.ct., o/. I ;ind a half. .\(piae ad., oz. \ 111. The .\ux can he gradually incrt'ased. J-Or ordinary forms a drachm of liihor of Soda instead of the 11^. l'"or Onychia: — Cocaine and remove the nail. .\ useful dust is the follow iu.uf: — Sublimate and horacic equal part.-, sometimes .""^ilvcr Xit. ii II TERTI.\RY. The lesions spread and pcr>ist. are <\ lumetrical. In the great majority of cases it means the formaiBon of pummata. X'iscera apt to he involved. May appear very early, when we expect nothing but secondary. .Xgain the secondary may (i I ■ 'M 4 ■ 82 SVRHERY !i t I M: go into the Tertiary witliout interruption, and in other cases interruption of many years. (lUinniata: ( iranulnina: — CdUcctions of small rouii'l cells grouped around vessels of structure involved. On the skin and nuic. niein. where exposed to injury and action of micro-organisms, they show a tendency to soften and sui)i)urate. The surface, hecotning congested, breaks, exposing wash leather slough, very tenacious, and take> a long time to come away. In deep N'iscera, Liver, Spleen, rare for ( hnnmata to hreak down and form ahcess. In liver where common, get simple granulation with cicatrization, resulting in puckering an I scarring of the siu'face. lir.iin: — C'hietly affect the Dura and I'ia. Changes: — N'essels cut off by pressure, have fatty degcn'n., sometimes cicatrization, (iununata resemble tubercles; they differ in containing no specific micro-org. ; the virus cannot be inoculated into animals, and ..i gunnuata there is a ten- dencv throughout to remain vascular. Thev varv in size from the size of a pe;i to a walnut. Tiiere is no tissue that may not be the seat of gummatous disease. Sclerosis : — Spinal cord, tabes, thickening of the arteries. \'eins rarely affected, .\rteriti.s predisposes to aneurisiti. Sclerosis of the tongue and rectal walls. Chronic irritation and tramua affect localization of Ter- tiary lesions. I rciiiiitiiit : — K.I. in gunu'Lita. and sclerosis .•insv.crs ad- mirably. In arterial disease depend upon mercury. Use mixed treatment. Hereditary Syphilis : — A healthy man or woman treated three full years, and having no symi)tonis the third year, rare- ly transmit the disease. Some subjects should never marry where a sort of cachexia is lighted up. Congenital, inherited and infantile : — Woman known to have syphilis and pregnant ; here active anti-syphilitic treat ment by inunction will not prevent but greatly modifies the heredfctarv lesions. that Use f HiUdHliY h:\ When iiilu'ritod from either parent, same as ao(|iiireil; few exceptions as interstitial keratitis. Disease less amenable to treatment. Tertiary lesions also harder to siihdue than ter- tiary lesions from primary infection. See methtxls of infeeiion of child. C'olles' law. Marly Ntfjns in the child: — I loarse i-ry. simrtle>^, earlv appear- ance (if htillae on tin.- palms and soU's, wrists and ankles; corn- ers »'" the mouth and nostrih cracked, ("achectic. wrinkled, an«eal lines: sometimes a j.jmmn;itons periostitis; nose idcerates. and st]>tnin per- forated, j^jivinj^ saddle nose; palate often arched, dentition de- layed. alTects the whole dental system. Teeth:- Tile teeth of eiiildren may l)e arrested in develop- ment by the nse of mercnrials, grey powdor. but siuh mcr- cnrial children, and also those who have suffered front stoma- titis, do not show affection of the centnd incisors. N'enereal Warts : — \ot necessarily connected with venereal disease as fonnd in lads .and virj.,Mns. In the male tliey ap- pear around the corona: if uncleanly wash; may j:;row to {jreat size. C'ommoidy accomi)anyin.ijf ji;onorrhoe:i. In fe- males accompan>inj^ leucorrhoea. May occur with syphilis, are then much more extensive ; ajipears to br due to the de- generation of a papule, and to want of cleanliness ; common iu-ounnth>: look atier j;(.'iHral li\>,Mc'nc. AXTIIKAX OK CIIARIW )X. I- an arutf infectious (hsease caused l)y hacdlus yitt frmn animals witii >pienic fever. It is cuninion in tanners, wool- sorliTs and huidur^. and is iran.sniitled hy this. It may enter llirnni^h an a))ra>i(>n nr a llydiite (rxternal anthrax • >\ inali^Miant pustule), or thron^di the resp. nr alimentary mue. memhranes. Anthrax hacillus is a widely known j^-^cnn, easil) innru- lali'il: .'uds ahrupt : sjxrres the most resistant known. It nnd- tiplies rapidly hy fission, ^rows in the tissues. Idood and out- side the hoily if there is oxygen and proper temp. Symptoms — General: — Staj^e of Jneuh;ition is from few liours to 8-iodays. (lej)eiiding ui)on the amouiu of virus :ind site of inoculation. With oi'.sft. Trmi). risi-s, pam^ all over the l.ody. .sometimes shiverinj,'-, (|uick pulse, sometimes s:nall and irrej^ular. ton^^ue dry, delirium, s(jmetimes headache, de.ith may occur from syncope, exhaustion or sutYocation from ocdrnia of ilie j,dottis. When infretion is internal hcsides the aiiove symptoms, i^et hronch-pneunionia. or {^'astro-enteritis. iUaih may occur hefcvre diaj;n»»sis made. Local: — Small, red, itchy, anp'y pustule at seat of inocula- tion, soon a vesicle containni); '.)lood\ sermn: .arounil the ve- sicle the tissues are red, brawny and icduratecl; soon vesicle !)ursts leavm^"- small i^cy spot, which hecojues hlack and .q:aii- ^^renous, and around this we hrve a rinj.;(>f vesicles, the indur- atid area heconiiuf^ more and more raised above the skin. The spot of j^an^.rrene may cnlarf^e to the size of 30 cent piece, and oedema extend for several inches This panjriene is tpiite dry, ain SlHUEliY 85 slt>u)^liinj,' of the surface hciieatli. Wla-n infectii)ii is intcraa'i tlicro is no very tleeiiled jiapule, but lar^'e brawny surface covered willi scalteretl vesicles. hiaj^nosis: — There is no (iifticiihy in the local form; it is more diflicuU in the ,i;cneral fMnn, tlic occupation and siir- roundintis l)eing the oidy j;uide sometimes. l'"..\amination uf the tUiid from the vesicles is immeihately (ha^nostic (l.ui^-e \vell-.staini,..t;. w iiU -■|n-i'ad hacilhi >i. Post iMorteni ap])earances: .\re maiidv tin ot poisiiiiiiij^. I\ccl:\ nn 'tic spots ciccnr beneath the serous sur- faces, s'lnie of whicii ma* have be^un to vlmi^'^li, i'dood is partly tluid, dark, spKi'n -on^ested M esenteru- }.jlaiiil> are greatly i'nlar^''i(l. .\t the si'at of inoculation nlv bl.u'k slouch. I'.acilli occur in aiTeced area, an(l in ecchymotic spots. rro).jtiosis: In tlie ixtenial form atid within sur^jical rcu-h is fairly ^dod and lr<-.itniciu i> oftin successful, liucrnal form is .dways yrave, Traitnuut:— Cauterize any external abrasion with pure rheni>l, or actual cauti-ry. suck oiu and apply soHd .Silver .\'i- trati". .After pustule has formed, free excision, and :napi)in>^ atMund \v'>un>l with Phenol, /inc Chlor. or K(»ll if nt ces- •sary. loduie is j^otxl when other thintjs fail. Injection i>f Phenol i-j();md i lo into intiltrateil rej.;ion every six lo eii,du liours until to.xic symptoms. Iree incisions into surround- intj tissius, and irri|.(ation. .Sublimati-. i-5 at'f(\-te(l (acute). I'arcy: — Where celhilar tissue and lymphatics ;;re aflfccted (chr iilllC). Syniptoiiis: Acute:— Aft er -'-.^-7 days, p'.-t a distinct cliil. jjreat rise of Temp., even up to io<') de^-.. with j^^'iieral fel)rile symptoms, and nasal sero-fihnnous dischar^-e. rapie- iil sui illen, ami ul ^■|>miIl^■ pmuliMit and find. Xose is red ai cers rapidly form in it, which i;:""'^tiie ra])i(lly lar^c and irre- gular, with well-marked base ami ajjcx. A few hours later or nev't d.'iy qet a ])apular en\ption on the face, chest and ah- dduun; the risj)irat()ry and di,L;;estive muc. mem. soon he- come pustular, I'ustules have a reddened, indurated base \ery nuiili like smalbpox, ;ind soon break, leaving- fo\ii irre- K ular uicers. [ \ cers ;d>o occur on tiie thij^hs and p.ilate. ani involve the periosteum and bt>ne, if paiieiit lives lon^ enoui;li, }4et f.arcy beads alou),,'- the hniphalics, and in the muscles lie- neath the >kin, which break il(»wn and cause troublesome ul- ceration. .Sub-maxillary j^laixls suj)pur;ite. Ilroncho ind riciud rnnimonia are apl to occur i-.'irly. he.ilh generally in ^ to o (l;i\s. I lU"' 'lllC c-s serious, louder incubation. !•■ lire i)ea'ls ♦ Uvelop jdon}.; the lymphatics, and cause deep ulccraf'oii. If nose is nf}4;lected. f;";in^;reiu' in rare cases m;i> -ft in and de- .«5iroy the bone. The chronic form may become si.ddenly acme, and m.iy ha\e fcv<.r ;ind lauj.;uor. rroi^nosis;— In the .acute foi-in it is always I'.ital; there is hope ill the chronic, as lon^^ .i^ ii i> within reach of surj^ical trtaiment; about one-half rev over, the ulcers healini,'". hi.'ijfuosis: — .Acute from rheumali>m, acute suppuration, Ismail pox ,ind '\'\ plic lid. I'hionic fioiii sypliilis ;mil iubcicle look for the ba- cillus in the |>\is. ;ind nas;d secretions. Inoculate llu' pus iiUo the alulomeii of the male ^iinnea-pi^,''. In .v.j da\s the scrotum ^ets red, shiny aim ii...v acute or-h'ti^ ai.d suppura- tion, which coiUains j.jlanders bacillus. '/"••, iJ/»/».)/r- Prophylaxis, ilcstroy the buspccleil ammd, care on the p-art of attemlants. t;rR(ii:iiy Ai'uti KiKirnious amount ••( stiimilaiits " Mallii 87 cau- trri/c the part tli' •!•. mj^lilv , \\a>h tlu' nasil iiiuc. iiK-m. with Soilii 1-10(J Suli •li., (Ill S ulpli. iC. aturati'd lii»racic. I'liciu)! G^r. Subl. I-!; 500CJ, ^railually im i\'a>^inf;' the strc-ii^ili. Siiapf all ahsiTsscs and miduk's and tlu>li willi antist-ptic liot; /iiK- ( jilur, j^r.s. N 1 . to tin.' ()/.. Clinmii- iUnn:- I'ot. ll wliili- «\ r >u Ipl UU' atiis and tiinii>. Acri\'( t.\n'(( tsis. A rari' inti'itivi- disca>c. dnc in iitn--iin"i' in tin.' ti>Mn.'> .it a N \ay I'unj^ns, wlmh j^anis iiitranii' fhi(Hij,Mi \\iiunii> of tiio f th ffsp. or ahnu'ntary tract. llnl iivorous at\iinal> arf inc affri'ti'd. [t is cliarartiTi/td l>y \\\v fjcvt'lopiufnt of small flrsliy tnasscs likr j,^rannlatioii tissut.», fioni tlii' si/c of a pea to a ualmn j^'i'iifrally ovL-r-lajipin^;" the scat of injury. These massr^ ou si-ction ^how a innnlur » if -sulphur yellow Itixlics like a nnlk't seed. I lave a greasy feel nil s(iucezin>,'", and niicros- copioally show a ninnhi r "f Inillts or thready lilanun!-. either like a star lisli, a hand or irrejLrular. 'I'lu'se are le^s niarkeil when there is sui»puration, wliieh is due to the intro-. In man infeetinn is >^en- erally throuj^h a wound in the moiuh, or dieayed tooth, some- time! thr'iuuh a entaneous wound he orij-.'iuisin u:\i ImH'II found in tlie month, ev'denll) awaitin^^ a ihaiue to de- velop, Symp: 'Uis:— Hej^duH as an ill di-hned growth nii the Imrder of the jaw, the alveolar border. UMially where some toi ih li.is been cxtraeied; it |o(»ks like a eaneer. and (he elieek soon ail- heres to it. It er-veps out of the month, or perforates the dieek, •a.oinj,; re( I pr oU' 11 esli IxKUes upon 1 t It ^rows steadilv. involvinj;- all the struelures it meets, ami eaii-ses constitutional .s\ mpt«ims. lelh ulitis of the neij.;liborin^' tis- sues occurs. Metastases occur from the fnuf^Mis jjctlinjf into h> tiVIHiKliY llii- vi'ins by ulciTation. in one case into the juj^ular. Ii may rxtciid ficiMi the jaw to tlie viTtehral ami tlic nnipital 1m nn-. but it (il'ttti shows a tendeiu-y to rrinain siiiJiTfu-ial. Lympha- tics are never involved, nor are the j4laiids until late. All \)\\^ iMintains the fnnj.,Mis. i)iaj4;n(>sis:— ilv liiidiuL;- the funj^us. I'immi :--((/) SarcMma. which iirviT suppurates, (h) Syphilis; liistniv of primary sore; ^lainl i'nlar}.;ement early, benelited by aiiti-syph. nineilies. d ) I'rum Tuberculosis; glands early mvolvt-d. I'r. ij^m )s|s ; Cnl ess reiui ived the entire mass c< nuaunni' tlu- fun).,'us will ^i) on until death ensues from exhaustion or septicaemia. Treatment: — l. F.xciso the infected area. v;"'"R w'h '"'" 'he heahhv tissur; this cures it d' im- I'.-irb I tills Is miprac- ticabie, siTape out each spot as much as ptissible. and use the canters. I )o this to i-ach sijspieions spot as it appears. \. InjciM 1 MiiiKil ( 5 pvT i-( Ml. \\\ I ilycerine) into the intihratcil area every \ to 4 days. .\. I'ot. lod. ^rs. XN\ daily, increasiu).; roti'ui ui I >nf c.isr cuiiil ; ilns rapiillv uj) to toleration, : is »'x;racted from cultures i.f the Staphyloci>ccus .Xuri-U!' I\Tl"Sri\.\!. ( )l',SIRr( TK )\'. ("auses:- ni ."^ir.uiLiul.'.tiou b\ bauds, (j) \'olvulus. (\) Intu-su-cc])tion. .\cuic and admit of nodrlay: — (4) Stricture. (5) ( )bstrnction by neopl.asm, (Ai ( "onipression l>\ tumors eMi'rnal to the bowel. (7) ( )bstrnction by ^all stones or I'.n- tt-roliths (ent»Ti>liths are faeces coated with I'me). (S) (^b- struition by faecal inasf.es. (9) Obstruction by worms; the latter six are chronic. llow these causes ;ict : — Some by dJ) altering,'- the normal outline of the bowel. (/•) ]>ressure on the bowel fr nn without. ((■) .aherinj; the wall of the cavity. I. STJ<.\N'(;ri..\Tio.N' nv Hands: — i. In this connection it is )OS- nnporianl to remember iMecKii s divirttculum, and t!ie 1 sib;lit\ of tlie liowel bein/.; twisted around it. when it is .at- tached to the navel, or after detachment from there has form- ed adhesions elsewhere. 15t»wel may \v,\\\\^ over or slip tinder it, or it may form a refjular arch. 1 I ■ mm^m ftrifGFRY hO 2. AfttT |)rrit"niti«i llu- ;i l)iii>inr stnti'lR'il im i fibrous Colds, ami the l>o\vcl may l)Ccoun' tv.istiMl around tlu-si*. .^ llrniia passinj,' iluMiij,'h the ft»raim'n of W iii>lo\v will cansi" similar ojistnii-tion. If inti'stiiic is fori-rd iridtr a Itaiul. viiioii-^ rftuni i> oh- strm-tfd, imtritioii is im|)i'rfri-t. and coats arc altered. »o that tiiicro-orLT.-misms pass tlir(»iij4;h and can^e jieritonitis. II. \'(»i.vri.rs: -A twi^t of part of the uMit mi its mesen- teric axi.- can oid\ ocnir with a lon^- mesentery. 'Ih'' situa- tion jv; most i''imnionI\ the siijnioid llexure (one fortieth of all ol.siruclioiis I. and luM thr lower ileum. Twisting of two parts of the intestine, one over the other, is sometimes called volvulus. It is rare under .V'. ui'"*'f''>"y hetwci'ii .^o and Tm). N'olvulus of tlu- ^iyinoid llexure is always fat.d in ahout () days, unless removed hv operation. C'.\fsi-:s o|- \'oi.\ri,rs - <.\) rrrdi>posin}.j:— i. I.oul; Me- sentery. J. .\d\anci'd .a^e, ;is sij.;;nif\ in^ thin mrscnti ry, less fat. .anil therefore more easily twisli-d. (p.) I'.xcitinjx:- l. I 'ne(|uallv distributed Intc-tin.-d contents. 2. I-A'cessive peristalsis. III. T\Tt ssrscKi'TloN':— .\ prol.ipse of one part of the lu- men of the intistine into that of the .adjoining- p;irl : il is i^cn- crallv a ilescendinp; invaijinatii-n. and forms 30 per cent, of all obstructions; it may be double or treble. .•\cute I'orins : 5f) per cent, .are in children under 10, rnd 25 per cent, umler oiu' yi'ar; this forms 75 per cent, of all inttstinal obstructions in children. ( "hronic I'orms: — (lenerally occiu" betwien the a^e> of jo to 40. Classification:—- 1. Ileo-caecal. .\4 per cent.. a])ex is ileo- caec.'d valve. 2. I'.ntiric, v^ per cent.. p;enerally lower Je- junum, ^■enerally onlv 1, to 10 inches, and upper ileum, in proportion of .\-\. ^\. ("olic, iH per cent. 4. Ilco-colic, 8 JKT cent., sometimes reaches rectum. MesenUrv is drawn into the sac, tlu' .arteries, and more especial! v tlu veins, are obstructed, and we may pet jj;rcat 'v'nj^orj;;^et,:'. lu. If the circulation is entirely interrupt e w IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 1.25 [f 1^ id ■^ !■■ 12 2 1^ lia lllllio U ill 1.6 V] a and peritonitis. Engorgement causes bits of bloody mucous, as well as straining at stool. Obstruction is rarely complete. Causes of Intussusception : — Tliese have been proved by ex- periment to be two in number : — 1. Ijv ])owerful electric stimulation, part ot rabbit's gut was contracted into a small cord, and then, if stimulate the Ijowel above or below we get irritative or spasmodic invagination. 2. (Jn crushing ])art of the bowel, the szzmt thing occurred. Paralytic Invagination. Stimulation aV>ve had very little effect upon invagination. l)Ut stimulation !>etow often reduced it, hence the value jf injecting salines per rectum. 3. Polypi and intestinal tumors geneially tend to cause in- ttissusception by constantly pulling down. Prognosis: — L'ltra-Acute end in one irm-. Acute end in 2 to 7 days, 48 per cent. Sul>-acute cml in 7 to 30 days, 34 per cent. Chronic cud in over 30 day?, 18 p>er cent. L'nder one year the death rate is 80 per cent., g'enerally by the 7th day. There are two ways of spontaneous cure : — [. It'.vagination may unroll. 2. In 42 per cent.: often in females; generally the enteric form. After six days have iulussiisception, slough- ing off cii masse after adhesions have foiraniedi at the neck, but over 40 per cent, of these die from -•- ;-':-:ion of the adhe- sions, etc. Adhesions don't form before -.':.c third day, some- times not until after the 7th or loth d^y. After adhesions form, operation is much more difficult and dangerous. I\'. Stricture: — Narrowing of the in:estinal vvall, not presstire from without. Til ,y arc : — (A) Simple, due to ulcers.' 1. Typhoid during healing. 2. Dysenteric; generally in the rectum, though sometimes as high as the hepatic flexure. 3. Catarrhal; in the caecum, including stercoral ulcers, which may rarely cause perforation. 4. Peptic; in pylorus and first pan of the duodenum may cause perforation, more often stricture. tis. as •as ,cl )n. -1. rle e.l in 54 er :h >n ly 1- it i'ff .s •t SURGE liY 91 5. Syphilitic from breaking down of gummata. arc often irregular, serpiginous, rarely annular, and rarely with under- mined edges, not deeper than the submucosa, generally pro- ceeding up with condyloma of rectum, in going up get ulcer. 6. Generalh' begins in the lymph follicles, following the vessels, forms an annular ulcer, conmionest in the lower ileum, but have been found at the ileo-caecal valve. 7. Injury ^aused by strangulated hernia. (B) ^lalignant: — i. Carcinoma; get generally cylindrical annular carcinoma: — Scirrhns. and medullary cancer are a rare occurrence. It is generally primary. Here stenosis is gradual, so that there is time for the bowel above to hyper- trophy in the endeavour to overcome obstruction, and if i)atient is weak it dilates. Death may be caused by acute obstruction, by plugging of the narrowed lumen by some hard substance, or by a valve-like plug of \ucotis membrane. Distinguish between simjile and malignant by the . If iowol an ends ; the otter 1S37, med, tion, leum Mnes 1. the nd a owel ause not it in then Lilae. can- ;• H suitaiJiiY t)5 After Colototny may have eczema, and if deeper celhditis, if muscular walls are septic; therefore don't separate, hut cut straij;ht ihrouf^h ; look out f' u- i)critonitis. There may he suppuration and ileath from exhaustion. ( iastrotomy is the openiu}.,'' of the stomach, and may he done for tile removal of foreign l)0(lies. Ciastrorrhapy: — The eh^sinj^j of a fistulous wound of the stomach. ( )peration for Ohslruction of Cardiac end of Stomach: — (lastrostomy : — Makinq^ a tistida hy hrinju^insjf the stomaoli to the edj^es of the ahdominal wound, suturing- and estab- lishing a permanent tistula, so that feeding may hi' carried on through this opening, when obstruction exists at '' v cardiao end. . Pyloric Obstruction: — 3 operations: — 1. ryloroi)lasty — llenike, Miculicy. Incision is macic longi- tudinally, its ends are brought together, and the cut sewn up iransversely. This is for non-malignant stricture. For malignant either of the following: — ■ 2. Gastro-enterostomy; this is done where the disease is so extensive that it cannot all be removed. 3. I'ylorectomy; is the best operation where the disease can be removed entirely. The pylorus with all tlK diseased area is excised, the duodenum inserted into an opening made from inside the stomach; sew up with Wolfler's suture, not taking in the mucosae; then for safety, if necessary, sew the mucosae separately. The greatest difficulty is in tying off the greater and lesser Omentum. Cregg-Smith questions the advisability of applying two serous surfaces, advocating applying raw surfaces, or raw surface to peritoneum. The orthodox view, however, is that the union of peritoneum to peritoneum gives a rapid union. ' il .* HERNIA. Is the escape of any organ from its containment, but, un- less specifically mentioned, the small or large intestines are referred to. i )^mm wmm 96 SURGERY Hernia is : — t. lemoral. 2. Inp^uinal. 3. I'nibilical. 4. Ventral. 5. ( )l)tr -ator. 6. Sciatic. 7. Perineal. 8. Pre- peritonea!. 9. Postperitoneal. Fre(|uency of the occurrence of hernia is not accurately known. 1 .5cx> out of (),ooo were under 5 years. It occurs twice as often in males as females. Causes: — t. Laborious occupation said to l)e more ajit to cause it. (?) 2. Abnormally long Mesentery; still, finding long mesenter\- on o])eratii)n does not prove its presence before, as mesentery may have been stretched. 3. Another cause is ab- dominal oi)erations. 4. Heredity. 5. bronchitis. 6. Stricture. 7. Whooping-cough. What forms a Hernia? T. Generally small intestine — F.nten^cele. Distinguished by percussion note. 2. Sometimes Omentum. Diplocele. 3. Stmietimcs both. Diplo-enterocele. Sac is tliin in a recent, thick in an old hernia. Adhesions may occur between the sac and the gut. Hernia is (a) Complete, or (b) Incomplete. Incomplete : — When not right down, i. e,, in the Inguinal canal. Reducible: — If it can be returned. Irreducible: — If it cannot be returned. Incarcerated Hernia : — Is one-in which the faeces cannot pass, but circulation can. Strangulated Hernia: — Where neither the blood nor faeces can pass. Inguinal Hernia — (1) Direct. (2) Oblique. Read in Heath the position of the External and Internal Abdominal rings; deep epigastric artery; covering of a her- nia. In old cases the different coverings of a hernia cannot be made out. Congenital Hernia : — Infantile — I""unicular — Congenital In- guinal hernia is almost the only kind met with in females. Symptoms : — Sense of weakness, followed by pyriform tumor. If obstruction, get vomiting and intestinal obstruc- tion. Impulse transmitted on coughing. Can be held in by the hand. Is opaque. Conies down again on rising from recumbent position w'ith a gurgling sound. re- ely .irs to ner \\\ ID- 1"0. eci IS al If It ?s il )t r amg^rngmm^r^mmim^^ ii ir^> '(I SURGERY 97 Diagnosis from : — i. Hydrocele; this p^encrally follows a local inilamniation, or trauma zcitli iiiiJa)iniiatio>i ; get large in- guinal glanfls. 2. Undescended Testicle — see that these are in scrotum. 3. \'aricocele — feels like a bag" of worms; if can- not be retained in the hand, when in the erect position, i. e., it slips down on rising in spite of pressure. Treatment: — Reduce and apply a well-fitting truss. Try the truss by bending and coughing. Xever stand erect ivith- out having truss on. If truss will not keep up the hernia, then operat';. Strangulation: — This is the most frequent cause of operation. Symptoms: — Nausea an months. The injection of irritants into the inguinal cavity to set up inllanmiation, and close it, are unwise, for a i)rocess is thus started, which cannot always be controlled. Constitutional treatment: — \'ery important. Relieve stric- ture of the rectum, or urethra, or poly|)i of the rectum, sec that bowels are regular. Tone uj) the system generally in lax states. FEMORAL IIERXIA. Hernia into the crural ring. This always accpiired. L'su- ally small and tense. Stricture is always at the internal ring, generally due to (iimbernat's ligament. Remember the abnormal position of the Obturator artery, which in 1-35 is liable to be cut in dividing Gimbernat liga- ment, hence use a dull knife. Femoral form about 10 per cent, of all hernias. Are com- mon in women, and more liable to strangulation than inguinal, and are generally formed h / the ileum. Omentum if present should be tied up. Percussion note may be resonant. Diagnosis from: — i. Psoa.c abscess; recognized by being out- side and beneath the vessels, and by the presence of spinal curvature, wdiich is nearly always concomitant. 2. Inguinal Hernia, recognized by its being above the spine of the pubes, 3. Varix of the saphena; can be held in by hand. 4. Single inflamed gland may be puzzling, especially if there is reflex vomiting from the genital branch of the genito-crural nerve. 5. Fatty tumour has a lobulated feel. 6. Hydrocele. n I 100 SURGE UY ].• Treatment: — Hernia truss, bevelled, so as to avoid pressure on the vessels, may be sufficient. If small and irreflucible, and only formed of omentum, a pad may be applied to pro- vent it increasingly in size, but generally best to cut down, and tie off omentum, and do a radical cure. Never tie omentum down to the ring'. Sheath which is hard to recognize is known by its glistening apjiearance and peculiar feel. In applying taxis, remember the direction in which hernia has come. Sack may be made mto a pad and fastened to the inside of ring, or tied off high up so as to have no depression for gut to rest in. Poupart's ligament is sutured to j)ubic fascia to prevent recurrence. Cure is complete, or only a slight truss is necessary. • UMBILICAL HERNIA. Tl'iTce kinds: — (i) Congenital. Often large, containing dif- ferent organs. If not too large, reduce, j)are the edges, and generally get union. (2) Infantile: — Use large Hat cork, cov- ered with cotton and pinned to binder. (3) Adult — generally in fat people. Ventral Hernia : — In different regions through abdominal parietes, are generally controlled by a truss. Lumbar Her- nia :^ — ^In Petit's triangle. Perineal Hernia: — In women may be into the Labia. Ischiatic Hernia: — Leaves the pelvis through the great sciatic notch, either above or below the pyriformis. Diaphragmatic: — Protrudes through the dia- phragm into the thoracic cavity. Pre-Peritoneal: — Dissects up the peritoneum from the abdominal wall. Retro-Peri- toneal: — In duodeno-jejunal fold. ABDOMINAL INJURIES. Whether penetrating, or non-penetrating, they require care- ful attention. If their nature is obscure, put patient to bed^ and apply ice. Diagnosis between penetrating and non-penetrating wounds is often very difficult. The passage of food through the wound and the vomiting of blood would indicate the wounding of the viscera. Abdo- SIROFRY lOJ " minal rlistonsion with ahscnoc of liver dullness is stroncf, but not infalliltlc evidence of visceral injury. Ilvflroq-en pas, or injecting air per rectum, is a test for intestinal lesit)ns; marked shock, especially with pallor and yawning, point to internal hemorrha'^e. Non-penetrating wounds: — Are easily treated, aseptic pre- cautions. Keep in bed 3-4 weeks, and wear binder 5-6 mos. to avoid hernia. Tenetratiiig wounds: — Fatal in HS per cent., especially if stomach, intestine or gall bladder (unless bile is aseiitic) are wounded, but chances arc better if operation is innnediate ; for while 5 out of 32 operated on .'ifter u hours recovered, 18 out of 39 operated upon before the 12th hour recovered. If there is evidence of perforations don't wait for symptoms, for then, when the shock is over, peristalsis will begin, and faeces, etc., forced into abdominal cavity. If there is marked collapse, and think hemorrhage is not now going on, it may be well to wait for a pa,rtial improve- ment, but, if hemorrhage is going on, then stimulate patient in every possible way, and go on at once. In shock, hypodermic of opium is very good. Follow up the original incision, or open in the median Ijne. Insuftla- tion of air or water may locate leak if hard to find. Suture the wound of the alimentary tract, and irrigate. If lesion is local, have irrigation local. After operation, rest, good food. Opium rarely advisal:)!e, for by paralyzing the bowel it promotes the formation of ad- hesions. Salines or hot water injections help the pain nuicli. DISEASES OF THE RECTUM. Anatomy: — The rectum begins at the left sacro-iliac syn- chondrosis, 6-8 inches long. It is said to be shaped like a large E, but Treves says it is "U" shaped. He says it be- gins at the 3nd sacral vertebra. Under Treves' definition, which Dr. Shepherd agrees with, we get rid of one of the curves, and make it 2" only in length. Rectum is divided into three parts : — 3rd, lies under the membranous urethra, 2nd, Covers the prostate and seminal 102 SVKUEIiY vesicles, ist, from, the tip of the prostate to the 3rd sacral vertebra. The rectuiu is a movable put, as lonp as it has a completely surroundinj,^ peritoneum. The distance between the anusaiid the peritoneuni is important in operating:. 1m)1(1s of tlie rectum are the columns of Mapapni. Ex- ternal sphincter is a voluntary muscle. Internal sphincter is an involuntary innsck'. and merely a collection of tlu- l(i\\i--r fibres of the bowel. The Recto-coccygeus passes from the coccvx to the rectum. The Levator Ani o])ens the anus, and at the same time closes the urethra. The rectal centre is in the lower lumbar cord. The anus is very sensitive, the rectum but little. Lympliatics : — 2 sets, (i) Anal to the g-roin. (2) Deep from peritoneal and subnmcous coats. Position for examination : — Lying on the left side with the knees drawn up is now thought much of by many specialists. Formerly patient leaned over a chair. Prolapse of the Rectum : — Causes : — i. Occurs often in weak children, in defecation, may be only a weak, lax condi- tion, constitutional cause. 2. A weak sacrum, or relaxed sphincter (in b>ance supjxised to mean unnatural coitus). 3. Worms. 4. Poly])i. 5. L'rethjal stricture. 6. Piles in adults. 7. Pregnancy is often a cause. May have only prolapse of the mucous membrane. This is the commonest form in children. Trcutiiiciil : — Remove the cause, such as worms, piles, stric- tin"e, ])hiniosis. atonic condition by change of climate, out- door life, — don't let child sit and strain at stool, have them defecate when standing, or have a very small hole cut. Wash the ])e.rt with cold water is good, or bathe with Tr. Ferri Perchlor. grs. XX. Oz. Ill, or use Hamcmel-.s. Painting rvith Nitric acid does well; not painful. Paque- lin's cautery when extreme, streaks not quite through the mucous membrane down to the bowel. Hemorrhoids : — Two classes : — i. External. 2. Internal. Hemorrhoids are distended veins. There are the, i. External hemorrhoidal veins. 2. Middle hemorrhoidal veins (French .. i! » 4 *%.* ,«*»,.. ^ HLRQEHY 103 T *i> anatomists say they are not concerned in hemorrhoidal dis- ease). 3. Internal Pudic. External Hemorrhoids : — Three kinds: — 1. Simple — dilatations appearing externally as little kimps, cannot be permanently returned within the rectum. Astrin- gent ointment may be used, such as Ext. of Belladonna, or Ext. of Opium, or Gall ointment with Plumbi kxlidi. Nitric acid sometimes 2. A little lobular form which is hard, and like a throm- bosed vein, though some say it is rupture and effusion into the cellular tissue, probably they are clots in the veins; the size varies from that of a pea to a httle tingor, and arc very sore. The treatment for these is just to wash and to slit across, and shell out the tumor. Give o])iate or 5 niiii. of cocaine solu- tion (4 per cent.) if necessary. If bleeding occurs, apply a bandage for 5 minutes. If necessary (very rare) apply a compress and bandage 12-24 hours. If operation is declined, rest and hot poultices. 3. Cutaneous Piles. Like tags of skin, sometimes veins dilated, sometimes fissure or ulcer, — clamp and cautery. They are called bleeding piles. Hemorrhage is nearly al- ways arterial. T'robai)ly never have arterial hemr'g. : may be veiious from ulcerating. Bleeding is generally of small quan- tity, but may go on for a long time, and cause anaemia. Internal Hemorrhoids : — These generally increase in size. They form the lowest part of the portal system, generally they are pedunculated. Treatment :—C\i\rx\'^ the p'le, cut off a quarter of an inch from the clamp, and cauterize the stump of the pile. This is generally satisfactory. Do not get clamps too far up, or dan- ger of getting secondar}' hemorrhage. Allingham's operation, modified from an old one. He used a ligature, divide mucous membrane all around it down to the venous wall, then put the ligature around in the groove. Tliis gives very little pain if the mucous membrane is thor- oughly divided. 104 SURGERY 1 I T i Another method of treatment is by injection of phenol, also used for External piles, although less frequently. Dr. Arm- strong 'las never used it. There are some cases where it should be used. Treatment consists in having 15 per cent., 30 per cent, and 50 per cent, solutions of Phenol. Inject 5-10 mins. into the base of pile. This cures hemorrhoids. Trouble is there may be severe sloughing, hence objection is that we cannot de- pend upon it. Besides this treatment, we must treat the general condition causing it. Constipation is a common cause. Give tonic treatment. FISSURE IN AXO. Is somewhat closely allied to piles, but is more painful; causes a great deal of irritation. When patient complains of a very great griawing pain after defecation or at other times, make an ex'-rrination, and gen- erally find a fissure; sometimes it is merely :'.;rj tail end of the large ulcer above. Diagnosis : — Re very careful in making diagnosis. The rectum should be examined in every case. Treatment: — One way is :o stretch and tear the sphincter, another way is i.^cision. .Stretch spliincter and rectum, and draw knife along ti.e base of the ulcer about a quarter of an inch in depth, and begin and end incision in healthy tissue; examine higher if ulcer present, scrape wth spoon. If deep scrape sides too. If hemorrhage touch vcit'ii Xitric acid. A few days rest in bed without a motion will enable it to heal. Another way is to stretch the sphincter under an anaes- thetic. This tears the sphincter. Treatment is thoroughly satisfactory. Some do operations under Cocaine. 4-5 min. oac- tures of the upper extremity are twice as freqv .nt as the lower, upper 52 per cent., lower 25.8 per cent. Other fractures 26.72 per cent. Causes of I""racture, almost always local. Liability to oc- cur much modified by predisposing causes. Local :--F.xternal vi'ilcnce and muscular action, or a com- bination of the two. External violence may be direct or indirect. By direct violence is meant the bone is broken at the direct spot where the violence is ajiplied, and is often complicated by injury ot the soft parts. By indirect violence: — We mean that force is applied to two parts of a bone, the fracture taking place be- tween the two parts; the fracture is at a distance from where the blow is '-eceived. Example: — Colics' fracture from the effect of a fall on the hand, weight of the body at the other end. I'Yacture of the l)ase of the skull by cou trc cou p. Frac- tures received by indirect violence are usually severe and tend more than others to be compound or comminuted. Muscular Aciiou — Rarer than tlie others, tisually the bone thus broken is the seat of some disease which alters it- struc- ture, fracture of the patella from quadriceps extensor, sternum broken in the strain of labor, of ribs in coughing, humerus by throwing stone, femur by kicking at football and missing. Muscular action often aids in tracture of bones by indirect violence, so that a drunken man falling is less liable to fractures than sober, because he does not try to save himself. ^ SURGERY 111 \ Predisposing Causes : — i. Normal. 2. Pathological. Normal : — Chietly position and shape of bone; exposed bones, and long bones; powerful muscular attachments. Age and sex: — These are normal causes. Fracture may occur at any stage. In children especially liable to separation of the epiphyses, espec''illy the humerus and femur. In children o".e-hali the cases in the upper limb are clavicle ; in lower, femur. Sex — Men •.v.orc liable; in nirn. shafts of long bones, cra- nium and pelvis. In wonioii, the clavicle, radius, tibia and neck of femur are conmionest. Below 5 years the liability of both sex is equal. After 5 years males are more liable up to middle age. After 45 in females, upper limbs exceed that in males, and this is espe- cially due to fracture of tlv radius in woman. Season especially in our climate in winter, more fre((uent in summer in children, owing to their games, etc. Pathological : — 'Certain conditions of the bone predispose. Fragilitas Ossium (boy 6-7 years of age had had 27 fractures), slight falls, turning legs, or tossing in bed, breaking femur, by tossing around. Frequently associated with rickets, often hereditary, most frequent in children, may persist throughout life. Mullities ( )ssium predisposes to fractures. Senile Atrophy, Rickets predispose to "Grecnstick" frac- trre. Carcinoma, Sarcoma, Strumous or Sypliiiiiic (3rd stage) pa- '-iixxis, Caries, Necrosis, Scurvy, Ostco-myelitis, Gout, Simple A'M>phy from disease will predispose. Atrophy may follow «.jt" y to nutrient artery. Fractures are complete or incomplete. — 1. Complete: — Entirely traverse the bone; they are Simple, Compound, 'Comminuted, Complicated, Multiple, Impacted. 2. Incomplete: — Only partially traverse the bone, as a "Greenstick" fracture. Simple : — Fracture is one unaccompanied by any open wound, communicating directly with the seat of fracture. Compound fracture communicates by a wound with the ■ Si t I H 112 /^-\ SURGERY surface of the body. The communication may occur in a variety of ways: — (i) Bullet injury. (2) Laceration of the soft parts by fragments protruding (commonly due to incautious handling). (3) Sloughing of the bruised tissue; simple may change to a compound, (4) By ulceration through the skin ot a pointed fragment. A fracture compound at the first is more serious than those secondarily compound. Comminuted: — Bone broken in several fragments, and dif- fers from multiple only in the size of fragments. Complicated : — Some important structure is injured at the same time, vein, artery, nerve, joint, or a dislocation. Multiple: — More '. xture than one has occurred in the same bone, or different s. Impacted: — The firm i- ae of the bone has been driven into the cancellous tissue;' as in head of femur, head of hu- merus, and lower end of radius. Direction or line of fracture, important; runs through in various ways : — transverse, oblique or longitudinal may have a combination of two of these. Transverse Fracture is seldom actuallv transverse, and is usually slightly oblique; almost always due to direct violence, or to muscular action, seen in the patella; s.eparation of the greater epiphyses are always transverse. Oblique : — Usually due to indirect violence, the bulk of fractures of the extremities are oblique; if one bone alone is broken, this is more likely to be oblique. The obliquity may be slight or very marked — may traverse half of one of the long bones. This more dangerous than transverse, and is more likely to cause compounse It. li- lt. Jf?^ n sujiatJfiY ii; In compound fractures there is often less amount, because exposed to supi)urati()n and absorption (i^eneral compoiuul fractures take three times as long to heal). Somewhat tlie same process takes place in the |)ii hyses of the bone. Time re(iuired for union : — Phalanges, metacarpals, car- pals, metatarsals, tarsals ami ribs, 3-4 weeks. Claviele, fnre- arm and fibula, 5 weeks. Humerus and tibia, 6-7 weeks. Both leg bones, 8 weeks. Femur, 10-12 weeks., i. e., union with sufficient firnmcss to allow of motion commencing. When longer than this we get delaycfl union. Delayed I'nion may be caused by: — (i) Constitutional de- bility. (2) Meddling with fracture, changing splints, or test- ing solidity. (7) Syjihilis is a common cause. (4) 111 health and dyspeptic conditions, and when (51 Much j)hosphates found in the urine. Dekycd union is not serious, but is worrying. Ircaimcnt: — (1) Improve the general health — tcMiics, nutriti- ous food, fresli air, nitro-muriatic acid. (2) Make fennir sjilints such as plaster of paris. (3) Goc'l to let patient ujion crutches, perhaps the confinement is bad. Massage of limb is good be- fore putting it uj). (4) In syphilis, treat this. Non-union: — When many weeks have elapsed the frag- ments are totally ununited, or only held together by fibrous tissue, e. g., bone cement was thrown out as usual, but some- thing changed it to fibrous tissue in-^'ead of bone. In tilirous union, the bones are simply held togetlie:* end to end. Another form is false joint, or pscudarthrosis : non- union has taken place between the ends, but the ends are smooth and rounded, and medulla closed v ith bone, and the ends are kept together with dense fibrous tissue, or fibro-car- tilage. This investment of fibrous tissu is really like a cap- sule, and the two ends are often found rtibbed into a ball and socket joint; seen in the humerus, w len the two Ixnies are together, then we have a hinge joint. This capstdc may have a pseudo-synovial membrane, giving out fluid. Causes of non-union: — (A) Constitutional, i. Often very 'li 'il US SUKGERT obscure; delicate people oftv'n have rapid union, while liealtliy I>cople may liave delayed (>r non-union. 2. Too long confine- ment to bed. ,v Some acute specific disease like pneumonia, fevers, etc.. preceding' <.r accompanying: the fracture. Syphilis, sciu-yy. cancer, rickets, trJK?, alcoholism. Brijc^ht's disease, j^out. paralysis, esi)ecijlly paralysis ajjitans. prej^nancy and advanced aj;;e. Spontaneous fractures rarely unite. (B) Local: — i. Meddle- some surgery. 2. Imperfect apposition of fragments. 3. ViM^ light ;nid too K>osely applied dressing. 4. Tot) early removal of spln',;s. 3. W'itle sej^aration 01 fragments. <). ()hli(iuc character of fr.icluie. 7. Injury to iniportatU nerxcs. S. in- teri)osition of soft parts of all kinds. 9. Interposition of frag- nu'Uts iif IxHU'. U). ( K'cunencc r»f abscess, resultin;.;- in ne- crosis and caries. 11. Ilydatitis. 12. Interference of vascular sujiply of one or both fragments, seen in fracture of the neck of the fenuu" in old iH*o]ile: the head anrl neck become carious. l.^ Tosiiiou of ilie uiurient arier>- with regard to the fr.ac- ture. Ununited fractures are common abine the point sup- plied by the nutrient artery. Treatment of non-union : — .-\ny fault in the general health should be ct^rrected if possible: l<>"»k more to the local means. T. (i) Re-arrange the splints cw try new splints, extend the limb. (2) Anaestheti/e. and rul> eivls of the fragments ti^gether, in order to set uj> an iutlammation. and obtain new callus. (3) Rub otT fibrous tis'-ue and bring the bones together. This is seldom sut'ficieii'. iviay arous bands with a te- notomy knife. I\'. liUrixluction of wire setons. V. Sul)cutaneous introduction of some irritating lluid. Iodine mine. X\ -XX.X with a long hypcniermic needle be- tween the ends of the bones. IV 0- IS, )o ir s. i-f SURQURY 119 VI. Dlsfenbeck's method : — Introduction of ivory plugs into the ends of the fragments. He tried tliis subcutaneously, driving them into the bones, and leaving them there for sev- eral weeks, or break them ofif, and leave them there for good. Dr. Roddick got good results from driving three awls into each piece of bone and leaving them there for six (6) weeks; no wound, except the holes left by the awls. VII. Re-section of the ends of bones : — Since antiseptic surgery established, this method has taken the place of all others. This is not without risk, and is not always successful. Extension is first applied for two or throe wcc'.cs, and tliis tires the muscles so that the two ends come opposite one an- other. Then prepare the patient, and make incision on the side nearest the bone, and avoid vessels and nerves (outside of thij^di). Incision 4-5 in. long. Incision made, tlien look for fragments, and clear all soft tissues from the ends, which are usually rounded, and perhaps one end smaller than the other one (usually the uppei one). A'arious methods : — i. Saw end of ea:h off. and bring ends together and wire them together or use silk, or cat-gut: wire by far the best; the wires should be cut off short, and wired down (hammered down); this not always satisfactory. 2. Better results from an oblique incision, which gives a large surface of bone, and wires easier applied, or may use MacEwan's pins, the same as used in excision of the knee- joint. One long pin which is removed at the end of 4-6 weeks is the best, or use two short pins, to be left in. 3. Another method is removing bone on o])posite sides of the two ends and fitting togetlier, which gives a still greater surface; two short permanent pins are the best here. Saw ofif parts according to which fragment is over-riding, so that the upper will hold down the lower. 4. Dr. Roddick did not see Treves use any pins, but he made a very oblicjue incision, and trusted to his splints alone. 5. Besides passing a wire through the fragnients, some pass a wire around the fragments. 6. Grafting pieces of bone between the fragments when the gap was large has been tried. ... i 120 SURGERY ■Keep fragments in warm boiled salt water while changing. Another surgeon filled the gap by turning down the pieces of bone, or sawing off pieces, and placing between. In some cases amputation has been necessar)-. Malposition. Malunion or vicious union. — May follow the impropei setting of fractures, too early removal of splints, neglect to straighten green-stick fractures; whatever be the cause the parts have joined in bad position. In early cases (6-10 weeks) refracture under an anaesthetic. If you fail to break, use an osteoclast (not much used). The surgeon now prefers a subcutaneous osteotomy, i. e.. intro- duce a chisel, and break up the bad union. If this fails may use an Adams' saw, or may have to take a wedge-shaped piece out. Com]>ound Fractures : — Require immediate and prompt attention. The first dressing largely influences the prognosis. Xo meddling with septic fingers should be allowed. If noth- ing at hand, put on a boiled water compress until we get something else. The technique should be as complete as in major operations. .Compound fractures are sometimes very severe. The first (juestion is whether to do a primary opera- tion and amputate, or try conservative processes. Lacera- tions may be too great, shock and loss of blood may prevent patient from being in a position to stand a long illness, and amputation is necessary. Give anaesthetic; cleanse the part very carefully in and about the wound; use alcohol, ether and turpentine, cleanse any protruding bone. If you have bone protruding, what do you do with it? Shall I remove it, or enlarge the wound to put it back. Very often necessary to do both. The fragments must be brought into apposition. Eidarge the wound, displace the soft parts that are in the way. and try to replace the protruding piece. If this fails, saw or chisel off the protruding piece. Then irri- gate wound thoroughly with sublimate; thorough flushing, attend to bleeding vessels. Bruised and soiled muscle mav be cut off with scissors, any cut tendons or nerves should be caught up and sutured. I i ' ii 8URQERY 121 Drrinaj^e : — Should be clepenclent; the drainage tube may be rubber, or iodoform gauze drain may be necessary along sides of fragments. In small fractures, as fingers and toes, silkworm gut, or cat-gut drain. Where plugging is neces- sary always use a drain. In a small clean wound all that is necessary is to flush it out and dress it witli Iodoform gauze, and introduce a piece of Iodoform gauze for drainage; parts put up in a heavy anti- septic dressing, and put splints on the outside; it must be dressed again in a few days, any kind of splint, but plaster of Paris if used may cause a good deal of disturbance in re- moving to dress the wound. Comminuted Fractures : — If fragments smal! and uncover- ed by periosteum, they should be removed. If covered, place back and leave. Even in aseptic wounds these often die. \\'here one of the two fragments is stripped of periostetmi, it is best to remove a piece of it to prevent necrosis. Don't re- move too much. Hemorrhage: — Occurring in compound fractures is trouble- some; oozing may continue for days; elevate the limb and apply heavy dressing, (.specially above the wound. Should the oozing continue, may have to open up wound, and look for the bleeding spot. Sutures are sometimes of use in a compound fracture, wound is usually left open. In favourable cases wound closes in from I0-20 days; does not in poor health. During this period no callus seems to be thrown out, now then put ends accur- ately together, remove heavy dressing, and apply accurate splints. If on the contrar}^ compound fracture goes wrong, this is indicated by the Temp, keeping up, and unhealthy signs about the wound. Expose the wound, and remove any sutures, and, if wound is small, enlarge it; then irrigate thoroughly with sublimate, cleanse afresh, redress, and wait for results. If you are afraid to cover it up, put a compress on of sublimate, and tell the nurse to keep it wet. This encourages the unhealthy fluid to come out, and keeps it disinfected. If this fails, irri- 1 ¥ j^ation must be practised; continuous, either with boiled water, with tube or lamp wick, or antiseptic solution. Sublimate T-iooo; Carbolic 1-200, Creolin, Lysol, Pot. Perniang. Keep these running day and night, and may carry it through drainage tube. Solution may be cold, lukewarm or hot; if much inflam- mation, cold is the best. If circulation is poor, hot water — this is called continuous irrigation. In case of ann, con- tinous immersion is the same thing. These prevent infection of discharges and collection of germs. By these methods we can usually get recovery, but the fragments of bone suffer. In these cases always remove all the small pieces for they will die, and freshen the ends of the two fragments. Where things go on from bad to worse, where patient is worn out, suppuratit^n is going on, high Temp., hectic, nu- merous incisions, etc., then we have to do a Secondary Am- putation. Amputation, whether Pr^mory or Secondary, is always very serious. In many cases there is no (piestion but that primary ami^utation should be performed, (i) Is it pt)ssible to render wound aseptic ? (2) What is the condition of ar- terial supply ? (3) Is the condition of the nerves such that the limb will n(H be paralyzed subsecpiently ? (4) Are the ten- dons not lacerated too much ? 5. Is repair of bone possible ? Ask yourself these f|uestions in primary amputation. Secondary Amputation : — Rule is that if limb be not re- moved within 24 houTs of accident, 8-10 days should be al- lowed before amputating. Operations during that stage are notoriously fatal, septic and traumatic fever present. Many exceptions to this irule; hmb may go bad so sudden- ly between the first 24 hours and the 8th to loth day that there is no choice but immediate operation. Accidents and Complications of Fracture : — During the treatment of all forms of fracture may get the following acci- dents : — I. Local. II. Constitutional. (i) Swelling: — iConstriction of the limb at some point; im- perfect reduction of fragments; extravasation of blood. 8URQERY 123 (2) Formation of Bullae or Blebs :— Especially in simple fracture, and comminuted fracture, especially in l(»\ver limbs. These ajrc due to extravasations of blocxl into the skin, size of split pea to a dollar, contain blood and s'^rum: they are best left alone, and allow absorption to take place. If opened they may ulcerate. {},) Spasm of muscles of a limb are often very troublesome, anil, if continuous for over a omctimes in in- jury (if the lung, where emphysema present in large quantities, may have to interfere. I'sually it is absorbed, even in severe cases. Treatment: — T'uncture in several sp(^ts. or enter trocliar in various places In emph; sema due to putrefaction, free inci- sion or amputation. Tetanus : — Invariably in compound fracture, due to the entrance of the bactiTia of tetanus with dirt, especially in fractures of the fingers and toes. 11. Fat. Embolism : — Important after fractures. I'at en- ters the circulafiDM, and is , xcreted with the urine 2-3 days later. I'at cells of the marrow of the medidla broken up, and lifjuid fat set free. The sane may occur of severe contusions of fat persons, also seen in 'iie acuie inflanmiation of the nnrrow of bone. Only when fat enters in large amouiU and blocks a large n'-.mbfr of vessels is it of imp(v.tan-e; if near the heart it is also .n(»re dangerous; fat is carried into the Rt. heart, and then ..lO the lung, where the first symptoms arise; as a rule within },(^>-72 hours after injury you get sudden and violent dyspmna; patient is pallid and cyanosed, coughing, frothy spnuim streaked wiil; blc^od, and may have distirict Ilaemtjp- tysis, eyes bulging, and subsecjuently in some cases jjueu- mt)nia follows, temp, low — small, rapid, irregular pulse. Many aftirm that fatality is due to obstruction in the brain; have shock (called secondary shock, long after acciutting on a cnm- prcss, held in position by broad straps of adhesive plaster, reaching half way arouud the body, 2 inches in width, and overlaiiping each other, and also passing over the sternum. Rest in bed and ])a(l between shoulders gives great relief. In cases of deformity oi»eration is not justitiable. Wiring is often followed by extensive necrosis. Ribs and costal cartilages : — Ribs, common; 18 per cent. of all fractures, rare in the young; 4th to the Sth inclusively, most common. 7th comiuonest of all. Conuuon aiuong the old and insane, ist rib unkiu)wn. Conuuonest site, at or near the angle, or about 4 inches from the vertebral column. Causes : — Direct or iiulirect violence or muscular ax'tion. Signs and symptoms : — 1. Stabbing pain increased on breathing. 2. Breathing abdominal and dia])hragmatic. 3. Passing finger along can usually get irregularity. 4. Can get crepitus usually by hand or leg; stethoscope. 5. Rmphysema may be very extensive. 6. Where fragment has penetrated the lung, we get haemoptysis, haemothorax and pneumothorax may occur, also haemo-pencardium. 7. If compound, or in 128 SVRdERY case of p^unshot wound, it is not rare to have wounding^ of the intercostal artery. 7';t'(;/;;uv;/.— ( )r(linarily simple inniiohilization of the cliest walls by strips of adhesive ])Iaster is sufficient. Ordinary ad- hesive ])laster is very little jjood. Rubber plaster or Mead's rubber plaster is the thing to use. .Measure from a little to the uninjured side behind to a little to the uninjured side in front, i. e., one and a half inches past the middle line, strips 2 inches wide. Apply fnim be- hind firmly, wrinklings the skin in front of you ; each strip should cover the other by about half an inch. Always follow the line of the chest. Recrin below and work up. Even if only one rib broken, it is best to cover the whole side of the chest; p^ood also to put stri[)s across these, which help and keep others in place; good also to en- circle the chest with a broad tlannel bandage, reaching from axilla down; should encircle the chest only once. Keep plas- ter strips over shoulders to the tlannel bandage to prevent it from slipping down. In applying bandage allow ])atient to take a fair breath, so as to prevent constriction of good lung. In compound fracture may get severe bleeding from the intercostal artery. In such cases have to ap]ily bandage over the dressing. Catch vessel and tie it if possible, if not plug with Iodoform gauze; insert, piece of gauze into cavity, and plug into this. In lunphysema. the air is usually absorl)ed. Cartilage : — I'racture at juncture with rib or in middle of cartilage itself. Causes : — Same as the rib symptoms, and treatment the same. Fracture of the Pelvis : — V^ery rare. Locations : — (i) Along crest of ileum. (2) In pelvic basin. (3) In Acetabulum. The crest alone is much less serious than the other two. Causes : — Heavy vehicles passing over the pelvis, coupling cars; heavy weights falling on pelvis. In old peo])le a fall alone on the trochanter may cause it. In fracture of the ileum alone we get: — (i) Intense local- ized pain. (2) Crepitus always. (3) Marked Ecchymosis. (4) Inability to move the muscles; too tender. ■ the licst ad- 1 1 r to ;o a lies be- trip U1(l vcr OSS en- it to ^'^■ he or 'ff k1 of le i fiVKllKin 120 In Fracture of the Basin: — Fracture usually passes through the tipper ramus, or where the jiubic l)one joins the ischium. Si^ns: — (i) Locahzed i)ain. (2) Oeijitus. deep and hard to locahzc. (3) Inabihty to lift hmb from bed. (4) ICcchymosis. (5) IVonnnence due to thsplacement. CompHcations, more serious than frarturi' itself. Ci) I'rcthra ohcn wounded by lari-rations, torn across, therefore always pass catheter to find out the condition. In bleediiif,^ or inability to [)ass catheter may have to do a I're- thotomy. (2) Rupture of the bladder, especially if full, is very seri- ous, rare if empty; sij.^ns are if pass catheter and find only blood, or inject aiuiseptic thiid, and none, or only a |)art returns. (3) Rectum and \'a^-ina are also sometimes iniured. I''ractures of the acetabidum : — ( )ften mistaken for fracture of the neck or j^rcat trochanter of femur (because trochanter cannot be feltV Treatment ol 1 'civic I'ractures : — Rest and position are here the luain indications; for the ileum, or if no complications, a firmly apphed catUon flannel bandagfe is all that is necessary, reaching above the ileum, and down beltnv the trochatUer, If trochanter is injured, this cannot be done. Very jsfood to cover this with two or three turns of plaster. l*"ouT to five weeks in bed is usually enough; they as a rule unite ver)' well. In fracture of the Acetabulum, a gutta percha splint sliould be used, c better, a long side splint witli weight and pu''',y. In rupture of the bladder may be obliged to do a laparotOi- my. Expose the bladder, and, if possible, avoid the Perito- neum. Wash out thoroughly, and sew ujj with Lembert sutures. Fracture of the Sacrum : — V'ory rare, except in gunshot injuries. Death ensues in almost all cases. Uncomplicated cases never mentioned. Transverse fracture, the upper i)art is pushed forward. Nerves always injured. Trcatmcut: — Same as of pelvis. Fracture of the Coccyx : — This commoner. il ! ! 180 SURGERY Causes : — Kicks, falls, parturition, defccatidii. Syniptotiis: — I'ain is very severe, especially while sittitij; and walking, frafjmcnt of the tif) always displaced forward, often followed by life-lonp neuraljj^ia, which is called coccy^jodynia. Treatment: — Keep in bed for 2 or 3 days, with a strap of belladonna plaster applied to the part. Subcutaneous division of the muscles and nerves to the coccyx may be necessary if union fails. Sometimes resec- tion of the whole bone. Fkmur: — Very important: 6 per cent, of all fractures. 3 parts : — (i) I'pper or pelvic end (a) within the capsule; (b) outside the capsule; (c) fractures of trochanters. (2) Shaft (a) upper; (/)) middle; (c) lower thirds. (3) Lower end; fracf.ue of condyles. Intracapsular F.acture : — Occurs v ithin the capsule of the joint. This ?s peculiar to old age. Seldom under 50 years of ae^e. M jre common in women. Occurs from slljij^ht- est causes t"s (i) Tripping. (2) Misstep on going down stairs. (3) Even turning in bed. In old age, especially on account of the change in the struc- ture, shape and position of the head of the bone. Xcck said to be more horizontal, and about the middle and under part of the neck compact bone is softened. Signs : — (i) Inability to raise limb from the bed. (2) Evcr- sion. (3) Alteration in shape of hip. (4) Shorter distance be- tween Trochanter and Acetabulum. (5) Less rotation of the limb. (6) Pain at the seat. (7) Shortening. (8) Crepitus. These signs will be modified by the presence of o the esec- siile; e ot r 50 Pht- airs. riic- said I^art ver- he- the nee cnt. ove TC- lue th- >sis 3ly i 8VRQERY 131 due to the capsule in front havnnp remained. Tlie lower frag- ment may be caupht in such a way as to cause this. (7) Shortening is at first exceedingly slight, -vs'Ki-ial'y ir. im- pacted femur, a quarter of an inch is usually the amount; half an inch is more rare. All depends upon nhc amount of im- liaction and the amount of rupture of die capsule. Later on the shortening is more appareiU. due to niovemtnts of patient and relaxation of muscles, may increase to 2 or 21-2 inches. Methods of estimating shortening: — i. Ant'r. Sup. Spi- nous process to imier malleolus; measure both legs in the same position ; evcrsion ; pass dctwri inner side of Pelvis, hallacies are: — (i) Congenital shortening. (2) Previous forgotten fracture. (3) Lessenetl development of one leg in length and diameter. 11. iiry.iiu's Triangle: — Bryant took two flxi-d points, the Ant. .^up. Spine and i!ie jjreat Trochanter, encircled the bcnly with a line crossing tlu Xnt'r. Sui). spines; then draw a lint from either side from great TrochaiUer uji to the circular line, and on affected side get a shortening; this converted iiUo ,1 triangle by connecting the Ant. Sup. Spine and the great Trochanter. TIT. Xelatt>n's line : — A line drrwn from the tubero'.'.ity of the ischium to the Ant'r. Su])'r. Spine, always passes over the point of the great Trochanter. In shortening the great TrochaiUer rises up above this line. 1 )iagnosis:— Make this with as little disturbance as possible No attempt should be made to elicit crqntus because intracap- sular fracture should \q looked upon as impacted: hope for this at any rate, for witiicnit this there will be no bony uni»>n. Make diagnosis from the age of the patient, slij^jht short- emng. flattt'tiing of trochanter. eversiiMi and inability of pa- tient to turn lind) in. and Iocalize- on account of the time the patient has HI 'I .M . ■ ii .111 }}% I j 132 HDRQERY to stay ill bed, bcsitles a nurse cannot work about a liouble baK I'rom the first give instructions about the parts of person rest'u^ on l)ed; alcohol and ahim rubbed on daily to prevent bed-sores. If old pers«m ancl no ini])action. don't ex- pect to g'et bony union. Just keq) lep between sandbars, and allow patient to sit up in three weeks, ami a])ply after this a ilatuiel or plaster of Paris bandage and lit patient i^et into a chair. Where there is impaction, no matter how f)ld the patient, try and g'et bony union; apply extension with weight ainxl pulley; a long splint is seldom required for these old people; they usually keej) pretty andage (batting) over rach malleolus, then apply Mead's i)iaster dressing above the knee joint, the i)iece of wfxxl for extension sliould be 2 inches below the sole, secure the plaster strips with a jilaster si>irally (»r spiral bandage. If a vigoTous old ni'.n, use a long splint. A long splint should reach the level of the i.ipple : 5-7 lbs. should be used. TX>lling on a pulley. I'oot of bed should be raised. If confinement is well borne keep in bed 6-8 weeks, and then allow u|>on crutches, first ai>i)lving a light plaster spica over the region of the hip. (")nc of the difficulties is the eversion which you should try to cor- rect by sand bags, or a guide to the other side; nearly all walk with everted f(X>t afterwanls. I'xtracapsular I'ractures : — May occur in eairly life by greait direct viple a fall on the hip may cause it. Signs: — Similar to Intracapsular form; owing to the amount of comminution it is always possible to get crepitus. Kver- sion marked. Inversion may occur, limb shortening from the first one-half to 2 inches; shock great, and extravasation of bl(K)tl greater than Intracapsular fracture. Diagnosis between Intiacapsular anlicati()n of long splint never attach it to limb by means of a bandage; attach splint at only two points, at the top around the body by a broad bandage, and at the bot- tom to a piece of w(>of the Fennir : — Gen- erally by a gunshot wound; clean out the wound and remove the fragments. If this fails do an excision. Fracttire of the head, neck and trochanter : — Same as In- tracapsular. Fracture of the great trochanter : — Very rare, b'racture of l'.pi|)liysis of great trochanter: — ( )nlv a few cases reported, from indirect violence or muscular contirac- tion. Always m young sul)jccts. Symptoms: — Pain, swelling, soft crepitus, fragment fell freely movable, and limitation of movement. In the II cases reported, 6 had iiipparation, and 5 died of septicaemia. . • ?1 r Ml > n I 184 SUKGEItY 1 1 Treatment: — Draw frapment down, and keep it in position with a pad and spica bandape; keep leg at rest. .Separation of Epiphysis of Lesser Trochanter : — Only one case in Canada. Dr. Fenwick's son. Died of suppura- tion. Fracture of the shaft of the Femur : — Very conunon, es- pecially in children. A quarter of all the fractures of child- ren under ten years. In children transverse. In adults obli- q\u\ usually overlap and much shortening. Signs: — Nearly all the signs are well marked. Displace- niicnt and deftwmity. In the upper tliird get an luuisual amount of displacement, owing to the Psoas and lliacus. lx)wer frag- ment is drawn inwards by the adductors, and up by the ham- strings. ALid ; then put on long splint. If you have nothing at hand, you can use temporarily a long side sj^lint, wuh three pairs of holes at the iof[>; secure *■ — " " ill- ntfitfr^ n' oli sition Only pura- i, cs- hilfi- obli- lace- ount "rafi:- latn- • WCT nta, we ligh etit. o a out ine ing Ills he on id l)V 111 - f*'f; SURGERY i:i5 this to the ffiot by a bandape around the foot, and into grooves at the end of the si)hnt, then jjass a piece of cotton (rolled up to about the size of a large handkerchief) between the thigh and scrotum Cperineal belt), and pass it across and into two of the holes at the upi)er end of the splint. \'ery good temporarily. In children and young adults fair results may follow plaster of Paris put on iininediately. it may be good in children, but often get bad results; shortening going on in spite of you. In young children ound, or com- minuted (stellate). Both patellae may be broken simultaneously, bone seldom broken m the centre. Large upper fragment, and small low- er as a rule. When from muscular action, the soft covering of the bone is lacerated, and greater separation of the frag- ments: in direct violence not so much separation, nor tearing of ap(jneurosis, and more likely to get bony union. I .§ >u^\ H : '4 m m HVKnF.RY Symptoms plain; snap heard when bone j^ave away; proove, indicatinj^ the jjap between the fragments always is found, swelUnp comes on (piickly, the joint is full of synovia and blood. Treatment: — Bony union is exceedingly rare, lipamentus is the rule; occasionally there is absolutely non-union, (rocid short stron^^ ligamentous luiion is as good as bony so far as usefulness is concerned. Immobilization of the extenrled limb, when not widely separated, and aponcumtic tearing slight. Immediate application of plaster of Paris is go^ :\ \ <^.. ^ <«* > ^v 1. '^ 23 WEST MAIN STREET WEBSTER, N.Y. M580 (716) 873-4503 ^ SURGERY 137 draws the two pieces tog^ether by wire. 'Care must be taken in both these cases to rub the two surfaces together. MacEwen found that lie could not get good resuhs by any method. He found, when fractures take place, that the soft structures covering the bone fell in between the frag- ments, and so prevented union, and he thought nothing but opening the joint would remedy this, done as follows: Operation of suturing the Patella : — Antisepsis; incision ver- tically over the patella, and expose the fragments, remove the blood clot, and irrigate the joint with Sublimate 1-2000. Take the two fragments and saw through them, making perfectly plain cut surfaces, bring them together with silk (best) cat- gut or wire, two sutures generally employed, one on each side. Make a dependent opening on one side well down behind for drainage. Put on a ]>osterior splint, and keep on for 4-6 weeks without disturbing; result is bony union. Care must be taken in beginning passive motion lest the bone snap again. Before flexing, massage and oil the limb. Compound and Comminuted fractures — falls from height, and gunshot wovmds. Irrigate the joint, remove all bone fragments, and suture together fragments with cat-gut, anti- septic dressing and posterior splint. Open suture of the patella should be apptroached with care, as many result badly. Stilif leg often results; Bryant, Barker, and Mayo Robson have given it up entirely. In hospital practice it may be advisable, as patient is watched carefully. Fractures ok thk Lec; : — The bones of the leg may be frac- tuired together or separately, and by direct, or indirect viol- ence. Direct violence here as elsewhere nearly always causes a transverse fracture, and bones broken opposite each other. In indirect violence we get of the tibia an oblique fracture downwards, forwards and inwards, and you look in vain about for fracture of the fibula, and overlook it, as it is fre- quently broken up near the head of the bone, and this therefore often overlooked. Always examine up high. In transverse there is little displacement, in the other great dis- placement. The calf muscles pull the upper end behind the other fragmen... i ! P hi ;'l! '11 V ; 'i 11 138 8URQERT Compound fracture is here commoner than in any other part of the body, owing to the sharp end of the tibia perfor- ating the skin. Simple fracture often converted mto a Com- pound by moving, e.g. attempting to walk. etc. Signs of fracture of both bones: — Usually unmistakable ; we get crepitus by rotating the foot inwards and outwards. Pre- ternatural mobility when both bones are fractured. Treatment fracture of both bones in the shaft : — Where displacement and extravasation is slight, put the limb in plaster of Paris at once, but when swelling is considerable, and blebs are present, it is better to put the limb, temporarily, in a MacEntyre's splint for a few days, or better still in a lax splint (two sides and a bottom, with foot piece and sides movable). Pad box splint with cotton wool, then assistant making extension fastens foot to foot-piece, bring the sides up and put strap across. Sides of box should be higher than the level of the tibia; if they are not put a pad under your straps. Have an extra pad or two at the seat of fracture. With an appliance you can apply ice and watch the blebs lest they burst; if they do, dress antiseptically. Better always to leave them alone. At the end of lo days may substitute a plaster of Paris bandage, or put on side splints such as "Klein's;" these should be padded ; they have openings opposite the mal- leoli. Carefully pad here. In a pair of Klein's splints, the outer has a foot piece, the inner may or may not have a footpiece. Keep on with bandage for a week, then remove, anly fd Dly :he m- ng en ;x- ■o- 3t- Ig- :us by he ,nd lad er. SURGERY 143 Another is Ericson's leather "T" shaped spUnt, arm piece long enough to extend from elbow to axilla, and as wide as the arm. Chest piece 15 inches or so by 7-8 inches. Gutta percha cap on the shoulder. These are put on while the assistant is making extension on the arm; secure the cap on the shoulder with a spica bandage. If a strong man keep in bed 2-3 days; weaker people no bed at all. Passive motion to prevent ankylosis. Great Tuberosity : — Very rare; violent action of three mus- cles inserted into it. Cirried upwards and backwards and usually get subluxation of joint itself. Shoulder from this looks broader; get crepitus. Treat: — Bring into place, and keep there by means of com- presses; put pad in the axilla, and arm close to side. Epiphysis: — Very rare after 21 years. Same symptoms and signs as fracture of the surgical neck. Crepitus is softer. Treatment: — Is the same. Shaft of the Humerus: — In any situation. Direct or indi- rect violence, or muscular action. Situation and obliquity of the fracture; modified by muscles; Deltoid, Latissimus Teres Maj. & Pectoralis Maj. may modify. Treat : — In weak people; and whore little displacement may apply plaster of Paris at once, using cxf,Mision wliile ap- plying. Better — by coaptation splints applied e:cactly as in case of fracture of the Femur. Gooch's splinting — use four of them. The outer and posterior should be loro-er than the other two. Bandage arm from hand up to elbow, pad splints and cover them with plaster; much depends upon the sling, which should l)e applied to the zvrist only, so as to have the weight of the arm pulling on the fracture. In strong people must apply extension, by weight and pulley, which are held by Mead's plaster (^^.y 4-5 lbs. weight). May use three coaptation splints, with back splints. Sling should always be about wrist and no higher. Lower end of the Humerus: — i. Simple transverse frac- ture, separating the articular surface from the shaft. 2. Form running into joint. 3. Separation of the Condyles; one or both. 4. Separation of Epiphysis. All caused by blows, and usually when elbow-joint is bent. ■til i' ■ !■•■ J 1: 144 8URQERY They are important, very common, and often very hard to make out, usually need an anaesthetic to diagnose. Sig-ns : — Much swelling; great effusion; sweUing may need several days of ice before can diagnose. Diagnosis: — Expose both elbows, and carefully compare, feel and compare the two condyles and the olecranon with other side; look for widening, narrowing or separation. Some stiffening, and deformity nearly always follows. Treatment: — If the bones of the forearm are not involved, best to treat with an anterior splint, not exactly at a right angle; may use any frrm material; best with a hinge. I-«ave elbow bare, use compresses for condyles, apply ice to bare elbow for some days. If, however, you have a doubt as to the fracture of other bones, position between pronation and supination is the best, with thumb upwards, and apply inter- nal splint. More comfortable, and best position in case of a stiff joint. Apply cold to the outside of joint for several days. Fr.acti'ke of Ulna: — (i) Olecranon. (2) Coronoid. (3) Shaft. Olecranon: — (Like the patella), from direct violence, or muscular violence (triceps), i. Oblique, peirhaps comminuted and little separated. 2. Transverse, great separation. The upper fragment is drawn up, joint involved, and much effusion into joint, and cannot extend. Union, by bone (direct violence). Ligamentous (muscular action). Treat: — Arm in almost straight position, slight flexing. Long anterior splint, and figuiie of 8 to draw fragments down. Passive motion early; fortnight. Coracoid Process: — Rare. Only seen in connection with dislocation of the forearm. Keep airm perfectly quiet in a sling, and an internal splint. Fr.xcture of the R.adius: — (i) Neck. (2) Shaft. (3) Lower extremity (CoUes). I. Neck: — This is rare, occasionally connected with dislcn cations ; can be diagnosed readily in a tWn person by holding the head firmly, and (rotating the hamd, find that head does not move. Internal angular splint, with thumb uppermost, use little compress over the head of the bone. to eed ire, rith me ed, jht ive are to ind er- f a ys. ^3) or ed ch lar th er es 5t. 5 ' SURGERY US 2. Shaft : — From direct or indirect violence, and should be treated as a fracture of both bones. Fracture of both be les of the Forearm : — Same rule should be followed as in both bones of the leg, when from direct viol- ence the fractures are directly opposite, when from indirect the radius in upper third, the Ulna in lower third, i. e., at their weakest points. Greenstick fracture a very common form from falls on the hand, etc. Diagnosis : — Easy, crepitus nearly always, preternatural mobility. Treat : — Apply anterior and posterior splints well padded, ordinary wooden splint to metacarpo-phalangeal articulation, posterior down to the wrist, not further unless fracture is very low down (rare) ; the anterior should have a pad at the end for the hand, put arm in the semi-flexed position, midway between pronation and supination. Splints should be always i^'idcr than arm, or we get permanent disabling from loss of the interosseous space, i. e., callus thrown out between the two bones, and so no pronation and supination ; pad the posterior especially well about the wrist ; the interosseous pads ad- vised by some are unnecessary, and besides may press on the nerves and cause paralysis, arm across the chest, supported by a sling from wrist to elbow. If in children correct the ben^., overcorrect it by giving anaesthetic, and completing the fracture, or greenstick may remain bent. Dr. Roddick does not believe in plaster of Paris for the forearm, on account of the danger of destroying the interosseous space. Use light splints in children. CoLLEs' Fracture : — Occurs about three-quarters of an inch above the lower articular surface of the Radius, results from falls on the palm of the hand ; especially common in old people, it is usually impacted, and is accompanied by character- istic " silver fork " deformity ; the upper fragment is thrown forwards, the lower fragment backwards ; find a distinct eleva- tion on the back of the wrist, while on the front of the wrist there is a corresponding prominence. Opposite the annular ligament there is a remarkable hollow, due to drawing of 10 m 1 if J ! 11 146 SURGERY soft parts; radius is adducted, and slightly rotated; the styloid process of the ulna is slightly displaced. Treat: — Usually impacted, and one would be inclined in an old person to leave the impaction, but here in spite of age we must break up the impaction, because the circulation about the wrist is very vigorous, and fracture about the wrist will unite by bone in the oldest person. If we fail to reduce, we get an unsightly, disabled arm, and a neuralgic condition. Variety of splints suggested : — i. Thin board 1-4 inch, and an anterior splint often sufficient with bandage at the end for fingers to grasp. 2. Some splints with hole for the thumb and wooden end, from the back of the wrist a piece of pasteboard leather, or gutta percha about four inches long, to two and a half wide, moulded in hot water to fit the back of the wrist comfortably ; pad with lint; no danger of the interosseous space here, a couple of pads of lint should be placed over the points where prominences were to prevent the return of deformity ; need also a couple of pieces of plaster. Break up the impaction; get crepitus; use forcible exten- sion on hand and abduct hand. Assistant keeps up abduc- tion and traction, while you apply splints — over the splints and plaster put a gauze bandage. Support the whole length of arm in a sling, and instruct patient to keep fingers quiet for three days, and after this en- courage him to move the fingers, and so prevent the callus from entangling the tendons, and prevent stiflf wrist, — at the end of two weeks remove, reapply for another week and then get good union; iremove and apply plaster of Paris bandage for two weeks more; perfect in five weeks. Metacarpal bones : — Ordinary anterior splint, or Lewiston's splint, to fit the palm of the hand. Phalanges : — Anterior curved Lewiston's splint, or whale- bone. Clavicle: — Very frequent, owing to exposed position, and shocks conveyed through the arm. Fracture may occur at any point. Direct or indirect violence. Commonest point n , n 1 i i • ,j, ': i A.. 1 SVROEKY 147 is just external to the centre, usually "greenstick" in children, *nd often overlooked. Signs : — Depend upon the seat. When about the middle the displacement is usually very great; deformity is due to the weight of the arm, and the action of the pectoralis. Outer extremity of the inner fragment is elevated, and may push through the skin; the outer fragment is the one that moves. Attitude — supporting arm. Treat : — i. By rest and position, is by far the best to prevent deformity; remain perfectly quiet in bed for a fortnight, the pillows should not press upon the afflicted shoulder; allow af- fected shoulder to drop, and so cause extension. Pressure of weight over the afifected part, such a^ with a bag of shot, extending from the sternal end to the acromial end, and held there by guides. The shot moulds the fragments into place, and so get excellent results. 2. Plaster of P. bandage sometimes does well in people who have to go about, figure of "8" may do for a day or two, but the best for going about is : 3. Sayres' adhesive plaster dressing. Two (2) strips of Meade's plaster three and a half inches wide are required. It should be measured so that the plaster goes once around arm and once and a half round body. Attach to the arm by a safety pin with adhesive side to the body; put once and a half around the body, and attach to the middle of back by sewing or a safety pin; the second piece is attached to the posterior part of the opposite shoulder, and is brought down the back of the arm to the point of elbow, where a slit is made to receive olecranon, then carry the pres- sure up the whole length of the arm and hand, and attach over the sound shoulder. Sayres used a thick plaster, but a wide gauze bandage is better. This is to hold arm to side, and should go around the body from elbow up to shoulder. Dr. Roddick takes a pad of ordinary lint and places it over the outer end of the inner prominent fragment and holds down by a piece of adhesive plaster ; this should be left on for a fortnight. This allows patient to go about. ,'"i 1 V i /'' 148 SURGERY n m DISLOCATIONS. A dislocation is a solution in the contiguity of bones where they touch each other, beinj^ in contrast to fractures which are a solution in continuity. They are in proportion to frac- tures as 1-8. Classification. — I. Simple. When joint displaced without in- jury to other structures, except ligaments which may be torn. II. Compound. — When displacement is of such a character us to open joint and expose it to the air. III. Complicated. — When, in addition to dislocation, we have a fracture, tearing of nerves, etc. A complete dislocation is one in which the joint surfaces are completely separated from each other. An incomplete or partial dislocation where they touch in some part. Dislocations of upper extremity form 3-4 of all. Most frequently the shouldar, then elbows, fingers, hips, etc. More frequent in males than females, except jaw. At extremes of life dislocations common. Varieties of Dislocations. — I. Congenital. II. Pathologic- al or spontaneous. III. Traumatic. I. Congenital. — Due to malformation of part, as in club foot. The joint most frequently aiTected is the hip, particularly in females. Many causes given as: Abnormal uterine con- tractions during pregnancy. Obstetrical disturbance. Un- fortunately this may not be recognized till child begins to walk. Other joints are shoulder, knee, ankle, patella, tarsus and phalanges. II. Pathological or spontaneous. — Occur as a result of joint disease, destruction of ligaments. Movements of patient and nmscular contraction does the rest. Sometimes caused by Morbus Senilis, and may also occur in Septic Arthritis. III. Traumatic dislocations occur in any joint from vio- lence. Causes: Predisposing and exciting. I. Predisposing. — Male sex, particulainly during adult life. Occupations: mining, machinists, millers. Congenital laxity of ligaments; weakness of ligaments from previous disloca- tions. Ball and socket joint more hable to dislocation than hinge joint. Paralysis of muscles surrounding joint. l' ' 1 STJRnERT U9 II. Kxritinp Causes. — Violence, muscular action, (a) Viol- ence. Direct, not very common, sliouMer. Indirect violence; the force heinp directed thrt)U>.,dv shoulder, Initnern^ actin.c^ as a lever, (h) Muscular action. — Throwing cricket ball. In action of yawninp;, as lower jaw. In tetanus, uraemia, 'Epi- lepsy. Symptoms. — Pain, loss of function of joint. Sip^ns. — I. Alteration in shape of joint. 2. Alterations in landmarks. 3. .Xhnormal position of hone. 4. Pre- ternatural immobility. 5. Shortening", rarely lenptheninp. 6. Alteration in direction of axis. 7. No tendency for deformity to return after reduction. 8. (")ccasionally after a time get pscudo-crepitus due to presence of blood clots, lymph oir erod- ed cartilaj^e. If there is much effusion of blocnl or serum, these sipis are often obscured. Pathology. — The severity of lesions depends on the force of violence ])ro(lucinp dislocation. Any wrenching or twist- ing movement will prove peculiarly disastrous. The whole capsule and associated lip^aments are more or less lacerated; short muscles may be completely ruptured or tightly stretched; ncig-hboring^ vessels and nerves may be contused, torn or pressed upon. Much blood extravasated in substance of con- tused muscle. General treatment in dislocations: — i. Reduce, i. e., bring liones back to natural position. 2. Hold them there until soft parts have had time to recover themselves, as a rule till serous and sanguineous effusions have been absorbed. Impediments to reduction. — i. Powelrful contractions of muscles. 2. Interposition of soft structures, muscles, tendons, ligaments. 3. Hitching of one bone upon another. Impediments in old unreduced dislocations: — i. New adhe- sions. 2. An adaptive shortening of soft structures, liga- ments, muscles, blood vessels, and nervous structures. As a rule, shortening is the common deformity. In ball and socket joint the rerrt may be comipletely closed up, and in old cases the misplaced bone will become changed in shape, it being partly absorbed, the cavity will become fill- ed up with fibrous tissue and more or less ossified. IP ■4 r' 150 SURGERY Methods of Reduction: — i. Manipulation, 2. Extension with counter extension . Manipulation, simple and more scientific. By this we attempt to make bone retrace steps taken in becoming dislocated, by putting it in a position to relieve tliose muscles which arc stretched. Must know anatomy. Extension and Counter Extension: — Is particularly useful in old standing dislocations, in which the alterations of out- line have prevented reduction by manipulation. Treatment: — For larger joints 10-12 to 21 days in splints; for smaller joints sometimes begin passive motion about 5th day; but this depends on inflammation. Friction; shampooing, massage to excite the absorption of inflammatory products. Sometimes use galvanism to pre- vent atrophy of muscles. Treatment of Compound Dislocations: — i. Reduction, usu- ally simple. 2. Wound may be enlarged; so treat as a wound of joint. 3. Drainage should be employed. When a fracture complicates a compound dislocation, wire parts together. Excision often the better treatment, allow- ing the space to be filled up with fibrous tissue, thus getting movement. One should not attempt to reduce a dislocated joint after an elapse of time equivalent to the time which the correspond- ing bone if fractured would take to unite. SPECIAL DISLOCATIONS. LowKR Jaw. — Causes: — i. Muscular action. 2. Indirect violence. Once having occuired is liable to occur again. In unilateral dislocations, symptoms are same; but not so mark- ed as in bilateral, in which the mouth is open and jaw fixed. When left unreduced, muscles and articulating surfaces adapt themselves to new position and parts become firm. Sub-luxation of lower jaw occurs in young individuals, usually those who can snap their thumb joints. When the mouth is opened, there is a little click and jaw slips out. It is due to relaxed ligaments, muscles and capsule. Treatment of Sub-luxation : — Preventative. Avoid eating fruit, yawning, crying out. on )re en :ve ^y- Ful It- er y; of e- u- id •c r- g r h I 1 i ill ^' SURGERY 161 Treatment of Dislocation: — i. Recent cases easy. Em- ploy an anaesthetic; wrap thumbs in towel and press down and backwards on molars, at same time lifting- chin with little fingers, and lower jaw goes in with a snap. Don't forget to cover thumbs. 2. Wedges between teeth and use tourniquet. 3. Pressing down lower jaw with lever. 4. Cooper's forceps. Constant diflocation : — Treated by, i. Injection of pure iodine into joint. 2. Opening joint and stitching cartilage to periosteum. Tliis dislocation ver^' difficult to reduce after fifth week, owing to cicatrization of capsule. CLAVICLE. Sternal end : — As a result of a blow ; sometimes as child is being barn; positions forwards, backwards, upwards. Sternal end not so frequently dislocated as acromial end. Diagnosis: — Measure distance on whole side, and then in- jured side; between distal end to sterno-clavicular articula- tion; sterno-mastoid is put on stretch. Reduction of forward dislocation: — Easy when early, i. Put knee in inter-scapular region and draw shoulders well back. 2. Place a wedge in axilla, and using humerus as a lever pry out the shoulder. 3. Bandage shoulder. Backward dislocation — Diagnosis: — Marked depression, pressure symptoms as shown by absence of radia' pulse, dysp- noea and dysphagia, tearing of posterior ligament. Reduction: — Draw the shoulder outwards and backwards, and maintain in this position by a fig of 8 bandage and wedge in inter-scapular region. Upward Dislocation: — Rare, as it cannot ocdr unless anter- ior, posterior and rhomlioid ligaments art torn, or else a frac- ture occurs. Sternal end of stern o-cleido mastoid very pro- minent, clavicular portion relaxed. Acromial end of Clavicle: — Exception to general nomencla- ture. Clavicle displaced on to acromion instead of beneath it. Cause, a blow or fall on shoulder. Symptoms : — Arm hangs by side, seems longer, shoulder de- pressed; clavicle rides up on acromion, boundary of posterior triangle prominent and tense, motion ver>' limited. m ^ '1S2 SUROERT Treatment: — The over-ridinpf is overcome by urawing shouM- er ovitward. Retention in position. Stimson's method. — A long strip of plaster, 3 inches wide, is placed with its centre under the point of the flexed elbow, and its ends arc carried up in front of and behind the arm, crossed over the end of clavicle, and secured over the front and back of chest; while the 'l>one is held in place by pressure upon the clavicle and elbow. Sup- port forearm in sling and bind arm to chest. Displacement of scapula may be due to paralysis of scratus magnus and T.'iomboid muscles. SHOULDER. Dislocations of the shoulder, as frequent as all the others taken together, ra)re in yoirth and old age; more frequent in men than in women. Predispositions: — Shallowness of cavit\, large size of head of bone, exposed joint, freedom' of movement, great laxity of capsular ligament, great leverage, mobility of scapula. Causes: — Direct and indirect violence, pathological and congenital. Classification: — i. Subcoracoid ; dislocation forwards and a little downwards. 2. Subglenoid; dislocation downwards and a little forwards. 3. Subclavi'cular ; dislocation forwards and inwards. 4. Subspinous; dislocation backwards. 5. Supra- coracoid; upwards and forwards. I. Subcoracoid Dislocation. — Cause: — Direct and indirect violence; muscular action. Symptoms common to all dislocations of shoulder: — i, A depression immediately beneath acromion. 2. Pain about part with more or less immobility. 3. Alteration in axis of limb, and head of bone in abnormal position. 4. Dugas' Test: — If fingers of injured limb be placed upon the sound shoulder, in dislocations the elbow cannot be brought against chest. 5. Callazi'ay's Test: — A tape round acromion and under ax- illa will measure about 2 inches more on the dislocated than on the sound side. 8 6. Hamilton's Test: — If a straight edge be applied to the outeir side of arm,, it can only be made to touch the acromion and external condyle at same time, when head of humerus is absent from glenoid cavity. In subcoracoid dislocation we have in addition: — i. Elbow carried backwards and directed away from side. 2. On deep palpation in axilla upper part of shaft of humerus is felt, and when elbow is raised, the head is felt anteriorly and internally. Subglenoid L>isUx:ation. — Cause: — Fall on abducted limb, or heavy blow on upper and outer end of humerus. Symp- toms. — Arm lengthened; elbow thrown away from side; hol- low beneath acromion marked ; head easily felt in axilla. Can pass fingers beneath coracoid above head of bone. Anterior axillary fold markedly lowered. Luxatio erecta. — Rare. Cause: — A fall, the patient clutch- ing something. Symptoms. — Arm abducted and raised, axis of humerus being directed upwards and outwards. Subclavicular Dislocation: — Arm shortened; elbow^ thrown backwards and outwards. Head of bone felt and seen below clavicle. Subspinous Dislocation: — Elbow advanced; arm rotated inwards and close to side; a marked hollow beneath coracoid process and a prominence under spine of scapula. Supra-coracoid Dislocation — Rare. Caused by violence in an upward direction either to shoulder or elbow. Symptoms, — Acromion or coracoid process usually fractured. Treatment: — I. Kocher's ]\Iethow forwards, up- wards and inwards until opposite median line, still maintain- ing external rotation and abduction of wliist. Thirdly. Rotate arm inwards, carrying hand towards opposite shoulder. II. Traction with knee in axilla against head of bone, make extension out\^^rds; then lower the arm, bending down the humerus over the knee. III. Extension with heel in axilla: — Patient lies on mattress or floor; the surgeon presses his heel against head of bone. Now make traction downwards and outwards at the same time, swinging humerus inwards, using heel as a fulcrum. • i I 'I .1 •1 t IS) SURGERY Treatment after reduction: — Bandage arm to side over a laige soft axillary pad, forearm in sling; apply spirit lotion, over joint. After a week begin massage and movement, in- creasing gradually. In a fortnight a sling is all that is re- quired. In a month encourage patient to use limb. When dislocation is complicated by firacture of shaft of bone, the head may be replaced by manipulation of upper fragment and clirect digital pressure in axilla on the head. If this fails must treat as a fracture, unless you expose the upper fragment and employ traction by inserting a hook into it. In this way the dislocation is readily reduced and then fracture is treated. Nerves and blood vessels sometimes injured. After treat- ment, immobilization of joint for a fortnight. Unreduced Dislocations: — After 4th week almost impos- sible to reduce shoulder joint, the healing of capsule, which takes place early, being a great impediment to reduction. Arthrotomy sometimes practised. Recurrent Dislocations: — Usvially due to unhealed capsules or ligaments, or gap being replaced by fibrous tissue. DISLOCATIONS OF ELBOW JOINT. Early diagnosis called for. Amount of swelling and great pain makes it almost impossible to 4iag"ose; so give anaes- thetic. May have dislocation of both bones or each bone separately. Both bones — Backwards, inwards, outwards, forwards. Radius — Backwards, forwards, outwards and downwards. Ulna — Backwards. Both backwards, commonest variety and usually the re- sult of fall on outstretched hand. Common in early life, due to coracoid process giving but little support to bone. In this anterior ligament is torn ; biceps stretched ; brachialis an- ticus torn and lacerated; partial dislocation the rule. Triceps stretched, carried backward, drawing olecranon upwards. Co- racoid process frequently torn off. Radius frequently re- tains attachment to ulna; forearm slightly flexed and fixed. Decided shortening when measured from styloid process of radius to internal condyle; olecranon distinctly prominent be- SVROERY 155 hind. Lower end of humerus presents a marked bulging. In a (Hslocation backwards olecranon rises above condyle. Hand and forearm are midway between supination and pronation; where reduced has a tendency to remain so. Treatment: — Overcome opposition of muscles by anaesthesia and reduce by traction, or ovor-extend the elbow and then re- duce by traction on forearm. Lateral Dislocation: — Usually from falls on closed fist or on back of hand; from direct blow on forearm, either inside or outside; or from machinery accidents. The radius and ulna may be dislocated incompletely to either side or complete- ly to the outer side. Incomplete inward Dislocation : — The sigmoid cavity of olecranon lies below and embraces the internal epicondyle, and the radius lies in front of and somewhat below the epitroch- lea. Both lateral ligaments are torn. Forearm pronated and slightly flexed ; olecranon and external condyle pix)minent : head of radius below and to inner side of normal position. Flexion and extension easy and not very painful. Reduction by traction on extended forearm and direct la- teral pressure at the elbow. Incomplete Outward Dislocation: — Tlie radius and ulna displaced outwardly, the radius lying below or entirely be- yond the external condyle. Both lateral ligaments torn and sometimes epitrochlea is broken off. Elbow flexed; forearm pronated. Internal condyle prominent, external marked by the projection of head of radius. Olecranon prominent. Treatment: — Disengage ridge of sigmoid from groove be- tween trochlea and capitellum, by traction, hyper-extension or abduction of extended forearm. Then push bones latterly into place by pressure on head of radius. Complete Outward Dislocation. — (Cause: — A fall on hand or elbow, or a blow upon inner side of forearm near elbow. Diagnosis : — Broadening of elbow and direction of bones of forearm. Elbow may be extended or flexed. Reduction easy on account of extensive laceration of the Hgaments. After treatment: — ImmobiUzation and rest. Forward Dislocation — Rare. Cause : — Violence received on back of flexed elbow. •ii i ir.6 SURaKRY m 1. Dislocation of ulna alone — very rare. Dislocation of radius alone — backwards, outwards, for- ^^•a^ds, downwards. I'ackwards: — Head displaced backwards and sometimes a little upwards behind humerus. Reduce by pressing forwards en head of radius. Outwards: — \'ery rare; head of radius being outside nor- mal position ; ulna normal. Forwards, the commonest dislocation fre(|uently accompa- r.ied by fracture of shaft of the ulna, due to fall upon hantl. Head of radius is displaced forv^ards and upwards, resting when elbow is flexed, against the anterior surface of exter- nal condyle. Head is felt in fold of elbow. Reduction: — Abduction of extended foreami and direct ptessure on head. Keep forearm flexed for three weeks. Downwards or Dislocation by Elongation. Clinical history characteristic. A child. 3 yeairs. is pulled by hand, cries out with pain ami refuses to use limb which hangs by side, partly flexed and pronated. Diagnosis: sensitiveness on pressure over head of radius; passive motion free in every direction, except supination. On forcible supination a click is felt as head goes into position. Practically can never reduce dislocations of elbow after fourth week. After this time unreduced dislocations demand excision. DISLOCATIONS AT WRIST. Lower Radio Ulnar Joint. — The ulna by usage is spoken of as the dislocated bone. May be forwards or backwards. Backwarfls. Cause — exaggerated ])ronation either volun- tary or by cxlcrnal violence. Ulna forms a marked pro- minence on bick of wrist. Reduce by direct pressure. Forwards —due to violence. Ulna projecting anteriorly, ove-- lapping radius as in previous. Reduce by direct pressure. Dislocation of Carpus from Radius: — Backward, forward, sometimes outward. Complete and incomplete. Cause.— I'orcible flexion or extension, or direct viohu'-.e Colks's fracture may be mistaken for dislocation of wrist SURGERY 157 backwards. Differential diagnosis is made by noting the position of styloid process of radius to its relations with that of the ulna and the projecting masi on back of wrist and with the metacarpus. Reduce by tr?,ctiou and pressure. Dislocation of Carpal Bones: — Backwards and forwards. Reduce by traction and pressure. Carpo Metacarpal Dislocation: — The metacarpal bone of thumb most frecjuently, usually backwards, more often in- complete than complete. Reduce by direct pressure i.nd ap- ply splint for a week or so to prevent recurrence. Dislocation of Thnmb: — Very common; great difficulty is frequently found in reducing backward variety; due to the interposition of the anterior or glenoid ligament and sesamoid bones. Backwards dislocations. — Incomplete, complete and complex. Incomplete form seen in people whose thumbs are double jointed; the first phalanx moving backward and standing at right angles to metacarpal bone. In the com- plete form the phalanx i? carried backwards and upwards on the dorsum of the metacarpal. Anterior hgament is torn and drawn backwards with sesam'oid bones past articular surface of head. The first phalanx is in extension at a right angle; terminal phalanx in flexion and Iiead of metacarpal is pro- minent in thenar eminence. By forced flexion of thumb this is changed into complex form, the glenoid ligament being turned upward so as to lie between the phalanx and head of metacarpal. Base of thumb can be felt as a prominence i)c- hind, and the head of metacaqial in front. Care must be taken in reduction to avoid transforming the complete into the complex form, Maintain extension; press thumb bodily downward until it overlaps the articular end of metacarpal; and then by flexing it, it is put in place. In this way the glenoid ligament and sesamoid bones are pushed before phalanx. In complex form same method but more force needed. Forward Dislocation of thumb: — Reduce by pressure IS ! I5s; SURCERY DISLOCATIONS OF HIP. «te Form from 2 p.c. to 10 p.c. of all dislocations, occurring at ail ages; more frequent in men than women. Backward Dislocations. — In which the head of femur pass- es over the posterior lip of acetabulum, and lodges close be- hind it. In the common dorsal form the limb retains an attitude of flexion, adduction and inward rotation. I. Dorsal Dislocation. — The most common form. It in- cludes those on to the dorsum ilii; into sciatic notch; iliac ; and ischiatic. Cause. — External violence acting from below upwards, pushing knee towards pelvis. Symptoms. — Limb adducted, rotated inwards; more or less flexed; knee resting in front of opposite thigh. Voluntary movements lost; there is passive flexion and r^-: .-n, but extension, outward rotation and abduction are impossible. Treatment: — Relax capsule and Y ligament; replace head of bone by traction and manipulation or by abduction and outward rotation. Place patient on his back; steady pelvis; flex knee to right angle, rotate thigh inward and flex to right angle; lift upwards, rotate outwards and lower in abduction. II. Dislocations Downwards and Inwards: — In which the head escapes at the lower artd inner part of socket; lodging in obturator foramen, or in perineum. III. Obturator Dislocation: — (Caused by violence on back of pelvis while thigh is flexed and abducted. The Y ligamen, is untorn and head is displaced downward and inward ;!)•':< being held in abduction and flexion, foot pointed forward r everted; extension o-- adduction impossible. Adductor longu.; stands out like a tigiit cord. Reduction: — Flex hip to right angle; adduct while -nking traction; lower the knee, rotating inwards. Perineal Dislocation. — Caused by forcible extreme abduc- tion with laceration of soft parts. Symptoms: marked flex- ion and abduction of limb; shortening 1-2 inch or more. Reduction:— Under ether by flexion, traction, adduction rind then lowering limb. at ss- 36- an Il- ls. ss It CHi ^Jidk a tl ar th ce ca] tia up SVliOERY • V I ~ — — — ^59 '"« flexion,- pres"- ;nrsa" e'°, i'™^ '"^'' "-"• ■'-- ra„„,s • •hrougl, capsular .e,„, re, J ^^t L ™:. '° ^''"^ "^ ^'4 "I- Extend in all case, «r, , ' "* ™a'or muscle, «etab„lu„,. ""'' '° ^= to make Lead of bonrentr General Treatment nf n- i . •7 weeks; passive n.cl^'tre'da";"'"",'.-'^"'""-'' f°-' Jn fracture of rim of acetahnl ' ' *PP''"''on of ice batr ;;-e„t dispiacetneutt:::::' 'C- r ^rt-'°? „ ^"^ ^'X to eip-ht Cmgcmial Dislocation -Not „ t^H when child is so born u „!,K ^"'^"""'^ """"e "'-■liv ■>• «- More common among ^^^72'"'^' 1™" ^■'"'' '°° ■' Acetabulum more or r.„ ''',™'es than males. '■«'ed with paxahS Not „f "''''• ^''^^'"'enth. as-o 'Syn? to,"""'"'''-- ""''""•~- ''"^'=">. ""e ."lorSi": ^r^dhnZ'^'T^i S-tlkerif "f ^"'•' P™""^'" abdomen ">^ough both tracha„,""^lif ,'°^''- ^'^'^'°"'^ '"'e r" cept abduction. ^' movements fairly free ""! Trcatiimit :■ — Lateral capsule from neck of bone^ako"" '""'''°"' '^" division of ta"y; then extend thigh whteheTr" ""'"'''^ ^"^-P^"«- "P for eight months sZ« ' '" ^".^''"lum. Put new acetabulum. ^omettmes necessaty .0 chisel out 160 SURGERY . . DISLOCATIONS OF KNEE. These arc not frequent. May be forward, backward, out- ward, inward and by rotation, in order of frequency. The dislocation is frequently complicated by injury of popliteal vessels; sometimes resulting in gangrene. Forward Dislocation: — Complete or incomplete. Cause: hy- per-extension of knee, or direct violence on front of thigh or back of leg. When complete: — Tibi? lies in front of condyles, and may be displaced upwards; laceration great. Incomplete: — Articular surfaces of tibia and femur partly in contact; laceration less. Reduce by traction and direct pressure. Backward Dislocation: — Complete or incomplete; caused by violence on front of leg or back of thigh; patella sometimes dislocated outwards. Reduce by traction and direct pressure, or by flexion and rotation of leg with traction in flexed position. Lateral Dislocations: — Less frequent; outward, inward, complete (rare); incomplete. Cause: Forced adduction, in- ward dislocations, and forced abduction, outward form. Symptoms. — Projection of head of ibia on one side, and condyle of t'onutr on other. _ Reduce b} traction and pressure, then immobilize limb for several weeks to allow lateral liga- ments to make firm union. Dislocation by rotation. — Outward or inward according to t'irection in which toes are turned. Condylar surface or sur- faces are displaced according to axis of rotation. Injury rare. Dislocation of Scinilimar Cartilages. — They may be de- tached at either end or peripherally displaced inwards or out- wards or lacerated. Cause. — Dislocation, flexion or sprain of knee. Rotation of leg. Symptoms: — Sudden painful locking of joint, fre- quently recurring. Treatment: — Bandage or pads to prevent displacement, or too great flexion of knee. Sometimes suture cartilage to tibia. Dislocations of Patella. — Outwards, inwards, edgewise, It- he ia\ ly- ?h ay :ly by es id ■d, n- k1 ■e, a- lo r- ■e. e- f_ . I- )n e- 3r a, e, i| II I iil iiii I HURQEHY 161 vertical, upwards or downwards. The last two due to rupture of li^amentuni patellae and quadriceps tendon, respectively. Outward Dislocation: — Patella rests against outer surface of external condyle, either by its inner, posterior, or anterior surface. Outer border is directed fonvard. Diagnosis. — Patella in abnormal position. Reduction by direct pressure, first re- laxing quadriceps by extension of knee and flexion of hip. Inward dislocations same as outward but less frequent. Dislocations of Fibula: — Upjier end. Outward and for- ward or backward and upward — rare. Is easily recognized and reduced by pressure on head of filnila. I'ackwards and upwards very rare. Dislocations of Foot. — Backward, forward, inward and out- ward. Backward: — iCause. — Extreme plantar flexion, lateral liga- ments torn, foot slips backwards, astragalus becoming fixed behind tibia. Symptoms — h'oot shortenel(»gy is doubtful. In certain subjects, i-k- pecially delicate boys 8-18, of an ill-nourished, and possibly strumous tendency. Pathology: — Long bones of the extremities are the most fre(|uent sites, more common in the lower. I'sually begins in the i-piphyseal line, by intlammation and effusion beneath the i)eriosteum; pus ([uickly forms and sjireads rapidly; it may reach from one epiphysis to the other. In injury the trouble begins at the point of injury. Pus goes through the perios- teum at several points, but seldom invades the epiphysis. In severe forms the joint may become involved, and may get suppurative arthritis. Many think it begins in the medullary canal, but text books vary. If not relieved, Septicaemia or Pyaemia result. Symptoms: — Rigcf early, Temp. 102-104, headache, mal- aise, vomiting, diarrhoea, patient thought to be sickening for specific fever; on the 2nd or 3rorts. Other methods : — i. Parenchymatous injection with hypo- dermic after drilling into bone and cavities of lo per cent. Iodoform and Glycerine, or lo per cent. Iodine or lo per cent. Balsam of Peru and Glycerine; repeat injection 2 to 3 times a week. 2. Acu-puncture — finest point of thermo-cautery. Pene- trate the diseased area in several places; pack with Iodoform gauze. This s around dead bone; gradually widening, separating the living from the dead ; at the same time granulations spring up, and lift the seques- trum away from the healthy bone. The ])eriosteum thickens and ossifies, and forms a roof over the sequestrum. If the periosteum is dead, the secjuestrum lies uncovered. Gradu- ally new bone grpws up around the sequestrum, and it becomes invaginated. At i)oints where pus originally escaped, we find cloacae. I'rom these, foul pus exudes, atid on ])assing in probe feel dead bone. The ultimate expulsion of the setjues- trum is caused by the gradual growth of granulations push- ing it up and through the cloacae. When invagination has taken place, the process is slow, and may be impossible. Treat: — When it can be got at the sequestrum should be removed as early as possible. The sequestrum is bloodless, dirty white or yellow, with probe, has hard ringing sonorous feel; on the free surface smooth; under surface is rough and worm-eaten appearance. When invaginated thoroughly, don't attempt to remove i< I 170 tiii{ut:uY early, f^ivc it tinii' t<» separate, and for pramilaiions to si)rinf^ up about it; niako incision ovei it free, make use of sinuse and cloacae; if these are not enou)^h use g^ougc, saw. gnaw- injjf forceps, etc. Should the se(|uestruni be lonp, Jind extend across the open- ing, break it up, and remove piece-meal. Thoroughly cleanse cavity. In early cases may leave the granulalions, but when old and stinking scrape them away. Zn. iCblor. 40 grs to the oz., or Carbolic may be used. Dust -.^ith Kulofurm. and allow it to till up. If ])erfectly sure it is clean, may fill it up by blood clot; rare. Decalcified bones are sometimes used as a framework. Keep the o])ening in the soft parts patent by means of lodofo'iii gauze. INFLAMMATORY DISEASKS (W TflF. JOIXTS. • Synovitis: — May be i. Acute. 2. Sub- Acute. 3. Chronic. Simple Acute : — Causes: — Blows, bruises, sprains, injuries in the neighborhood, rheumatism and gout, gonorrhoea, acute S])eciric diseases, early stages of syphilis (secondary), tabetic. Pathology: — Synovial membrane red and congested, lo.-t its lustre, synovia increased -- amount, thin, serous im qual- ity; mixed with inflammatory exudation; some cases go on past this and gel turgid; blood red and a condition resembling chemosis. Should resolution ensue all will disappear; if not, it may go on to an arthritis; suppuration may ensue; rare to get a primary suppurative synovitis. Symptoms: — Heat, swelling, pain, distension of joint, fluc- tuation. ])ain worse at night, sharp usually; in gouty and rheumatic subjects it is gnawing. Heat dififuse. difference in tem]). of the two joints. Knee is flexed on account of the relaxation of all the ligaments; all hollows are obliterated, the patella riding. Constitutional symptoms: — Fever always. Should! reso- lution ensue, the constitutional symptoms disappear rapidly; occasionally get suppuration. Treat: — Absolute rest, confinement to bed; some kind of fi i • 1 SURGERY 171 si)lint. Ice always indicated. cxcc])t in rlicunialisiii or jj^mit, where we use hot fotnentatioiis. Leitcr's tubes, soothing' hninicnt; tjpiuin, and helhidonna later. internally : — In simple form Pot. I'icarh, dose or two of Quinine, nothing is really necessary. Rheumatism Sodii .Salicyl. (iout. Colchicum, (lonorrhoea, lo ^rs. .Sod. Sal. with a drachm Tr. L'uhebs. Sy])hilis, lltj. Dover's for pain. Aspiratioti, if disteiuion very j^reat, and unresolved. Sub-Acute Synovitis: — Similar to the above. Chronic Synovitis: — Should be limited, to cases where ef- fusion remains serous, and usually whvre acute syini)toms have subsided. Symptoms:— Little pain, no lieat. Tenderness and swelling', weakness in the joiiU. There is here the danger that in strumous patients 't may become tubercular. The great trouble is effusion which con- timies; we get a regular dropsy of the joint; Hydrops arti- cuh; Hydrarthrosis. This condition may be du<' to ruptm-e of the synovial membrane. Termination: — May be complete resolution after weeks or even months. \'egetations often result; the lingers may be- come thickened; flail sort of joint may result from over-dis- tension. 'treatment: — F. rfect rest, not necessary to go to bed, but immobilization should i)e secured by means oi leather, paste- board, or Thomas' splints. I'niform pressure assists in al)- sorption. Pot. lod I'ng. Fly-blisters (small ones) followed by poultices, or Hiniodide I'ng. 3 grs. to the oz. Strapping, Scott's dressing, Cautery, later massage, I'riction. passive motion, internally K. T. In Hydroarthrosis try the above treatment, and if failure it is justifiable to aspirate and apply pressure by means of rubber bandage or cotton wool. Change of aii and scene should dropsy return. Inject K. I. i to 2 or 3 of water into the joint. Manipulate the joint to rub it over the surface in- tc.mally, then let fluid run out by means of a canula ; this restilts in acute synovitis; be caireful not to let a-ny air into the joint. 172 SURGERY If all fail, open the joint, drain, Weep in lo days, dress antisep- tic, after dropsy joint will be weak, and needs a brace for a long time, salt-bathing and massage. INJURIES AND INFLAMMATIONS OF THE. MALE URETHRA. Rupture: — Any part; most frequently the bulbous or mem- branous. The Spongy Urethra ; 5-6 inches long. Mem- branous three-ciuarters of an inch longer above than below. Prostatic one and a half inches long. 1. The Spongy part may be ruptured by a kick on the flaccid ])enis. \'iolcnt connection in erection. In attempt to straighten chord cc. Symptoms: — Intense pain at the seat. Hemorrhage. Ring- like thickening at the point of rupture, with depression in front. Urethra drawn back, causing thickening; passage of urine may be obstructed. Infiltration of the tissues with urine, if urine passed shortly afterwards. 2. Mcmbrant)iis: — Kick while legs wide apart. Falling astride some object. Complication of fracture of the pelvis. Symptoms : — In a few cases there is only a little hemr'g. ; as a rule it is great, continuous, and recurring; early trouble in micturition; partial or complete retention. Rule: — Soon get evidences of swelling of the perinaeum, indicating infiltration, whiich as a rule extends. Part also ecchymosed. Treat : — If catheter passed, do so carefully; rule is to pass the catheter cautiously under anaesthetic. Thii>s to drain bladder and prevent infiltration, and by pressure to arrest hemorrhage. In the penile portion, can bandage around the penis. In the bull>ous portion a comi)ress and a T bandage. If he- morrhage continues, use injections of cold water, flakes of ice; styptics as tannic. If fail pass catheter, watch for infil- tration, and do an early perineal section. If seen 24 hours after the accident, find the rupture if pos- sible, bring the ends together and suture over the catheter, which is now in place. Leave the catheter in 5-8 days. Leave ■ •;' ) .: (5^ ■ cr , suuc,i:ry 17:? the perineal wound open; pack and let heal from the hottom. as the infiltrating urine will lead to ahscess. If not seen until after the expiration f 2-3 days, and there is much mnceration, then the urethra caiumt l)e rei>aire(l. ^\'e can repair the ure- thra if get within 24 hours: sometimes in 48 hours we are able to repair. Foreign bodies in the urethra: — Pencils, grain, calculi, etc.. may be impacted into the wall: dislodged by flow of urine, or may ])ass back into the bladder, forming nuclei for stone. In the spongy prostatic portion, foreign bodies may be lodged for a long time. rh(>si)hatic calculi may fomi in the Urethra. Treat : — Tf bcxly smooth and in the penile portion, it may be f1ushee sure meatus is large enough: if necessary, slit. If near the meatus may ex- tract with sinus forceps, where difficulty use urethral forceps, manipulate. .Sometimes have to open the urethra: small in- cision and press out: suture the urethra, and skin over ca- theter, and leave catheter in 5-6 days. Where body impacted far back:— (i) I)is|)lace backwards into the bladder. (2) Make perineal section. The latter is the best. Can close up. as no infiltration: leave catheter as bef ore. INFLAMMATIONS OF THE URETHRA. (i) Specific. (lonorrhoea. (2) Non-specific. The latter may arise from any cause: foreign bodic^- ex- cess of lithic acid: over-dose of drugs; excessive i " al habit : cotUact with Icucorrhot-al discharge. Ititlanunations spreading from stone in the bladder, Sometimes tubercular. Symi)toms: — Absence of itching; pain and gaping of ure- thra; no chordee in non-specific form. Removal of cause cures; no gleet follows. Microscope does not show gonococci. Treat : — Bland injection of Boracic. Tonics. Removal of cause; Lithic form more troublesome; cutting pain at the Meatus. Tubercular follows tubercle in the bladder: discharge some- times purulent, sometimes blood; more pain. HI 111 III I 174 SURQERY 3- Or- Stricture : — (A narrowing). Three (3) forms: — i. Spasmodic. 2. Cong-estive. ganic (few cases congenital). I. Spasmodic contraction of the Urethral muscle; this fre- quently occurs when passing an instrument. Cause: — Sensi- tive condition; nervous jjatient. commonly disturbed montal condition, also in the gouty and debilitated. Local llyperacmia may light up a spasm. Drugs: — Can- tharides, Tun^entine. Rectal conditions: — Inflamed hemorrhoids, fissure. In al- coholics it is common. Any part of the Urethra is affected, es])ecially the membranous portion. In passing a catheter, gently press against the stricture, and, if spasmodic, relaxa- tion soon follows. Spasmodic stricture has been taken for Organic and cut. I'n- der anaesthetic always try to pass sound as a test. A small ca- theter causes a spasmodic stricture ([uicker then a large one; hence the rule to use large sound. Trcaimcut: — Hot bath; opiate; fill with olive oil and trv' and pass catheter; if not successful give anaesthetic. Congestive stricture: — Some obstruction from inflammatory swelling; often acct)mpanied by spasm; small stream. In gout this condition is common, and occasionally also get a uretlir ritis. Trcatinait: — That of I'rethritis. Bland drink, linseed, Hyoscyamus. Pot. Cit. injections of linseed tea. ( )rganic stricture: — Cicatricial narrowing: — (i) Idiopathic. (2) Traumatic. (1) Idio])athic; — Causes: Gonorrhoea 75 per cent., or any urethritis; mt^re prolonged gonorrhoea, greater danger. Rc- l)eated "claps" are almost sure to result in stricture. Intra- urethral chancre; within i inch of the opening. Misturliation. (2) Traumatic : — From laceration of the Urethra. Kicks t)r Idows on the Perinaeum. Correction of Qiordce. Injuries from various causes, as already reviewed. The causes modify the character and extenit of the stricture. Cionorrhoca; softer, don't contract so viciously. Individual peculiarities influence strictures. 1 m i sniui:iiY 17J In syphilitic and tuberculous subjects, sti iircs are more extensive. The extent and shape of the stricture depends upon the mode of deposit of tlie cicatricial tissue. I. Linear or Ribbon. 2. Annular. 3. Band crossinjj^ canal, or bridle stricture, cohesion of two opposite ulcers. 4. Tun- neling. Consistency: — r. Soft and yielding. 2. Klastic or Resilient. 3. Hard and indurated. Cartilaginous or the whole Crethra may become blocked, which known as 4. Impermeable stric- turo. Sensation: — (i) Irritable stricture. Calibre: — According to the amount of deposit, i. .Small calibre, big deposit. 2. Large calibre, small depcjsit. Seat: — Commonest. Hulbo-membranoiLs [)ortion, involv- ing all the membranous, and the posterior one (i) inch of the bulbous. Next in fretiuency: — The Ant'r. two and a half inch of the Urethra. Results: — Changes in the Urethra, Bladder, Ureters, Kid- neys. The part in front is normal. Heliind the walls are thin. Canal relaxed and pouched, usually evidences of ulceration by dannned up urine. Ulcera- tion goes on the perforation into the periurethral tissues, re- sulting in abscess; usually j)osterior; perineal abscess. lUadder hypertrophied, sacculated. Urine accunndates iti pouches ; Cystitis; Calculi; Ureters undergo cHlatation. In old cases the kidneys sufTer, first get catarrhal pyelitis, hydro, pyo- nephrosis, multiple abscess. Symptoms: — Constitutional disturbances are usually slight; sometimes get rigors, or chilliness, due to ulcerations behind the stricture. I'Vequent nricturition in the day-time. Stream small, force reduced, twisting and forking (es])ecially in ant'r. stricture, and may occur without stricture). If at the bulb 3- membranous portion, there may be no change in fonn of strx^am. Dribbling of urine. Incontinence sometimes from constant straining. Retention from the slightest provocation, an excess of alcoholic stimulants, driving, cold, wet seat, etc., i where congestion influcod. Vesical tcncsmns. rilocty dis- charge from ulceration. I'ain and weight after ooiuiection, from (lainniin^- of seminal fluid. Cystitis common. Hemorr- hoids from straining, sometimes prolapse. I)ia|;rnosis: — By urethral examination; sec patient pass wa- ter; ivresence of resi(hial urine. Hep^in with soft I'rench I'.oug-ie .Vo. lo, or hctter testers with olivary ends; these, aft it passjn^^ the shoidder catclies, and demonstrites best the location of the stricture. If experienced use solid instrument; best forms. Lister with olivary bulb; \'an I'uren American, and best (ierman. Use a large instrument, Xo. lo anyway. This prevents spasm; does not catch. Treat : — Look into the general condition, especially the uritie, cut off all alcohol. If very acid Pot. Bicarb, and Tr. Hyoscyamus, and if putrid Boracic acid, lo grs. t.-i. d. in sohition alone, or with tonic, geiuian, etc., as routine. '1 he tieatnunt dineu' upon the kind and calibre of the stric- ture, and the i)atient: — r. Gradual dilatation. 2. Contimious dilatation. 3. I'Drcible expansion, or rupture. 4. liUernal Urethrotomy. 5. Lxternal Urethrotomy, or I'erineal Sec- tion. Three Operations: — (t.Symes. 2. Wheelhouse. 3. Cocks.) 6. l^lectrolysis. 7. Treatment by caustics . 8. P)y excision. I. (Gradual : — Stricture through which a 2-3-5 can be ad- mitted, patient camiot lie U]); comes every two to three days, and at each sitting you increase the size of the instrument. This is safe and satisfactory. In passing the soimd, the bow- els should be empty. Take every precaution with instrument, warmed except in gleet, lubricated with Olive oil. Keep well covered. If difficult, inject Ohve oil. If chilly after, introduce an- tiseptics into the bladder, and leave a little in. Thiersch's, or Boracic. 2. Continuous dilatation : — Start with 3-5 ; tie in a gum elas- tic catheter; inject antiseptics; change the catheter every two days for a larger one. May have some septic absorption, and pyoint of in.strument presses upon collapsed bladder wall, some- times causing serious ulceration. S!ROh:NY 177 3. I'orciblc Dilatation:-- Able to pass inustruincnt at least a Mo. 4. Holt's operation. Holt's (lilatt>r, also a Thomp- son's dilator; niplurc tin- tniicoiis nictnbraiu' in two or throe I)laccs, and f;ct a j^jood deal of scar tissue. 4. Internal I 'retlirotomy :— Done in strictures of small caHbre, eases n-lapsinj; after other methods of treatnient. and where all other modes of j,'ettinK" ililatation fail. I'ost results are in eartilapinous; irritable and resilient forms, and wiiere there is ;i ienme, blade sheathed. Here. Maisomieuve's mo-;s cavity and the urethra; then may (jpen abscess. If abscess openeil hastily, or bursts, the abscess ca- vity contracts uiuil we ^et a fistula resultinj2f. Urinary fistula may occur in any part of the urinar)- tract, from the kidney down. In the urethra, it is called urethral fistula. I-'istula may be straight or irregular, tortuous and long. In these infdtration more conmion. Diagnosed by tiie pre- sence of urine, previous history, and probe. Treat: L'rinary I'istula: — Simple recent case; straight fis- tula; treat stricture by dilatation, and inject Zn. Sulph. Sil. Xit., or armed probe. Hot wire. (lalvanic current; care being always taken to pass catheter before micturition. In more troublesome cases must cut stricture, and do a perineal section, at tlie same time opening up the stricture, or rather fistulae, scraping or excising. Subsetiuently i-ack and treat antisei^tically. Tie catheter in the bladder. \\ here in the penile jKurtion, close by urethro-jjlastic oper- atioii. Urethral l-ever : — Passage of instrument, or any operation on the urethra, may produce a peculiar febrile C(jndi*Jon, ca- theter fever, uraemic fever, etc. Common for rigor to follow the first introduction of an instrumtnt. even where no abrasion; due to nervous or ureth- ral shock. In other cases symptoms may not occuir until several hours after the operation, or upon the first micturition afterwards, when patient has chills, Temp., vomiting, thirst, anxious look, pains in the back and head; may last oidy a few hours, may last all night, accompanied by weakness, and sometimes suj)- pression of urine. In fulminating type, may be fatal in from 6-24 hours. Temp. 106, suppression of urine and distinct chill. Another class including prostatic cases, slight rigor, from which appears to recover, feels poorly for a few days, chilli- ness, loses appetite, thirst, tongue wn, Urine 1«0 .SUUOh'RY \ I imico-|)us. may p;o on for weeks, patient sufferinp; from a low form of s'-pticaf r.iia; develops pyelo-nephritis, dies at the end of two (2) months of surgical kidney. I'atholofj^y un- ex])lore(l. SfJinc cases may he of nervous oripin. Majority due to toxic ])roducts. Sternl)ur{^ found the Hac. Coli-Commxmis in some cases. Whether the micro-org-anism breeds in the tis- sues, (^r in the I'rine, is not known, proliahly hoth. Treat: — Prevent'on; do as little violence as possihie to the nnic. memh. '("horonj^h asepsis and antisei)sis. t'arefuUy examine tlie 24 hours urine before any operation. See the catheters are boiled with soda, atid bladder wash- ed out with antiseptic thiid. liorac acid for a week before grs. X t. i. d., or every six (6) hours. Aconite min. 3-5 with Horacic. (Juinine 10 grs. on the morninp of the operation; hot bath previously. Where mischief done; hot fomentations to the kidneys to prevent retention; dry cnpijinfj; hot enemata. I'ur^e with 6- 10 prains of Calomel. l""uhninatin<:;' form; Aconite min. V (|. h. Kepeat the i|uinine. Pilocarpine a-tenth to a-quaitcr < f a ^rrain hypodermically. I'alse l'as;;a.i;es : — Most connnon in br<'!:e stricture. If far forward the risk is nt)t jLi^i'eat : if in the usual district may wf)und th': prostate, ma\- run between the luethra and the rectiuu. .\otice by tiu-ninjj of handle and sudden start; the instrument comes near the outside fui{:^er. Withdraw the instrument, inject antiseptic Huioliitiuii. (_>) Ahsei'ss. (,^) (lironie inflammation. Treat :- Hrin}4;inj^ about resolution; pay no further atten- tion to tile jLjonorrlioea. Calomel puij^je; diet seen to. Inject with (K'ep s\rin,!4-e ^ilvl■r nit -'-5 ,y;rs. to oz. .\(|. Hot hip baths. l"'omeiitations to perineum with <»pium. Ice in rectum; early cases; ice l>aj.f to perineiun. Suppositaries of r.elladonna and Iodoform. .\bscess: — Pus suspected 1)\ increased pain; throbbing char- acter, chilliness or rij^or. rectum hot and full, excessively ten- der, may re<|uire an anaesthetic to make exanunation. Ab- scess marki'd in tlu- bowel. Detect tlucluation, one linger in the rectum, and the other in the perineum, pains in the groins, painful erections, cotistitutional symptoms. I inirsl into the urethui spontaneously, " " " " on p.isV of in- to p.c ^ ' ° [ " " '• rectum. Where a good deal of peri-prostatitis, the pus may btuTow forward to the base of scrotum, or into the i-chio-rectal region. Treat : Try and find pUN through the perineal incision, which is moditied "( ocks;" (one-h;dl an inch between wind and water.) .\void the urethra, and guiile with finger in rectum. Go in half an inch, then pass the director. ;ind. if find the i)us, pass the forceps along the director, open and drain. Where jioiming into rectum, open there; u>e a duckbill speculum, puncture with history; drain and inject with curved syringe, pa-k loilofonn. Keep bowel clean with injections. Starve th(> patient. If it bursts iiUo urethra, keep aseptic with Thiersch or Boracic. I'hronic inflammation: — Prostate. — Enlargement remains, flakes and shreds in the urine, scjme pain, frecpient micturition; gets up at night. 182 SVliUKItY T'-xaiuiiiatioii : — May find one lobe resolved; may have with this a chronic abscess formation ; suspect, tnbercle in l)hthisical subjects. lUiild up. Claret, Cod Liver oil. sea voy- ap;e. sea bathitif^; perineal douche, rectal injections of cold water. lUisteriiifjf of the perineum; blister H liours; poultice 24 hours; then biniodide of \\^. Inj^., half strenj^-th to keep open. .Suppositories of l!elladf)nna and I'b. Iodide into rec- tum at nij^^ht, and jjcrhaps ichthyol. .Silver nitrate into ureth- ra. ji,^rs. II. to the oz. Atrophy of jirostate : — .\trophy rare; jj[ives no symptoms. Hypertrophy of the prostate: — Advanced life, rare imder 55. iii'iy bcK'in before this. ( )idy recognized when symj)toms appear. ("auses:— .Syphilis, fj^out. stricture, sexual excesses, by de- terminiiif^ blood to the part act as a predisposinj^- cause, but the etioloj^' is very obscure, and i^roof that any tiling- out- side of f)l(l a^^e can cause it is wantinp;'. It is due to hyi)ertrophy of normal structures. .Ml struc- tures are more or less affected. (Karly stajj^es. jj^l.'UKhdar tissue chiefly involved, later the fibrous tissue p;-rowth is out of pro- portion to the j^landular and muscular. Distinct fibrous prowths'may occur in ^land. size of a pea to a walnut; imbedded in trl-nid with a distinct capsule, re- seml)lin{:r uterine fibroids; may be i)edunculated. Enlarge- ment and tumor may both obtain at the same time. Kniarpement is usually fjeneral; sometimes asynunetrical, or middle lobe most decidedly increased, assuminjj;' pyriform shape, sometimes pedunculated. With asynunetrical etdarj^ement. urethra becomes tortuous. When b(-»th enlarjjed. the urethra is elonjj^ated and com- pressed, slit like openinp^ for urethra. Symptoms: — .'Ml i\\\v to urinary obstruction. Sometimes symptoms are present without the knowledu^e of the patient. First notices loss of force of stream. Stream falling- directly from the penis; later he has to strain eonsiderablv; may seek treatment for piles, due to straining. Prolai)sus ani may oc- cur. Inp^uinal hernia also common. Straininp;. Frequency (nocturnal). Act not followed by relief; constant feeling of I tiVlidEllY 188 \veij,'lit aiul fiilliu-ss in tlu- jji-ritu'iuii. Ai'tiial pain is ran-. I'ritu' altered. Does not lk healthy. l''irst tiirhid: then alkaline, finally aininoniaeal. Always residual tirim-; I)lad empty. 1 )ribl)linj4'; i\\\': to atony of the blad«k'r; later some pain with sub-acute cystitis, liladdcr be- comes hypertrophie ibic Sciences Corporalion 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 m iV ^q) V 184 SURGERY drachm to the pint of Tr. of Iodine. Where soft rubber will not pass Coude and Becoude, the next best are the gum elastic, with stilette, finally the prostatic silver catheter may pass where everything else fails. No. 12. Operative measures : — Where in severe cystitis catheter causes ulceration of the neck; great pain, where the l)la(l{ler has been punctured, where prostatic calculus, where from a number of circumstances life becomes intolerable, then oper- ate. In emergencies, aspiration may be performed. Best method, perineal section; incision i inch in front of anus, three-quarters of an inch long, and make way towards the membranous urethra, using where possible a grooved stafif. Make an incision in the membranous urethra large enough to admit finger, then dilate prostatic urethra with finger if pos- sible, if too hard use Hilton's method, and pass in forceps, and dilate them. Go into bladder, remove stone, if any pre- sent, and pass in a large tube for drainage, examine if part of prostate within reach cannot be enucleated through this opening. Introduce a large round cube, leading to bed pan, or carry through mattresses, stitch tube to the edge of wound. This gives great relief; retained 10 days, may be changed after the 5th day; may be left in three weeks; the presence of tube displaces, and causes absorption of the prostate; three weeks more rest in healing external wound; catheter can readily be passed. Harrison's method — tunnel with trochar and canula, thrust through the prostatic tissues, then the rubber tube is passed through the canula; method causes shrinkage; not to be recommended; may miss the prostate, and transfix the blad- der, etc. Supra-Pubic Puncture: — As before, where no assistance. Supra-Pubic Incision: — Incision, introduce drainage tube, without attempting to remove any part of the prostate. Supra-Pubic Incision with Prostatectomy: — Bladder open- ed, projecting portion enucleated, only slightly adherent, in- cise muc. memb., reflect with finger, and enucleate. Pedunculated masses with small neck, remove with scis- \ <>ib--awa»3>flaj^-^-g*^^'-'~^i'|^ m SVROERY 185 sors, first throwing- a noose around the pedicle to prevent he- morrhage. Hemorrhage is sometimes alarming, needs very hot water 120-130. The mortality is very high, and found that patients are not benefited very much. Chronic form of retention due to atony of the bladder. Perineal section is most simple: drainage dejicndent, can sometimes remove part of the mass. Can always do a supra-pubic operation later, and here get better results; a week to 10 days should be al- lowed between operations. Castration for Prostatic Hypertrophy: — Ramur, of Christ- iana, jiroposed the operation in '93, as removal of the ovaries produced atrophic changes in fibroids. Where castration in the young, prostate does not develop. Wlvite, of Philadelphia, & Mnllen & Fenwick, in Europe, followed: removal of one testic. ; is no good. In a percentage of the cases reported, voluntary micturi- tion has been obtained. Marked shrinkage in many cases undoubted. Some cases where no fibroids in the prostatic mass, castration probal)ly docs little good. Atony of the bladder is not improved by operation, many mistakes have been made; calculus, tumor, etc., so conserva- tive surgeons recommend perineal section first. Ligature of the vas deferens: — As an alternative reconunend- ed by Harrison. Two ligatures over the cord after incision made, and then incise between. In some cases it is an im- provement. Testicles are retained, and this overcomes strong objection. Malignant disease of prostate: — ( ;) Carcinoma, and (2) Sar- coma. Sarcoma is seen in children, but is rare. Carcinoma in men over 50: diagnosis between the two is clinically im- possible. Cancer may be: — i. Primary. 2. By extension. 3. By metastasis. Symptoms: — Haematuria, pain, obstinate cystitis; bleeding extensive, pain in the perineum, in the rectum, and down the thighs. Diagnosis: — Per rectum, a hard, rapidly growing mass; not \ I 186 SUROERT like hypertrophy, irregular and nodular, later the glands be- come enlarged. Cachexia, pallor and emaciation. Usually fatal in one year. Sarcoma in children fatal in a few months. Treat: — Palliative, morphine freely, soft catheter; when too painful, do a supra-pubic cystotomy. For hemorrhage, injec- tions of tannic acid. Tuberculosis of the prostate: — i. Primary. 2. Secondary; between 15 and 35 years, subjects may be at times otherwise robust and healthy. Symptoms : — History of acute prostatitis, frequency and pain in micturition; pus in the urine, and sometimes blood. Slight elevation of temperature; generally secondary to tuber- culosis of the testicle, etc. Treat: — Improve the hygiene, change of air. Guaiacol, with glycerine and almond oil. Remove tuberculous testicle. At- tempts at radical cure are fertile. Germs in the pus found in urine. 'r . ! DISEASES OF THE BLADDER. Absence of the bladder has been seen ; ureter or rather ure- ters, generally opened directly into the urethra, vagina or rectum, or end in little sacs which contained considerable fluid. Multiple bladders known ; some cases only sacculations. Hernia, or cystocele, as inguinal hernia, wh.re the tumor is gradually returned without gurgling, and without other signs of intestinal hernia, especially where after return there is a desire to urinate immediately, then suspect a cystocele. Inversion of bladder, very rare — really occur only in women with short and relaxed iirethra. In male some cases of in- version as far as the membranous portion. In women the treatment consists in retuiming the mass; introducing the catheter, recumbent position, hips raised, cauterizing urethra. A long course of treatment is required. Exstrophy or Ectropion Vesicae: — Failure of development in anterior wall of bladder and abdominal wall in front ; blad- der projecting from the abdominal walls; the posterior wall be- lally iths. too ijec- ary; wise and 3od. bor- vith At- 1 in ire- or Lble •ns. • is ^ns s a len in- .ss; ed, ed. ent id- ^all -^ • -. SURGERY 187 of bladder is continuous with the ant'r. abdominal wall. Most frefjuent congenital malformation, in the proportion of boys 9 to girls I. Symphisis is absent; complete epispadias: pros- tate ill developed ; vesiculae seminales absent. Testicles ab- sent, sometimes present; often retained in inguinal canal; sa- crum projects foirward. Female: — X'agina converted into a slit. Clitoris labiae se- parated, vagina is ])atent. and uterus present, although un- developed. Tumor itself is irregular in shape, irregular, triangular.oval or circular, absence of umbilicus; leading up from mass a deitression indicating the linea alba. ]\Iass florid, injected, secretion below; projects forward from the pressure of the intestines behind, like half an orange skin. Sometimes like hernia, the surface bleeds readily, tender; orifices of the ureters seen as small round projections, and urine trickles, patients Avet; troubled with excoriations, collections of phosphates; erythema in the neighborhood; liable to erysipelas; concep- tion may occur. Treatment: — Appliances no good. Wood's operation : — Cio deep enough and do not excoriate the lateral flaps to cover the raw surface of middle flap. This modified by Ager. Modification in the male; turn scrotum up Morley's operation; defective; hairs cause collec- tion of phosphates. Thiersch: — He ,uggests lateral flaps, planting end in a gutter on the opposite side. In a few weeks take another flap ov6r on opposite side from above. Edges of flaps joined by scoring. Trendelenberg: — Only under five years; brings side walls together. Wounds: — Bladder; inflicted within or without. Within, surgical, foreign bodies: — (i) Penetrating. (2) Non-penetra- ting, as when, separating the bladder from other structures, also internally, such as are made with sounds or lithotrite, 1. Penetrating: — (a) Ex-peritoneal; sometimes a complica- tion of a fracture; stabs, and gunshot wounds with distended bladder; falls from a height. (M Intracapsular; commoner, «i>i .'I m • I I 188 SVR0ER7 I I u tlie prc.'itiT ])art covered with peritoneum, and besides this thinnest part, (c) Subperitoneal; vesical wall alone ruptured; very rare. S\niptonis: — History of injury, sometimes the bladder is n. 2. Chronic Cystitis. 3. I'l- ceration. 4. Abscess formation. 'rrcatiiiciit: — I^emove the cause; recfij^-nize the variety of T>acterial infecticMi; dilute urine by the administration of bland li(|uids; barley, rice and g^um water; Hq. Pot., or Pot.I'icarb., and Hyoscyamus; i)ut to bed; hot poultices over the bladder, and perineum 3-4 Hot Sit/, baths; morphine; no instrumenta- tion until urine becon.es fou', then use a rubber catheter, and Pioracic, Salol. or Salycylic acid. Diet milk and soda water. Early stag'es, where suspect that it is goinj^ to be bad; may- shorten by an injection of silver nit., a (|uarter of a grain to the oz.; increase daily if aggravation continues. In very severe cases may be justified in doing a perineal section one inch in front of anus into memb. part. • Chronic Cystitis: — Resulting from acute cystitis, more fre- (|ucnt a foreign body, stone, tubercle. Symptoms: — Insidious and slow. The three cardinal symp- toms of the acute variety: — i. Frecjuency. 2. Pain. 3. Pus. The freciuency of micturition is not so marked; more urine is tolerated by the bladder; pain is less. Pus differs; not so mixed up in the urine; most abundant at the beginning and the end of micturition. Largely mixed with mucus; tenacious, i^ t glaiiT)' and stringy. "Catarrh" of the blacklor is the old name. Mnco-])urulcnl discharge may interfere witli micturition. I rine alk.iHne, ainmoniacal, otTensive. Shreads of nuieons tneinh. (kie to (les(|naniative processes; large portions of the mucous metnhranes may come away ; croupous cystitis. Pathological changes. Mucous mem. ecchyniosed, mottled, slate coloured, covered with nuico-pus. At the trigone and the ojiening of the ureters tind the greatest changes; mul- tiple abscesses in the bladder walls, (langrene in some cases, hypertrophy, and sacculation. Diagnosis: — (i) I'yelo-nephritis. (2) Tuberculosis. To find if pus frvtni pelvis or ureter, wash the bladder, leave catheter in situ, then if pus iii ist urine it comes from kidney. Tiratniiiit: — Prophylaxis, remove any cause, catheter daily from the first; use a Xo. 8. Solution hotter than the body. Use Thiersch's solution or Boiracic acid, or Thompson's bladder solution: — Cdyc. Dzij.; water ozij.; sod. bibor. dri to ox. 1\' of warm water, ackl a tablespoon of the above. Silver nit. gri. to the oz., or nitric acid minims, one to the oz.) Sublnnate i-ioooo or 15000. Quinine i or 2 grs. to the oz., with minims. 1-2 of acetic to dissolve. Iodoform grs. 2 to 3 in gum water oz. i. Zn. Sulp. l^ot. Permang , copper sulp. Never inject more than 3-4 oz. at a time. Con- tinue until we get a clear tlnid. If injections not well borne, then try suppositories of iodo- form and gelatine. Internal treatment: — Diet; alcohol prohibited; drugs as s|)e- cifics. Drugs: — Buchu, Uva ursi, trit repens, as infusions, pint in 24 hours, besides potash mixture. Liq. not so good as other potash salts. Where gonococcus infection give copaiba. Hy- oscyanuis and morphine for tenesmus. Tuberculosis conies next of diseases of bladder. Tuberculosis; Tubercular Cystitis: — Proportion: Men 3 ; w-omen i. Primary form is rare. Usually secondary from extension from the pulmonary regionis, or effusion from the kidney. Tubercle extends most commonly from the prostate, seminal vesicles, testicle, kidney. SUROERY 191 The exciting cause is invasion by the tub. bac.,but usu- ally find evidences of predisposing causes, damaged walls go- nococcus predisposing. Seat is trigon, and openings of the ureters, first red then pufify, swollen, fungus looking. Then get an ulceration tend- ing usually to spread superficially, or rarely to perforate, re- sulting in fistulae. Symptoms: — Frequent micturition, most common after meals and at night. The urine is tinged with blood and later pus. Pain does not come on early, but late, and is then in- termittent, finally with ulceration intense and continuous. Later in the disease get infection of the blood by pyogenic germs. Constitutional symptoms are not marked at first, but later are distinct from loss of sleep and pain. Prognosis: — More rapid when secondary. Death from Tub. Peritonitis, spreading to the kidney, miliary tubercu- losis, etc. Treatment: — That for Tuberculosis. Irrigation is harmful. Instillations of Sublimate 1-500; 10 mins. to .:;o mins. inject- ed every 2-3 days. (Guyon's method), also Iodoform 2, Gly- cerine 2, Mucilage 4. Water 20 parts, inject two drachms once or twice a day. If late give opium. Perineal, or Supra- pubic operations. Perineal is not recommended as likely to ulcerate; cannot examine the bladder well. Cannot examine local'y or scrape, or apply Iodoform directly, as in Supra-pubic operations, which is the operation to be recommended. In the female, no operation!, d'ilatation of the urethra. FOREIGN BODIES. Foreign bodies: — Pieces of instruments, spent bullet, piece of bone from a fractured bone in the neighborhood, buttons, clothes, ulceration of outside bodies into the bladder; other bodies forming a nucleus for a stone. Symptoms : — Pain ; frequent micturition ; blood stained mic- turition. Pain is greater when body is first introduced, as in- crustations of the angles and sharp corners reduces the irrita- bility. u Oi> III I!! 192 SURGERY . Treat : — Elec. cystoscope; lithotrite; body must be caught end on. unless filiform guide, or gum elastic catheter; distend the urethra rather than operate. Operation: — Perineal section. If body recently introduced, and no cystitis, close. TUMORS OF BLADDER. (i) Benign. Papilloma. Myxoma. Fibroma. Myoma; Der- moid. Hydatids, Angioma, rare. (2) Malignant. Sarcoma, Carcinoma. . Hydatids involve the bladder secondarily. Papillomata most common; frequently occur; sessile or pedunculated; may have pedicle; cauliflower growth. The pedunculated are the most common. Sarcoma: — Round and spindle celled. Few cases of lympho-saircoma and sessile papilloma. Difficulty in mak- ing diagnosis, especially if lasted some time, and ulcerated. Sarcoma grows more rapidly. Carcinoma: — Epithelioma. Glandular; hard and soft; prim- ary are rare. Symptoms: — All varieties; all ages; myxomata. Sarcomata most frecjuent in children. Papilloma most frecjuent during adult life. Carcinoma 40 to 60. Haematuria is most com- mon and constant; bleeding without any apparent cause; oc- curs spontaneously; increased with catheterization, occurs at end of micturition; not always present; sometimes the difficulty in making water is due to clot. Bleeding may take place at the end of micturition, and cause large clot, due to bladder con- tracting down on tumor. Bleeding is due: — i. Squeezing by bladder. 2. Ulceration; hence in malignant tumor bleeding is more constant. Frag- ments of tumor may be passed. Pain not constant. Villous tuft may get caught in urethro-vesical orifice. Frequent mic- turition is not always an early symptom. Pre ofs : — Fragments in the urine. Cystoscope. These with presence of tumor. Bi-manual examination of rectum and abdomen is a valuable method. Tumors of the bladder grow at all points; most frequently the neck. By rectal examination may conclude whether they are sessile or pedunculated. ■i 1 i ^ h Wi SURGERY id: Prognosis: — Is al\va\s serious. Benign i.'turn sometimes. Hemorrhage may be serions: die from a suppurative cystitis extending up. Malignant tumors extend. Transformation from Ijenign to malignant. Treat : — Palliative ; Turpentine 3-4. increasing to mins. ten (10) on sugar t. i. il. Hemorrhage. Injections of hot water. Ice. Tannic 20 grains to the ounce. Rectal suppositories of opium. Curative treatment: — Xot attemi)ted, if bladder walls in- filtrated. As a rule, where the base is normal can remove with a fair prospect of recovery: — i. Through the urethra. 2. Perineal lith. 3. Sub-pubic cystotomy. I. Through the urethra:— ( )nl\- in the female; dilate thor- oughly. In young i)ersons where the bladder can be readily felt and explored by the linger i)erineal operation is very good, but should never be attem])ted where enlarged prostate; such a cond'ition would not give a chance to explore. Suprapubic is the accepted o])eration: growth torn or twist- ed off, where pedunculated; large peduncle; wire. I! STONE. Sediment, Tiravel, Calculus, or stone. Calculus originates in the bladder, or was i)rimarily formed in the kidney; passed into the bladder when small. Has stone formed in the bladder or in the kidney ? Two classes: — i. Those formed out of the constituents of the urine, owing to diathesis, or constitutional conditions. Uric Hcid and salts, oxalate of lime, cystine. 2. Local Origin; from precipitation of phosphates, formed in the bladder, ammonium magnesium phosphate. 3. Mixed; starting in one kind, and covered with phosphates. 4. Foreign bodies covered with phosphates. \'arious substances may form a nucleus. In a few cases no nucleus, e. g. : — Generally phosphatic. ^lay have vesicle or oil globule. Cause: — Remote. Water is a slight cause. More import- ant is eating Albun'tinous food in excess, creating a gouty 13 194 SURGERY w m\ nil. i ji !?;! diathesis; insufficient exercise. Hereditary jiredispositioii. Poor living;-; l)a(l livfj^iene. Malt liquor. Local IVcdisposin^ Cause: — lMiosi)hatic stones in stagna- tion of urine in bladder in cystitis. Found in any period of life, most freciuently in youth ; males rather than females, owinjT to the leng'th and narrowness of the urethra; children of the i)Oor; rare in laborint;- men; men of the hig-her classes. The niuiiber of calculi in the l)lad"der varies a good deal. URINARY CALCULI. Uric acid, reddish, layers, slightly rough, fairly firm; pretty heavy. Oxalate of Lime: — Darker; sometimes black; nodulated mulberry; shaq^ processes. Phosphatic; white; slightly rough, or perfectly smooth. Stones: — Single or multiple. In children usually only one, Phosphatic are inclined to be multiple. Uric are very small ; when multiple, tendency for them to become facetted. I'a- cetting is not always present in multiple stone, where there is residual urine, or atony of the bladder, liable to be absent. It is rather found where the tone is good, and the stones are ground together until the bladder is distended. A number of stones may be ground together and become united; irre- gularities in sha])e may be due to partial sacculation. Cystine and Xanthine: — Cystine is very rare; contains 26 per cent, of sulphur; composed of hexagonal plates; peculiar yellow colour becoming green, waxy, may be hereditary. Xanthine is very rare; grey, or brownish; greasy. .Carbonate of calcium is very rare; hour-glass form; fusion of two; sometimes growing out of a saccule. vSomctimes one appears, sometimes tw-o; may get uric acid nucleus in saccule, and phosphatic portion outside. Symptoms: — (i) Pain. (2) Freq. micturition. (3) Flemr'g, (4) Sudden stopping, stoppage of the stream; this may be worse with a small calculi, as constantly rolling around, more marked when empty. Oxalate of lime the most irritating. Pain is sharp, or dull, increased by joWng; shaking; dis- suitatJitY lOA iijip-i'.rs ill the rct-uiiihi'iit position; worso after luichiriti')!!, rcffrrid" to tin- rc^non of tlu- l)l;nl(Ur. or forwanl to tlif nid of till" penis, and uiuUt surfacH- of the penis; more severe in eliiM reiii, viscits more tender. In the old. cnlarj^ed prostate pro- tects the neek of the bhidcK-r. As time ):joes on pain inav (hminish, owinj;' to rounding up with i)h()sphates, atid irrita- tion may cause fibrinous exudate, with impriscjnnient of the stone. It may become sacculated. Sometimes sole of the foot is visited by pain, ])ain in the loins, etc. In children the pain is relieved by puUint,'- on the ])rei)uce. 'J"he frecpiency of micturition is due to cystitis an«l mechanical irritation; it is more marked by day. I'rine ])asses in small (|uantities, and frequency increased verv nuich b\- moving". Hemorrhage is often an early sign, common in children, and should lead to a sus])icion of stone, llem'g-. may be large after exertion or mictnrition; it may also disap])ear suddenly, owing- to the rounding- off of the stone, or its being covered with mucns, after which toleration occtirs. StO|)page of the stream; mechanical; more in children; lie on back or side to keep stone from urethral orifice. ( )ther signs: — Tenesmus of the bladder; pria])isni, especi- ally in children ; prolapse of the rectum. In old men the symi)- toms are masked, and may suddenly disa])i)ear owing- to stone getting^ into a sacculus. Besides the conditions already given, snspect a child when it is in an irritable condition, screams af- ter micturition; wets chnhes and bed; i)ulliiig at penis. Examination: — Hoys ])ossible to examine per rectum, wo- men per vagina; this can't be done in adults except the stone is very large; in these cases usually use sounds and cy>-toscope. Sound, short, deej) instrument. Thompson's short beak turn up or down; with hollow, can inject at the same time; the click is not so distinct, therefore the solid are safer. Best sounds arc with round handle so that can turn easily. Prepare the patient carefully: empty the bladder: put ui 4-6 oz. of Antiseptic fluid, pass sound. Examine the distal portion, then the near, above the pubes, and below; draw off some of the fluid, change the position of the patient. f\: Ui 'if- 1 9a iiuuai::iiy I'lrrcrs arc likely to (nciir. owiiij;" to a thick imicous i.H)at- iiiji; 111! stoiK'; poiicliiii^-; bcliind middle lobe of prostate; if beliitul or covered by a fold of mucous membraue which is intlamed; or above the pubes; may imaj;ine have stone when none, may feel in children the promontory of the sacrum, or nia\- lind an incrustation of phosphates on the wall of the bladder. In doubtful cases examine a second time; j^ive an anaesthe- tic; forcibly distend the bladder; throw in with force to distend the bladder; with soimd judi;e the (juality, and by drawing across the surface ,qau,t;e the size. If want to be accurate pass the lithotrite. throw out and tr\ and catch in the smallest di- ameter, and then in largest. Removal, ( )pcrating: — Prophylaxis is efficient in those where uric acid, or a gouty histt>ry; diet; exercise; general mode of life; drink large (piantities of water; 'Pollinaris useful in uric acid diathesis. Richelieu and Radnor, the idea being to dilute the urine. Abundance of vegetables, fruit and tish; no alcohol, sugar and fats. Saline purgatives; l'"rei(lrichshal. Hunyadi. Apenta, Medicinally: — Lithia. Carbonate and Phosphate of Sodium, Jjoro-citrate of Magnesium, Piperazine; Salicylates of Lithia in rheumatic diathesis, ( )xalates of Lime. Mineral acitls. When stone is formed and soft, something in the way of a solvent may be used, but generally n9t satisfactory. 2 per cent. Piperazine has been used, but not thought satisfactory. Operations : — Two. i. Lithotomy, Perineal, a. Median. />. Lateral. 2. Lithotrity Suprapubic; Litholapaxy (Bigelow's o|)eration). Median Perineal in cases where stricture, as can at the same time divide the stricture and remove the stone. Also in cases of small stone, and where have prostatic calculus, and where from condition of the patient you want very little hemorrhage. Lateral Perineal: — Cases of moderate size hard stone, which could not be crushed; as small oxalate of lime stone, or have atony of the bladder present in a marked degree, where supra- pubic drainage not good, and litholapaxy not desirable. SUKUERY m This is the best and safest in chiUhm up to 12. Siil^rapubir: — Wliere stone unusually larg-e and hard : in cases of enc\sted stone; sacculated bladder; in cases of en- larj^cd prostate, where other operations are out of the c|uestion; this the safest operation in kidney disease. LifJiotrily: — Soft or nioilerately hard stones; urethra healthy; bladder in p^ood condition, and will retain 6-8 oz. of solution. Kidneys o. k.; jjeneral health fair. Crush the stone, expel or extract the fras^j-ments throui;li the urethra; first performed by C'iviale in 1818. Aniussat & Leroy. also IJrodie did it. r>i_<^elow in '78 improved the instrument serrated blade, sug's^ested the cvacuator; lar^x' catheter. Prepare the patient, see that kidneys are workint;- all rij^ht, see to the bladder. Inject 1-20 of solution. Thiersch or I'lO- racic to improve the bladder walls, ^-ive I'oracic ac. or Salol.; put bed; milk diet. Prepare the field; withdraw the urine; inject 4-6-8 oz. of Uoric solution. Rectum empty; anaesthe- tic; instrument warmed and lubricated; allowed to go in by its own weight; grope for the stone; grasp and draw fonvard; bring-ing it towards the pubis; turn in all directions to see that no mticous membrane entangled. Having crushed the ston? ni several places, take out the heavy instrument, and intro- duce lighter one (Thompson's). Then employ Pigelow's eva- cuator. Repeat uiuil nothing further comes; if little blood following may introduce iiihotrite again. Finish at one sitting. Afterwards put to Ix'd; milk diet; (piinine 10 grs., followerl by IJoracic acid; keeji 10 days. If cystitis introduce boracic. Contra-indication of this ( )peration : — h'ibrous stricture in the deep urethra; great enlargnient of the ])rostati.'; severe chronic cystitis. Stone of great size antl hardness, or where there is a suspicion that the nucleus is a foreign body and cannot be crushed. There is great danger in this operation of injury t<> the bladder walls, and for this reason some prefer Harrison's mo- dified operation; which is to make a median incision, as in the "Median Operation," and crush the stone through the wound; we can afterwards examine the bladder with the I n 198 SURGERY finger; also does it in the pouch of the bladder should stone be in a pouch. This operation gives complete rest to the bladder, and i)erfect drainage. Lateral Lithotomy: — In 15. C 400 Hippocrates advised his followers not to perform it. Early operations done without a staff. In earliest days performed by itinerant operators called "cutting on the gripe." Some pushed into the perineum. Towards the end of the 17th century, Frere Jacques (Hd 50-3 cases successfully before knowing the anatomy. Operation was subsequently relinquished. Chelseden perfected it; he had 213 cases all ages, and only 10 deaths. Later a blunt knife was used. KIDXEV DISEASES. K. normally cannot l)e i)al]:)ate(l. Anomalies: — of size, shape, position and attachment. Floating; congenital with mcsonephron; these exceedingly rare; operations are intraperitoneal. Movable ; retro-periton- eal ; due to stretching of normal attachments, never congenital. Causes of this latter: — Pregnancy; injuries to lumbar re- gion; lax abdominal wall; disease causing absorption of peri- renal fat (women more than men; Rt. side the most conmion). Sometimes no pain. — Someti'ies pain in the lumbar region. Coli:y or ])aroxysnial due to't\vist in ureters or deranged blood supply, causing jiainful contraction of the muscles, simetimes vomiting, may simulate renal colic; called acute renal dislocation. L'rine may become scanty, high coloured. After attack it is of low s. g.. large quantity of urine passed. Penetrating wounds of kidney :— Symptoms: — Blood in the urine; urine in the wound, other symptoms about the same as in subparietal injuries; gunshot wounds are more serious, owing to infiltration of retro-peritoneal tissue by urine. Treatment of all Injuries: — Good drainage; complete hae- mostasis; perfect rest; care of the kidneys, that is. care of the sound kidney, by looking after the bladder. Perinephritic Abscesses; — Cause: — Cold, extension from renal injuries, appendicitis, petulent cystitis, cancer of the colon, -extension from the gall bladder, general pyaemia, oper- aticMis on tne testicle, urethra, blalder and rectum. SUIWIJRY 199 vSuch conditions arc frequently taken for liunha.ijo. Abscess may open in the thi|:]^h. loin, buttock, inguinal, or pleural cavity, producing- pyothorax. History of pain in side or back, and flexion of the thigh preceding ])yothorax, shoukl point to the kidney. From appendicitis it may be differentiated, by the pain being rather more in the loin than inguinal ; radiates to the testicle; history of renal calculus; attitude and gait, leaning to one side. Spinal caries, rigid muscles, etc., may have pain in the hip. and knee in no]:)hritic abscess. No wast- ing of the gluteal muscles. Treatment: — Relieve j^ain by hot fomentations, cupping, leeches; empty colon to relieve the ])ressure on the kidney. On exploration and evacuation of pus, always examine for stone. Drainage of incised kidney with tube, and pack the incised K. with gauze. In trans-peritoneal o])erations keep oiitside the colon to avoid injury to blood supply. Suppurations : — (i) Pyelitis. (2) Sup])urative nephritis. (3) Pyelonc])hritis. (4) Pyonephrosis, due to retention of pus in the pelvis; all may be induced from nephritic stone. 1. Catarrhal Pyelitis; obstruction below; concentrated urine. In exanthemata from Toxines, TuT])entinc, Cubebs, and Copoiba, blow in the lumbar region. 2. Purulent l^yelitis; organisms present; entrance by pro- pagation along nnicous membrane from e.g., urethra to blad- der and from here up ureter. Passive congestion of mucous membrane from gonorrhoea, etc., instrumentation, bursting of abscess of contiguous organs, as in sarcoma of the colon; through the blood. .Symptoms : — Pain in the loin, anterior and posterior, in- creased by pressure, frequent micturition ; excess of mucus, acid urine depositing pus rai)idly. pain slight or intense. Epi- thelial cells, sometimes haematuria sinmlating calculus. I'ever, rapid onset, and severe. Treatment: — Remove the exciting cause, stone, stricture, large prostate, antiseptics, diuretics, render urine alkaline, re- duce the frequency of micturition. Dry cupping. 3. Pyonephrosis. — (i) Dannning of pus in the pelvis. (2) In- fection of Hydro-nephrosis. Cause, obstruction in the ureters, ' if II ■ ;i ; • Hi . I ti 200 8VRGERT cysts, pressure of tumors. Produces a most rapid destruction of the Icidnev substance. Licpiids may be absorbed, and in- spissated pus may be found as a chalky mass p.m. Spontan- eous evacuation may take place through the loin. If ob- struction is a stone, we may t^et occasional draininj:^, with dis- appearance of tumor. Symptoins: — Pus may or may not be present in the urme. Pain in the lumbar region increased by pressure in front. Sometimes relieved by ])iressure l^ehind, development oi tumor in the loin; elastic and fluctuating, or hartl and doughv. If tumor is not surrounded by inflannnatory adhesions, it is movable, it descends with inspiration. In perinephritic inflam- mations the kidney is fixed. I'A'idences of deep-seated sup- puration: — Toxic effects chill, sweating, remittent fever, loss of appetite, headaches, frequently rapid emaciation and pinch- ed features of chronic septic poisoning. In Hydro-nephrosis: — Get same cause, same tumor, obstruction is misleading, so that diagn>sis must chiefly be made by constitutional symptoms: slow, absence of pyeli- tis preceding. In Hydronephrosis, don't get oedema and waxy swelling in the loin. Trat)nciit : — Hydro-pyonephrosis and Perinephritic Ab- scess the same. Diagnosis from aneurism, enlarged spleen or liver, sarcoma of the kidney, tumor of the suprarenal. The treatment (iepends upon the cause. Alorris reconnnends mas- sage; hot water; jolting exercise. Bed, light diet, hot fomen- tations in any serious cases or in intermittent type. Operation is the proper remedy. Spontaneous evacuation through the walls, perforating the diaphragm, and through the lung mav occur. Aspiration not to be reconnnended. P^ree incision through the lumbar route, and thorough drain- age; exploration for calculi. Drainage tube into pelvis, pack- ing of cellular tissue forming base of wound. Don't do neph- rectomy at this stage; wait. Pyelonephritis : — Surgical kidney. Following a pyelitis, especially if damaged prostate, ureter or bladder, especially if any surgical interference. May I)egin as a suppurative neph- ritis, with pelvis involved secondarily; this most common in Tuberculosis. , HVIUIERY 2(1 1 Exciting causes: — Those of I'velitis, or Pyo ticphrosi-;. Pyelo-nephrosis associated with siiij^le or inuhiple abscess. The whole kidney substance destroyed. Symptoms -I'ain in the loin. Marked diminution in the (puintity of the urine; sometimes sudden suppression, usually acid. If acute, blood appears as well as pus from pyelitis. If cystitis, the urine is alkaline, and have all the symptoms of supi>urative cystitis. ■ ' ' , | Rejvjattd chills, \\\i:,\\ fever. sweatinJ,^ typhoid state; mut- tering- deliiiium; j^eneral i)rostration ; sinks in bed. finally coma, and death 12th to 14th day. The treatment is a sup- portinjj;- one. that of i)yemia. Prophylaxis, ini])ortant in the ])roper preparation of patient for all urethral and bladdor examinations. Treves says the followinj:!;- diseases follow path, conditions of knver urinary passa.q-es : — I'yelitis. Pyelo-ncphritis. 1I\- dro-ne])hrosis. Suppurative kidney, where suppuration i)rini- arily in the kidney. I'orni 1' urinary fever: — C'ongestive. Intlanmiatory. Sup- l)urative. 1 lydro-nephnisis : — This condition mav be congenital or accpiired; permanent or transitory (temporary). Remittent or recurring". L'nilateral or bilateral. L'reter above the obstruc- tion is dilated, below it is contracted. Where rapid obstruction, may get atrophy. Where slow, we get the greatest degree of Ifydro-nephrosis. Where complete obstruction, the fluid may be cystic. Where chronic obstruction, and some of paren- chyma left, fluid may resemble closely normal urine. Mild degrees of Ilydro-nephrosis may give rise to no symptoms. Where cong-enital and bilateral, death may occur early from uraemia. L'nilateral congenital hydro-ncphrosis probably ac- counts for cases of large hypertrophied single kidneys. Causes of Congen. Hyd., Xep.: — f. Imperforate ureter, double. 2. Imperforate ureter, unilateral. 3. Angle of junc- ture of ureter with kidney forming a kink. 4. Anomalous folds of nuicous membrane. 5. Congenital tumors of the bladder pressing upon the entrance of the ureters. 6. Pres- sure of tumors. 7. Floating kidney. Complete congenital is f ■■■ i I wm ' 202 SURGIJItY N! I liable to cause a larj^cr liydronep. Kidney than Acquired com- plete obstruction. Causes of ac(|uired :— ( i ) Stricture of the urethra. En- larged prostate, especially the middle lobe. Tumors of or- gans; movable kidney. Pressure of displaced orphans; renal calculi. Tuberculosis of the bladder and ureter. Irritable bladder with frecpient micturition. Injuries to the lumbar re- j.jion; subsequent cicatricial contraction of ureters. Ob- struction of ureter by blood clot. Hydatid cysts; papyloma- tous pfrowths; enlarg'ed lymphatic f^'lands. Ajcfc has no in- fluences; both sexes etpially liable, as also are both kidneys. .Symptoms: — Unless laixe. palpation is impossible, or too l)ainful, unless anaesthetic is j^iven. If larc^e bul^'inj^' of the loin; nodular; tense; dullness in the loin. Double and complemental antu'ia, with uraemic symptoms. ^\'here one kidney completel\- obstructed some time before from stone, then j^et compensation, finally obstniction of the second by stone. I'ain and swellinj^ in the loin. Urine is frecjuently subnormal in (juantity. An intermittent, sudden- ly appearing tumor, fluctuating reduced (juantity of urine, followed by increase, at the same time being albiuninous, al- kaline, with disappearance of tumor, more frequently due to movable kidney, ureter becomes twisted, then relaxes. Trcatinciif: — Massage and manipulation dangerous. Dan- ger of rupture and producing peritonitis. Tapping some- times followed by good results. Nephrotomy, the operation, opening and draining the sac. Nephrectomy may be neces- sary if renal fistulae or suppuration. Aspiration is justified in urgent cases, but if repeated liable to get fistulae. Nephrotomy is followed by fistula, w^here any kidney substance remaining. Tuberculosis: — (i) Acute or (2) Chronic. Miliary tuberculosis — there are no symptoms pointing to this especially. Scrofulous kidney; strumous pyelitis; scro- fulous; pyelonephritis. Tuberculosis may be primary in the kidney, but nearly always ass'ciated with tubercle in other ])ortions of the genito-urinary tract. Adolescence and old age; attacks papillae; ulcerates; disease spreads; new deposits; ulceration, etc. II- ll ill;u'. Svmptonu aiii in the luinl)ar ri'^^ion, aolnn.i; or ])ar(txys- nial, radiating- to tin- pnint (tf the penis. thi.LTli^ said tu-vir to pnidiu'c conttaiMiiin of llic Icstick-. Syniptonn utluTwisf ex- actly resemble those of ealrnhis. Innior may lU'velop: no- dular. i'"amily history of vahu'. I'olynria of ;i murky type; frequent mielurition. .Sudden ehills and severe pains, unasso- ciated with eolie. l"re(|uenl micturition may he due to aeid mine in early stai;e, also to polyuria, ("olie is not so severe ; more ajil to he preceded l)\ passin.u" hlood, ulceration aiul breaking' down of tidnrcular masses: may have passage of a calculus followi'd by blood. rriiie is cloudy from a mi.xture of pus; it is acid, and of low .Sp. (i. JJf;;ht coloured, depositiuju;- a thin layer of pus, with sif^ns of blood, a continuous haematuria; not marked. Sonietitues small lum])s of caseous material. It is of p^reat importance to demonstrate tlie presence of the. (frecjuently exam, for T. \\. ('.). rrine in the later staj.,'es shows albuminuria. Frefjucnt micturition is due to Polyuria; irritation of the bladder by septic infection of the muc. mem. 'rubercle extendintj' to the bladder, the most frecpient site bein.q' the triq-one. Where case advanced, caseation and pus thrown off by the kidneys. Clet constitutional symptoms, hectic, etc.. no tumor in the loin, and absence of tubercular material. May sus])cct this condition, but absolutely to diag-nose is imT)ossible. I'enwick: — i. I'amily history of tubercle. 2. Apfe 20 to 40. 3. Personal history of tuber, lesion. 4. Polyuria. 5. \'a_efuc lumbar pain. 6. Sudden chills. 7. Fre(|ucnt micturition at ni.j^fht in early stag-es. 8. Where colic ap])ears. it is later, preceded by a flow of blood. (). Said no retraction of the te.sticle. 10. Haematuria slijifht. u. Uninfluenced by rest or motion. General condition; ailing, anaemic, easily fatij^ucd, early anorexia. 2nd group of Symptoms : — 1. Family history nep^ativc. 2. Apfc 40. 3. Personal history negative, or complains of k / 204 ^UliOFRY i I pravel or rod (lo])()sit. 4. Woakiuss iti tlio loin; subjects of litliaomia. 5. Testicular ucuralf^ia. 6. \'as^uc huubar ])aiu.. 7. Marked colic. S. l'"re(|uency of niiclurition due to irrita- tion; more frcciuent by day and after exercise, 'ir manipulation of the loin. (). C'olic followed by blood. 10. I laeniaturia; not persisteiU, and associated with exercise (look up lithacniia, oxaluria). Where the cortex lirst affected. i)olyuria may be the onlv symptom for some time; process more rapid, where j)elvis first invobed. 'i'oxines with acid urine first cause ca- tarrh of the bladder, especially the trij,n)nc. Treat: — Codeia best relieves pain and irritability of the bladder. C"od liver oil, iiypophosphates, diet, climate, sup- portini;- treatment folic: — Anodynes, opium, hot batlis, anaesthetics. Kenal Calculus: — l'Uioloi;y obscure. Whether a constitu- tional disturbance or ])rimarily a disorder of the kidney is not definitely known. Predisposing' causes.— Sedentary habits; hi^h living-, poor leeding. Absence of milk from the diet of children. Calculi orijj^inate in calices, then droj) into the jjclvis and either pass with colic or remain with.in. the pelvis : may be- come encysted; i^ivint;- rise to no symptoms. Renal stones are irreg-ular; seldom facetted; absence of attrition. Symptoms; — l*ain. blood.' pus. calculous frafjuients, renal colic, frecpiency micturition, nausea, and vomitinp;'. suppres- sion or diminution of urine. Tain in the lumbar reg'ion. and nearly always on the same side, increased bv pressure and exercise. Pain is constant in typical cases; dull and acliint;-, freciuent sudden exacerbations at nij^fht. apart from the colic due to the jjassapj'e of flatus in the colon (Jacobson). Morris thinks due to fresh deposit. Pain radiates to tlie testicle, loin and groin, calf, si)metimes the sole. All the symptoms may be referred to the intestines, or all to the bladder. Sharp stabbing ])ain due on deep palpation to jyrcssure of the renal sub.'Uance against sliarj) stone. Renal colic due to passag^e of stone or frag'ment of gravel along ureter. Typical attacks, apart from renal, are sometimes met with. IlaematmHa mav or mav not be marked; not as SUUaKUY 2(1 -> marked is in inaiij^MiaiU diseasi', and unac-coinpanied I)v siudi niarlhia hypodermicilly ; sometimes anaesthetic, hot ap])lications, hcjt baths. Radical treatment: — Xephrolithotomy ; extraction of stone frtjm a kidney otherwise healthy. Xe])hrotomy when asso- ciated with other degenerative conditions in the kidney. Operation : — .Semi-prone, hard ])illow under the lower loin to increase the distance l^etween the last rib an of ith lis. .ir- ■X of he ce he C'll vc lU Is. IC Id le i- le 3f a. a ' « ■I - "' rilVrf f iilTl f l i -m iiii^pMii SUHGI-JUY 207 til can distinguish the cavity of the bhulder with the same left iorefingcr. If the incision is not sufficient or satisfactory, enlarge it with a blunt bistoury, pointed along the finger or director. Examine for stone ; a small stone may pass with gush from the wound. Keep left forefinger in the wound, grope, if feel stone, pass the forceps, coax stone into the jaws, and, if large or rough, extract by rotatory motion to prevent dilatation. Accidents of operation; operation wound, by getting too far in, or due to gas. May wound artery of the bulb if carried too high. Internal pudic artery if too far out. In wounds of the rectum do nothing; kee]) em])ty and aseptic ; 9 out of 10 per cent, good healing. If artery to the bulb wounded, catch, and leave forceps on; don't tie. Internal pudic artery serious; digital pressure by relays; forceps, if lucky. If hemr'g. or oozing from prostatic plexus, then use I)u- puytren's chemise. Take a large rubber or silver instrument, tie a piece of antiseptic gauze around it, and pack with an- tiseptic gauze. May miss the groove, and divide the tissues outside the urethra, or make the wound too wide, and get outside the prostate. In children may tear the urethra across with finger, and push the whole back into the pelvis. May wound the posterior wall of the bladder. In tearing the urethra, or where cannot find blad l)oc()tuo j^lazcd over, and loss liability to absorption. Tut to bed; lu>t water bottles; li(|uid diet; paek with iodi)- forni; morphia; barley and rice water; milk and soda. l"'our days on lis^ht food, sometimes stinndants. W'hethi'r tube be in or not the urine dribbles out of wound at lirst for ,^ or 4 days; then in 24 hom-s passes by the urethra, thru a^ain by the wound until the 17th or 18th day. Where there is a ten- dency to a ])hosi)halic deposit, the wound delays in healinj^; troublesome. Min. i of nitric to the oz. aids this condition ; or stimulate the wound by A^. No. 3, Cu So 4, iodoform. On the 18th to 19th day, i)ass sound. This prevents the meni- ])ranous portit)n from becoming" contracted with stricture. Median Lithotomy : — A i:;^rcat favorite, but danj^erous in a larc:e stone; seldom performed, never in children; small stones in adults; in bladders where suspect prostatic calculi. Prepare in the same way. Incision 1-1 -J inches above the anus, down to the marqin of tlie anus; staff i^rooved on ])osterior border; feel .-taff in mend), urethra; divide comj^rcssor. Vrcthra, meml). urethra, and on into bladder; no hcm'g'. ; artery to the bulb may be wounded if ^o too far forward; follow knife with fin,c;-er, rotate and i^radually dilate wound, or open the blades of stone forceps. lntrt)duce drainag-e tube. Less risk of hemorrhai^j'e; no danger abnormal arteries; prostate not seri- ously impaired; prostatic j^lex-us not opened; less danger of phlebitis and intlanmiation, heals rapidly, 3-4 days in the healthy bladder. Disadvantage; — Little room, cannot lie perft)rnied in child- ren. Supra-Pubic Lithotomy: — Prepare the patient, shave the mons., g-ive oil. and an enemeta. Peterson's bag-, properly shaped, like kidney (of Kiel), placed in the rectum, distended with 8-10 oz. of water or air. Wash bladder with boracic; inject 10-12 oz. of boracic or Thiersch. This rolls the peri- toneum well up. Table; Trendclenberg; raise pelvis, so that intestines roll away. Incision begun over the pubic bone, and half an inch of the bone may be exposed, extending- up 3 inches; nothing injured; medium line ; through linea alba, come down on the fat and ■HHH HH I '!ft H ] avKGEuy 200 \iins. l)k'c(l freely: st'iiaratc the fat rather than cut; then eome on (lark blue l)la(l(ler walls coursed with lar^c veins. Catch \\\) with silk sutures ov forceps; this j^ives the assistant some- thin.a^ to hold uj) the wall with. Make incision in the middle line towards the jjubes three-iiuartcrs of an inch to introduce the tinner with liitle force. Allow fluid to flow off f^radually. It need more room, then increase the incision downwards. (ir enlars^e with forceps. Remove stone with f()rce])s or wi*!i linger and scooj). Forceps on the! whole are the most handy; explore the bladder. Subseiiuent treatment : — The best is simple drainas^e; 2 tubes, and bring- the rest of the wound toj^ethcr; patient (ju side. End of 3 weeks wound all healed; infiltration rare ; draina.ne better than ])erineal or urethral. CxASTRIC SrRCI'.RY. Dysphagia due: — i. ?iIalformations, stricture, fistulae and diverticulae. 2. Pouches. 3. luT^reipi bodies impacted. 4. Ruptures. 5. Wounds and injuries. 6. Acute inflammations. 7. Tumors, and strictures, benign and malignant. 8. Aneur- ism. 9. Pott's disease. 10. Hysteria in the young. 11. Pa- ralysis; usually about the pharynx and soft palate with regur- gitation through the nose. History is important; if sure of an obstruction pass boug-ie, if no aneurism is suspected, g"um elastic 24 inches long- or olive pointed bougies; useful in testing the size and location of stricture. Before using warm to render plialde; cover with glycerine. P^atient straight in chair, head a little back. Left hand forefinger to epiglottis; care don't pass into larynx. In nialig. disease use great care; the tissues are soft, and there is danger of perforating; a fatal accident. Oesophagus 9 inches long, cardiac orifice 16 inches from the teeth, bear in mind the bending of the bougie. Diagnosis aided by ausculta- tion of oesoph. during the swallowing of soft food, the bolus is heard to be arrested at obstrttction. Oesophagoscope "X" rays. Localized dilatation is ustially acquired; fistulae re- mains; bronchial clefts; if closed at outer and inner ends get a cyst; sebaceous or mucous. - 14 li 1 ii f Pouches — from pressure within, or contraction, or scar tis- sue without, as caseous bronchial glands; may be dissected ofY and oesophagus sutured up. Foreign bodies: — I'sually in children, if near top, and press on the larynx epiglottis may cause suffocation; im- l)acted l)odies may cause vomiting and dishjdgment, but bad ])ractice to give emetic; three points of lodging; at eitlier end or crossing of bronchus. Diagnosis: — History, i)ain. expectoration, bloody mucus, especially if high up; passing the sound final. If high up, may be reached with forceps. If low, push down with sponge probe; if very low, and impacted, gastrotomy may be per- formed, and reached below, or introduce a horsehair probang. Oesophogotomy : — Through incision along the ant'r. border of the Stemo-mastoid of the left side. Start level with the Cricoid, incision 4 inches long. Where there are important structures, always make a long incision. Oesophagus, to left of larynx, artery external, do not injure the Sup. Thyroid, or recurrent laryngeal ; keep wound clean. To secure the oesophagus pass four (4) sutur nto the incisiou longitudinally; hemorrhage controlled rceps; ])ass bougie as a guide; open over the foreign body. Closure of wound may be practiced if sure of no infection, but drain- age is usually practiced. Rupture of Oesophagus; always fatal; cellulitis; vomiting after a heavy meal, drinking bout. '"Chemicals" swallowed : — Allay the pain; large doses of opium, then stimulants, food by the rectum; if patient rallies, and intianuuation subsides, may feed 1)y the mouth Cod Liver oil and lime water. Bougies later to prevent cicatricial con- traction. Intianmiation: — Secondary to stomatitis or gastric trouble; may become croupous; rectal feeding; opium. ^klalignant tumors are common, cause stricture. We may also have strictures of benign origin, as following tubercu- losis, swallowing corrosive chemncals, as also congenital. Course of malignant is rapid, ulceration early, trachea opened out, food enters the trachea, or air regurgitates. May - IT'IT , l'i«r'---'— -r Hi l!i !?■ ^S tiURGERT 211 have rupture of the pleura, or pericardium, which is rapidly fatal. Treat: — In stricture dilatation with br gie throup^h mouth, or having opened tie stomach from cl w; silk string from mouth out throu; . incision in the stomach, and saw through. Symond's tubes useful early in malignant cases. Operations : — Gastrotomy. RurTiKE OF Stomacfi: — I-'rcjui horse kick ; sometimes only partial, the serous coat escaping. Syni])toms: — Pain, and slight peritonitis, not general; cica- trix may contract, and if at pylorus, may cause stricture. Total rupture is most conunon, both from within and with- out. Symptoms: — Shock, sometimes instant death. Patient usually imconscious; pulse threa :y. Skin moist, cold and pale. ]^csp. shallow, if not unconscious vcr>' restless, moan- ing, anxious expi'ession. Pain, usually sudden in onset, sev^erc and burning at the moment contents of stomach escape; this is a variable symp- tom, however, and may be al>sent; usually depends upon the amount of food in the stomach, l^ain continuous; unlike colic; in upper part oi abdomen at first. X'omiting is continuou.^, comes on rather late; first stomach contents, then green bile. Wmiiting is very easy. Percussion. Liver duUnes-s disappears; may get loose move- ment of the bowels shortly after perforating, great thirst, water being regurgitated; chilliness. The later symptoms are tlK)Sj of peritonitis. Temp, is first belov/ normal; it then rises, but is on the whole very uncertain. Tenderness be- comes a marked sym])tom; rigid abdominal walls. Distension, constipation, and finally deatl,. The above is typical. in other cases the pain and shock may be absent. Again may have fatal perit ithout pain, tenderness, disten- sion or rigidity. What viscera involved ? Consider the history and site of pain. L'i.ckr: — Tn young women; rare in men, or after youth, historv of indigestion, haeniatemesis, etc. i! 1 : 'I !i 11 212 SURGERY Pain :— Stomach, upper part abdomen. Appendix, Rt. in- guinal. Tvphoid, on Rt. side. 1* in doubt do an exi)loratory incision. Perforation of the stomach, c-ills for pnjmpt action; alxlomen o])ened. Perfor- ation found and closed. If patient in a condition of shoci<, may have to wait a little. Ulcer leads fre(|uently to stenosis and dilatation. Dilata- tion may be due to liypertrophy, as of the nmscle fibres at the pylorus. Operations: — Loreta : — Digital operation; open the stom- ach and dilate with the frnj^er. lleinecke. Mekuiicz, (iastro- enterostomy. (See pai;e 216.) Carcinoma: — Affects the deep layers of the niuc. memb., s]}readinjT^ irapidly. 60 ])e;r cent, at the pylorus; next the les- ser curve. Tendency to ulcerate and spread to the surround- ing parts; perforation of the stomach is not connnon; may get gastro-intestinal fistula. Symptoms: — Hemorrhage is severe; coffee ground; large vomit, Tumor ei)igastric usually, to the Rt. of the middle line, sometimes found on the left side. Pylorus very movable; sometimes tumors movable, but usually early fixed. Emaciation is rapid, owing to: — i. Cachexia from growth of the cancer. 2. Actual starvation. Diagnose: — From gastric crises of locomotor ataxia. Gas- tric fistula: — rare. Gastric Fistula: — Three causes: — i. Gunshot wound (Mar- tin). '. Simple ulcer. 3. Malignant ulcer. Xon-malignant condition closed by plastic operation. Foreign liodies: — Any body ])assing through the oesoph- agus generally finds its way out; may be 10 days to 3 weeks in passing. Treatment: — Mashed potatoes; cathartics contra-incHcated. If body remains in the stomach, may clo a gastrotomy -'8 cases; 24 recoveries. I'.r. Med. J. lor ( )ct., a case of gastric varix of the veins of the deep layers of the mucous mem- brane. A vein here ruptured . and patient died of hemorr- hage. This the first case. Many fatal cases reported as ulcer, mav have been due to varix. Later Dr. Adami's case at R. V. H. m- )r- ta- at n- ()- av '•e 111 It 1- 8 SURGERY 213 Operations: — Two (2) incisions. (i) Fengcr: — Oblique incision, parallel with ribs of leftside 3 inches; one a iialf fingers distant from the edge, through rectus muscle obliquely. This somewhat modi- fied, l)ecause found that cutting rectus not necessary, and weakened the muscle; therefore skin incision the same fibres of rectus separated by blunt dissection in vertical way; only the fascia incised. (2) Median: — Ensiform to umbilicus, according to thick- ness of abdom. wall. This latter operation is the most useful; little or no hemorrhage; in opening the peritoneum be care- ful not to injure the underlying 01 adherent organs. In closing incision, less danger t)f hernia than in lower abdomin- al region. Sew like to like; three layers of sutures the best; 1st. continuous; 2nd, interrupted (both gut); 3rd, silk worm- gut from skin. Intestinal Suturing: — Czerney; Lembert; Czerney, through mucous and submucous layer. Lembert brings serous coats into api)osition; peritoneal adhesions form in a couple of hours, needle entered half an inch from the cut surface, brought out after passing through the submucous coats near the cut surface; re-entered on the other side in the same way. In interrupted sutures, catch both layers, or, as used here, the continuous suture is found very satisfactory', \\here inver- sion difficult, owing to inflammation and infiltration, omental grafts are used, suture the omentum over the wound. Drain where necessary, use a round cambric needle ; twisted Chinese silk; where suture line long, better interrujit occasionally, as if one opens the whole line is liable to loosen if not inter- ruptetl. In operating, be careful of the packing, gauze, sponges; always count before closing. Perforation from ( iastric I'lcer: — Without operation, uni- formly fatal. I. h'ind ulcer. 2. CK)se. 3. Cleanse and drain peritoneal cavity. Perform section as early as diagnosis of perforation made; median incision. Examine with great care, break down ad- hesions carefully ; pack well ; when i)eritoneum opened. may get ixn escape of gas and stomach contents. The more m M 214 SURGERY that escapes the graver the prognosis, aUhough the stomach contents are not so virulent as the intestinal. Ulcers most common on the posterior, but perforation most common on the anterior wall of stomach, and on the lesser rather than the greater curve; the cardiac end rather than the pyloric. The nearer to the cardiac the greater the difftculty in suturing, ovving to fixity. It is not necessary to trim edges or remove the ulcer; the rapidity of the operation is important. Lembcrt suture; a double row if necessary. Where we cannot suture, pass a tube into the stomach; pack cairefully. or make gastric fistula, by stitching to the abdominal incision. Irrigate with normal saline at 115 (leg. Irrigate system atically; begin by irrigating the region of disease; cleansing by dry sponging may suffice. Drainage to ulcer, and suture line, and over pelvic bone into pelvis. Danger (i) of Peri- tonitis. (2) shock of operation and anaesthetic. (3) second- ary perforation. Gastrotomy: — Indications; foreign bodies. If body felt, incise over it; otherwise a median incision. Make out the body; great care if sharp, cut down on the blunt end and ex- tract. Incision; transverse of thp long axis with the vessels; large enough to give room; can avoid most vessels. Extract the foreign body with forceps or with fingers. Manipula- tions gentle oi-i, account of inflammation. If nutch fluid, then swab out with gauze. Close with Czerney-Lcmbcrt, drain, 48 hours, nothing by the mouth, then a small c|uantity of milk or lime water, one drachm every hour, gradually in- creasing; if patient very debilitated, start feeding in 24 hours if no vomiting. Start nutrient enemata inuuediately after operations 4 oz every three hours. Gastrostomy : — Indications; cancer of the oesophagus, or mediastinal glands; cicatricial contraction of the oesophagus; cancer of the pharynx; must not be put ofT too long. Let patient bear the responsibility of operation. Surgeon may well refuse where too late. So long as semi-fluid food can fe' isiitaiJitY 215 l>i' taken, put in Syniond's tubes; jjassod on an applicator; uuiy wait. Where patient restricted to fluid diet no time to lose. Where cannot swallow anythinj^ — too late, i'mg^ress of case is the index when to operate. If other orj^^ans implicated and chief cause of decline, don't operate. Methods: — "llowse" two (2) stages: — Two days between; ist, make a vertical incision through the rectus; blunt dissec- titjn; open into ])eritoneum; stomach jirobably up under the liver; if difficult to find, follow the peritoneum from the an- terior l)(jrder of the liver ; stomach is thicker, and pink. Choose site near cardiac end; suture to abdominal wall. Su- tures (lie inch back from edge of wound; put two sutures of silk into the middle cjf the exposed stomach walls; antisep. dressings. -Mid stage; 2. 3 or 4 days later; exjjose stomach c«jvered with lymph, and re(|uire a larger tube. First feed pre])ared milk, and brandy, yolk of eggs, later chicken broth, soup, and semi solid foovl. Hemorrhage is not usually serious. Xo anaesthetic f(jr se- cond operation. May have difficulty in finding the stomach. i'"sca|)ing gastric juice is irritating; causes dermatitis. To overcome the leakage Kader suggested bringing the stomach through the 8th intercostal space. "Frank" makes an incision close to the bortler of the ribs ; draws stomach well out, sutures peritoneum all round. Jml incision above and parallel to the ist, and a little U> the left; undermines the skin, and draws stomach through, the skin being closed over the ist incision. X'ery fairly successful. "Witzel," at one sitting. Incision through the left semilunar line, or parallel to the costal b(jrder; does not matter; want to get to the stomach well outside. Take a soft rubber ca- theter, and lay on abdominal wall, and put cat-gut suture through the abdominal wall to hold the catheter, then by means of Lembert sutures infold the catheter 3 inches, having made a small opening: cover well by infolding; reinforce with a second row of sutures, fix to the abdominal wall and dress. Leave tube in several days, and when taking out to cleanse must be earlv returned. 1 I ' 1 ' 1 216 SURHKRY Dif,ntal Dilatation: — "Lorcta's." Pass fin.trcr into Pylorus; may i)ass thrt-c fni^t-rs. Suitable also for cardiac constriction. This is not a surj^ical procedure, and stricture liable to recur. Lorcta's is not safe; nxay get mpture ami peritonitis. Pylonjplasty : — Ileinecke, Mikulicz. .\ longitudinal inci- sion 1-2 inch long. Only applicable for cicatricial contrac- tions; sew up transversely. I'ylorectoniy: — In cancerous strictures, remove the pylorus and reunite the stomach and duodenum, "liillroth" ties off the mesentery, cuts out the cancerous area; ])artially sews up the opening in the stomach to fit the ducjdenum; sutures duodenum. "W'oltHer's method : — Closes the stomach wound entirely after suturing the duodenum into the side of the stomach. "Von Ilakar." Gastro-luiterostomy : — Median incision, come ou the omen- tum; push to the right, and find jejunum, anrc'vi'nt hernia. Stretch tlie cord hy j^radnal ])nnin!.^. Where hernia considerahle, do a radical cure, and remove testick\ Hydrocele: — Drop-^y of the testicle. This may he: — Infant- ile. Congenital. ,\cf|uired. Infantile— sustainc(l injury, and resenihles adult form. C'onjj^enital — conununication with ])entoneal cavity. .\c(|uired — cause of. adult hy. l-'ailinj:;' this inject cavity, after tap- l)ini;'; injection 2 dr. of Tr. hxune, allow in.c^ one (i) dr. to flow hack, or if pain inject a few mins. of 5 per cent, cocaine. I'd. I'^xt. of Ivrg-ot (Irs. 1\'., allowing^ 2 drs. to flow out; this lights up an acute inthunmation ; next day an effusion large as ever, i)ut to hed for a week or ten days; or: — Incision— |)ack with Iodoform gauze, and exjjose the sac; gradually withdraw gauze: this causes closure; ma>' he suf- ficient. Cocaine or ICthyl Chloride. I'ailing this: — l'>cc Incision: — And dissecting away of the sac; only justifiahle when other methotls fail. Infantile — diagnose carehdly ; when not congenital in- jections of one-half the strength of Iodine. Congenital: — Close oft" the sac with a ])ad, and ai)ply an evaporating lotion. Haematocele: — An effusion of hlood usually into the Tunica W'lginalis, sometimes into the testicle and scrotum, or all three. ii. If! \ I- 1 i'i ! i 4 Ill* hi 'iK Causes: — Injury, blow, i;training, tapping', hydirocek-. Read- ily made out by effusion into the scrofim; ecchyniosed — rounder than hydrocele; no pain unless ol great extent; only a feeling of weight. 'ircotmcnt: — if small rest in bed, elevation, cold ice bag; lead and spirit lotion under ice bag; frecjuently fails. Determine by palpation if lluid, or clo.. If fluid ta]) and keej) up lotion. Many cases of clotting begin early, atid get laminated clot; fret- opening; turnin<:^ out clots; catch any bleeding vessels. J'ack with Iodoform gauze and heal from the i)ottoin Acute ()rchitis: — ''"re(|uently associated with epididymitis, gonorrhoea, injury, gout. ])rostatitis; irritation of catheter in the urethra, prostatic calculi. (Hand is painful. I'.pididy- mitis if chiefly affected behir..l. If both it is wedge-shaped ; pain in the groin and back. History. rrciitiiiciit: — Depends upon the cause. If combined condi- tion, cold, ice bag inunediately. Simple, h'pidid. — Heat if carefully applied. Ice is auto- matic; not such f'\'c|u .nt changing. Local ilepletion. leeches, opening 3-4 Ir.rf^est scrotal veins. I'oment 20 niin. with hot water. Tenotomy knife i)referable to leeches, which liable to inllame. h'or p:iir. lead and- opium, puncturing with a narri)w knife; oivn albugmia. allow of the escape of the ef- fusion: also sometimes a little hydrocele, which likewise al- lowed .0 escape. As case j)rog:resses ; I'ng. r.elladonna and Vh. Iodide; Straj^ping'; suspensory b;mdag"e. Xenralgna : — I're<[uently accompanies varicocele. Likely to occur ia nervous and d\spe])tic men. Patieiu coniplai.is of .1 continuous irritable condition, usuall\ in epididvnuis, radiates to the gfroin. Only tenderness of the patient; increases ner\-H3us tenden.\v. melancholia and suicide; nervous headache most often affected. Tonics; — l'"e. Zn. never M'.i)rphia. Locally Aconite Lin.; JNlenthol & Belladonna L'; g.. susp. bandage, salt douching, sea bathing. If everything^ fails may excise. A verv sericnis uiK'ertaking. Solid Enlargement of the Testicle; Sarcoccie; Chronic Or- chitis; Sv'.hilitic Sarcocele; Tubercular Sarcoccie. ^ l 8VRQER7 !l'> True Tumor: — Adenoma, Fibroma, Sarcoma and Carci- noma. Tuberculosis: — Seltlom j;et pure Chronic ( )rcbitis lastinj^ any length of time; usually associated with 'I'ubercular or Sy- jihilitic condition. Sometimes it is the result of an acute ( )r- cliitis, which not resolved, kicks and scjueezes, in disease of the prostate, rheumatic, and ^outy subjects; irritatioji of catheterization. Symptoms: — Cniformly lari^^e, heavy, hard to the feel, tes- ticular sensation remains; ei)ididynms merged into the borlv of the testicle, or when testicle affected first and chietly may }^et a v'u\^v between. In time the cord becomes thickened; skin healthy uidess suppuration; oidy (Jiie testicle involved. If irritation of lonjj;" standing-, sup])uration may bei;in; the skin adheres at one ])oint; softeiiinj^', and pus exudes. If a larp^e piece of skin involved; slouR'hinij;'; may get "hernia tes- tis" or protrusion : red bleedini;- covered with ji;ranulations. In cases of abscess a fistulous opening. Treat: — Chronic ( )rchitis, where unresolved, strap])int:;' ap- ])lication Pb. lod. and Uelladoima (a dr. of the solid I'.Xi. to dr. \ N of I'b. lod.) llg. Cng. Hydrocele ta])ped. but not injected. Tonics K.T.Tr. Xux. Abscess oj)ened early, scraped, packe-' with Iodoform, l^xamine ])us; may have tuberculous disease. Where late; hernia, cauterize; let slough separate; dress with Iodoform; granulate. If large, shave off, freshen scrotal incision; close uj). h.xcise in extreme cases. .^^yphilitic Testicle:- This may occur at any stage; rare pri- mary, luirly secondary get epididymitis; an indurateii of tlu- iDiiti'iits of tlio bladdi'r; water is al)surbL(l .iiul solids inspissated and Xtallizod. Muc. iikmhIj. secretes oholesterin. CaKuli vary in color, size and mitiil)cr, usuallv i-io. from the si/e of a marble to a waltnit. pearly wliiti-, vcllow. preen or black. Soft or very bard, dependiti}.,' ui)t>ii tlu- amount of lime salts. I'recjuenlly prest-nt where no symptoms. More common in elderly women 5, _'. Rea- sons; wearing corsets, want of exercise, the liver becomes sluggish. If a number of stones they will be facetted. Tain only in jjassinj^- throu^'h the cystic duct; peristalsis in the duct, blad- der secretes actively, and increases the "vis a terjji'o."' Duct may be j4;reatly dilated by a lartje stf)n<> !'rj(iuently passaLje of stone le.'ids to i)ermanenl dilatation. I'lceration into the stomach, duodenum and colon. Itiliary colic, sudden, pain in the reijion of the liver; shoot- inj^ tin-' luph to the back and shoulder, faintness, naiisea and vomitinj^". sweatin^^ paroxysms, doubled up; no '["emp. Half an hour in duration uj) to a couple of days, stops suddenly. If jaundice due to obstruction in the connnon duct, always en(|uire as to previous attacks of "indit,'esti(>n." ."^mall cal- culi are freipiently the cause of symptoms in this le^'ion. If jaundice slowly and jjcradiially increasing, the pain is probably rhie to malii;nant disease. In case where no operation doiu' ma\ L;et:--i Se])tic fever; debilitatint:^ efTects of jaundice. 2. llceratini throug-h of Calculi. 3. Maligant disease. Time of ()peration: — 1. Patients wishes to be consulted. 2. Don't wait until played out before operating. 3 Xever certain about getting recurrence of attack; operation gives permanent relief. Single stone may cause recurrent attacks. Some of the names of operations: — i. Cholecystostomy. -:. Cholecystectomy. 3. Choledochotoniy. 4. Cholccystcnteros- tomy. 5. Cholelithotrity, Cholecystostomy: — Incision vertically 3 inches frotn the end of the loth rib. \'iscus may be displaced downward or cov- ered with adhesions, bring up to the incision, and pack with It4 SVIKIKUY pauzcs (iK'ver sure storikj. Ri-move fluid atui aspirate; in- larjji' the iiu'isioti. pass fuigcr — stouos rttuovcd forcc'i)s. scoop or tinj^'^iT, llun searrli tlu- stop hiie. I'.ilo stools shows the passaj^'e o.k. Where jj^rey stools cotuiiuie. there is a stone in the conitnon duct, <»»■ If bile stools, and tiie bladder discharging,' stone in the (vstic. Peristalsis ni.i\ be reversed and stone i)assed thro igh the openinjj^. C liolecystectomy : — Chief indication is nialifj^nant disease. S'^parate the peritoneun> and bladder by a blunt dissection, pass lifrature around the cystic duct. Cut ofi and cauterize. Choledochotomy: — Same incision. Kaise the shoulders and chest to allow the iiUestines to pfravitate down, hold up the liver. Draw the colon to the median line and away, pack the field of operation. Incise the peritoneum from the cystic duct towards the duodenum, and ^vt duct out as it goes be- hind the duodenum. Incise longitudinally, remove stone, and sew up. If con(htion bad, it is g(X)d surgery not to close the incision, but to insert gauze, pack, and drain; gauze i>ressing the sides of the incision in duct together. Cholelithotrity: — Either finger and thumb or forccjis suj)- plements the other operations, and may use a goofl deal of force without injury to the duct. Cholecystenterostoniy: — Establishing a fistulous opening between the gall bladder and the colon or ducxlenum; latter preferred; easier with the colon. Anastamosis by simple su- ture or a Murphy button. * 'H I- : aUIWEUY •m CllULKLlTlllASlS. ( l;ill stoius arc very friiniciil, hciiij^ prcsctit in from 5 p.r. to 12 p.f. of all autopsies. ^Vt' !nay liti i,n of (jall Stones.— i. .More frequent in women than men, and in a lar,u;e percentage of cases in those whf have honu- lari'<- families. 2. 'V\\::;\\{ lacing, t.- dimiiiishinj;' llu' moviinents. ^. Laxity of ahdoniin.'d walls, allowing' liver to fall down so that fimdus of {j^all bladder is considerably I)ili>w level of junction of cystic and hepatic ducts, thus favonrin;; tlic rc- teiuion >f hilc. 4. 1 )iminislu{l n\oveinents of ial)ctcs ><. Infection of bile ducts by typhoid, small-pox, typhus ami puerperal fevers. Cholesterin is ft^rmed from a s(»lntion of the epithelial lin- injj of the biliary ducts, caused by inilannnatory atrections, etc. I'ilirnbin calcium.- In the normal biU- these two are not conibined. In catarrh of j^all bladder, albumen is formed from the disinte^r.tted epitlulium. and in all prol)aI)ilil\ lhi> favtM'^ the precipitation of bilirubin calcium. ■J'reatment in Lholeiulnasis.- Tartly medical and partly «ur}4:ical. I'.mpyaema of j,'all bladrugs, sulphate or phos- phate of soda, two drachms daily. These are believed to prevent the concentration of bile and the formation of stones. The diet should he regidated. av< tiding starchy and saccharine fo(Mls. Regular exercise benoticial. I'or the intense itching, powder with starch, strong alkaline baths, llypodermically, hot pilocarpin. gr. 1-8 to i-(), and an- lipyrir.. grs. viij. Relief sometimes obtained by ichthyol a. id lanolin ointment. If gall stone in bladiu' of liirm. If tlicy dir it is 'Im* to the conditions which you find. Dr. Johnson's opinion at autopsy of a fatal case was that death was duo t<> i>aralysis of bowel ptXKluccd by nuorphia, because the tield of operation was clean. When a patient has had morphia previ(nis to operation, it is an excellent rule to give ICxt. Heiladonnae, grs. i-| every four hours. DLSKASES OF THE HRlvAS'PS. Malformations: — .'\inasia, microniasia, plicomascia, super- ntunary breasts in the axilla, lower mammary region, front of thif^h. usually n»»t developed. .Agalactia; no milk. ( ialac- torrhoea excessive do. Ilyiiertrophy: — Steady increase for years; i or both: a^ a rule both; weightmaybegreat.consistencyuniform.no pain ; plamls not involved; may become anaemic. I'ailiiilugy: — .\u increase of all the ct>nstituenls no cause. l)iagni»sis: — l-'r. I'atty tumors, and Cystic growth. 'rrcdtiiii-itt: — l'.(|ually applied presstu'e. K. I. Iodine anung; more frequent in old women. Mastodynia; — Neuralgia; like testicular neuralgia; paroxys- mal; radiating pain; periodical at the menses may be contiiui- (Mis; thinks slu- lias cmcer. I'.xamiii;itiou fails to find :my pathological condition. heal: — Correct an\ menstrual irregularity. Fe As, general management, .i sea voyage. Locally l>elladomia as ung. or |>laster, supporting the breast with plaster. N'ipple: — During lactation fre(|uently sore and cracke<|. Paget's Disease:- -Xow known to be an eczema, but re- (piires altention. as is a precursor of carcinoma. lU-gins with a chronic eczema of the nipple and areola. The discharge is viscid or watery; clothes stick; becomes dir)-; scab; induration of structures. I'issures and ulcerations which may destroy the nipple. Treat: — I'arly stages Cocaine, and 20-40 gr. sol. of silver nitrate, followeil up by a soothing lotion. Horo-glye., Pb, ? IMAGE EVALUATION TEST TARGET (MT-3) h I / II % ^% 1.0 I.I 11.25 bills ■ 50 '""^~ « ^^ II 2:5 1^ ill 2.2 1^ 1^ 1. ^ 1.4 ^ / Photographic Sciences Corporation -i3 WEST MAIN STREET WEBSTER, N.Y. 14580 (71£) 872-4503 ^ I SURGERY 231 lotion, Pb. Ung., Belladonna; before apply silver nit. may apply sublimate to kill the parasites. Ulceration destroys the nipple, then it is best to urge excision of the whole breast. Inflammation of the Breast: — At puberty; girl from rapid development changes, get pain, swelling, and some induration, some constitutional disturbance; rarely ends in suppuration. Treat: — Pb. lotion, and Belladonna plaster. Mammary Abscess: — (i) Su])raniammary, frequent, any age, resulting from injury. (2) Intramammar}'. (3) Post or submammary. The first is readily made out; the third is the most difficult; when in doubt aspirate. Treat: — In supramammary incision in any direction. In intramammary, incision radiates from nipple, so as to divide breast in the line of ducts. Submammary; at the lower mar- gin of breast; most dependent part. Chronic Abscess : — Chronic, lobular interstitial mastitis, fol- lowing lactation and miscarriage; frequent in tuljerc. pa- tients. Onset is chronic, becomes hard and tense, pain; gradual retraction of the nipple or dimpling (may confound carcinoma). Later on get oedema. Treatment: — Incision; Volkman spoon; Iodoform gauze. If tubercular, incise the cyst wall or the whole breast. Sometimes have a series of these abscesses in women, who, after parturition, have some suppuration. Syphilis : — i. Ex. -Genital chancre. 2. Secondary ; not noted. 3. Gummata; ulcerating. Actinomycosis: — Treat by amputation. Tumors: — (i) Simple, and (2) Malignant. Cysts: — 2 classes: — (i) Those arising from distension of some part of the glandular apparatus. (2) Those arising independently of gland structure: — ((/) Galactocele. (b) Duct cysts, (c) Involution cysts. Galactocele: — Distension of duct or rupture of duct and infiltration of the surrounding tissues; grows rapidly; may empty partly when nursing; iremains fluid some time, then becomes inspissated, shrinks from coagulation of milk and now and then disappears. N L if I c 1 232 SURGERY Treatment: — It is small, and so symptoms until suckling is over. If painful aspirate and apply pressure. If still persists, open, clean out and dress. Thoug^ht sometimes to become chronic abscess; may become the seat of tuberculous disease. (b) Duct Cysts: — Always in the ducts, may burst through the duct, and form cyst-like galactocele, usually remains in connection with nipple; when may give no trouble, but from chronic inflammation may become cut ofT; distends; hard in- durated nodule; walls become thickened; apt to develop a pap- illomatous condition of the walls, fluid blood tinged, which escapes; clothing stained, and presence of bloody discharge from nipplj should make us think of beginning carcinoma. (2) Connective tissue or serous cysts: — Hydatids; Dermoids. (a) Connective tissue or serous cysts: — Dilatation of lymph spaces, walls of the surrounding connective tissue pressed to- . gether and thickened, usually single, sometimes multiple, supra or sub-mammary preferring the margin. Ranging in size from the size of a filbert to containing several ounces of clear serous fluid, albumin and cholesterin. This is outside the breast structure proper. Never evacuated through the nipple. Grow a great size; thin translucent walls. (Hydrocele of the breast), get light test readily. Hydatids and dermoids are rare. Diagnosis: — When i; connects with the nipple it is easy ; where lying deeply and tense it is difficult. If elastic, small yielding point in the centre points to a cyst, said growtli in the centre is hard. If in doubt, use an exploring needle. Exam, patient lying down. Treat: — Expectant for the time. Drainage through the nipple, may cure itself; aspirate, etc. Better free incision. Brush Iodine, or Zu. chloride; pack with Iodoform, and al- low to granul.-i.te up. Where any suspicious contents, papil- lomatous growths, excise the whole breast. 11 i 1^ SURGERY 233 SOLID TUMORS OF THE BRE/ Vf. Adenomata, Fibromata, Sakcomata and Ca inomata. Adenomata: — True Adenomata are very rare, occurs as a circumscribed ovoid tumour, usually surrounded by a capsule of connective tissue, white or pink. Very much like breast tissue during lactation. True fibroma also exceedingly rare. FriJKo-ADi'.xoMA: — Common simple tumour of the breast, single or multiple, young women under 30. At age 18-25 frequent neurasthenics, or hysterical, caused by blows, or ir- ritation during nursing. At first it is small, grows slowly, may attain a considerable size, varies from size small orange to one weighing 5 lbs. First noticed at the border of the gland. Can be isolated from the Breast substance. Usually little pain except in anaemic and neuralgic subjects. In time becomes attaclicd to the gland and tissues, does not affect the skin or veins, no oedema, does not affect the nipple, the axillary glands are free, does not return after removal. Treatment: — May be largely removed by counter irritation, Elastic pressure. Iodine, J>elladonna with I. and I'b. Ung. Blisters, and K. I. internally; the latter is well coml)ined with Fe. treacment. If not satisfactory, recommend excision ; oc- casions no disturbance of the gland. If very numerous and patient passed the menopause, excise the whole breast. Cystic Adenoma: — More Elastic; History of efTusion from the nipple; usually painless except in neuralgic subjects. Usually does not involve skin or nipple, but by pressure, may cause ulceration of the skin, presenting the characters of malignant growth. Treatment: — In simpler forms, excision may be practiced of the cyst itself. If skin involved, and evidence of papillomatous growth shown by the blood, excise the whole breast. Malignant Tumors: — Sarcoma:- Spindle cells are the most common. At first encapsulated, later infiltrating, most comtnon in women over 30. Oval rounded tumors elastic feel, painless and movable for a long time, and show slight II I ■]: fit 234 SURGERY ! tendency to infect the glands ; seldom retract the skin or retract the nipple — tend to become cystic. As a rule, the health is not much affected. Local malignancy is their remarkable feature. Tend to recur; softer growth; recurrence more rapid. Several re- movals may be necessary before tendency to recur wears out. Tends later to perforate the skin and protude as a fungus. Diagnosis: — Difificult between cystic growths and softer Carcinoma, known by absence of skin affection, freedom of glands. Prognosis is always serious. Treatment. — Early and thorough extirpation. Local recur- rences, should be thoroughly and repeatedly removed. DISEASES OF THE TONGUE. Malformations: — Bifid. Very small tongue. Hyportro- phied. Few cases of absence. Adhesions to the floor. Short- ened fraenum. Shortening is usually a central defect. Treat: — Snip the muc. memb., and tear. Loose string — rarely occurs; the tongue falls back and get troublesome breathing. Wounds and burns of the tongue, treated on general grounds; antiseptic mouth wash. Glossitis: — Sometimes acute from too much Hg. in treat- ment of Syph., carious teeth, sleeping with mouth open and sting of spider or bee. Sometimes following fever. Symptoms: — Rapidly swelling tongue, may threaten breath- ing, oedema of the glottis. Resolution or abscess; abscess to one side of raphe. Treatment: — Ice and bleeding; fargle with Pot. Chlor. In- cision in the long axis, and encouraged to bleed with hot water. Abscess; incise. Chronic Abscess: — Following acute inflammation in tuber- culair subjects. Chronic superficial glossitis: — Psoriasis of the T. Ichthyo- sis and leucoplakia. This is confined to the mucous membrane in smokers, common in dyspeptics; irritation of a tooth, and obstinate syphilis. Most common in smokers at points where ;if^V:y,> .^. JA- ^lAfcxI' SURGERY 235 the smoke inipinfj:os. Swellinfr, collection of Kpitiielium, and white patch formed; may heco'ine raised, whole surface of the ton^-ue covered. F.pithelium may become heaped up, may become malipiant. Treat: — Not satisfactory, where of lonp; standing: not read- ily removed. Mouth wash; where hea])e(l up. Lactic ac. and p^lyceriue eipial i)arts, increasing' to 80 per cent, of lactic. Don't irritate with caustics. Where used always destroy growth. Where raised, and does ncn yield to treatment, and localized, better advise excision of the i)art involved A "V," shaped incision, or from surface of dorsum of tongue. Cysts: — Tumors, naevi, fatty tumors, warts, dermoids, fi- bronia and enchoiidroma. Naevi arc most common, sometimes recpiiring operation, puncture and acturl cautery. Cysts in the floor Ranula. semi-transparent, lobular, walnut in size, on the floor beneath tongue, pushing the tongue up and back, interfering with swallowing, probably due to tiie dilatation of a duct of one of the mucous glands; beneath the tongue; contains a glairy stringy fluid; not cyst of Whar- ton's duct. Treat: — Pinching up, opening with scissors, and drain. Touch the wdiole floor with an armed probe. Seaton silk or horsehair for a couple of weeks with mouth wash ; failing to close, dissect out the sac. Ulcers: — Simple, Syphilitic and Tuberculosis; also F.jjithe- liomatous. Actinomycosis; rare. Simple: — Cominon dyspeptic; irritation of a tooth, dental ulcer, usually on the side; apt to become chronic raised; may become the seat of malignant disease. Relieve the cause, tooth or gastric; mouth wash, soothing. Tf becomes chronic, actual cautery. Syphilitic. Tuberculosis : — Generally secondarily to the larynx, or the lungs, primary condition is rare. Prefers the tip. Begins as a minute white spot; others appear; heipetic patch; vessels burst. Ulcers extend along the border and under the surface, extremely painful. Becomes unhealthv; covered with sloughy granulations. Bacilli are fine, and hard to find; sometimes invades chrouio abscess. f . 'I 'if 2M SURGERY Treat : — Unsatisfactory, scrai)ing- and then cauterize. Co- caine cover Iodoform, dissolved in ether; if this fails excise if localized, and surrd'g. tissue not infiltrated. In advanced phthisis; palliative treatment. Cocaine and morphia; Iodo- form powder. Epithelioma: — Squamous carcinoma. Ap^es 40-60 or 45-55- Men most frefiuently. Causes: — I're-existinp irritation; some cases no such his- tory, hut the majority may he traced to some form of irrita- tion. Sharj) tooth; dental ulcor, ichthyosis; old syphilitic scar; hadly fitting plate; fa!.^e teeth; simple ulcer irritated by caustics; smoking-. I'ejT^ins at the edp^e above the middle third, or opposite the molar or tricuspid teeth, and tends to spread backwards. Get a few on the ti]); floor, rarely on the dorsum, the posterior half rarely afifected first. Ik'pns as a fissure, tubercle, or watery growth, ulcer irre- gular, ragged, everted edges; slougliing base; difficult to clean; tissues infiltrated, growth rapid, foetor, salivation, pain, this becomes severe, at first localized, then shooting, neural- gic along the P»r. of the 5th nerve over the side of the head, and the ear especially. Movements in deglutition, nuiscular and articular, gives pain. Cdands are early involved, ist under the jaw. then the glands of the neck. Tissues infiltrated. Later ulcers in the throat from breaking down these glands. Salivation becomes severe; swallowing foul discharges, he- morrhage, and sapracmia. Diagnosis: — It is wdiile it is localized that we meet with the difficulty. Where in doubt excise a small portion and examine. Where doubtful try syphilitic treatment; if malig- nant it will probably be aggravated. Operations. — Removal of a portion of the tongue justifiable when epithelioma is confined to tip or border of anterior half, and if the submaxillary glands are not enlarged. Draw tongue out by means of ligatures inserted into tip. Introduce a gag. Split tongue down middle and then free diseased half from floor and side of mouth and remove with scissors. * I ; *-a' ■»*itiaj\|'- Where posterior half of tongue is involved, it is necessary to remove the whole organ. Hemorrhage is one of the chief dangers. Heath's method of arresting hemorrhage, whether occurring accidentally during operation or afterwards: — Pass forcfuigcr down to epiglottis, hook forward hyoid bone and drag up towards symphysis menti. This stretches lingual arteries, controlling the flow of blood for a time. In operator must endeavour to prevent hemorrhage; pre- vent blood from entering air passages; and afterwards ma'n- form a felted network in centre of colony with a radiate appear- ance at periphery. It grows well under anaerobic conditions, at body temperature. It lives outside the body, being propa- gated through barley and cereals. I'ortals of entrance, through the tonsils, or carious teeth, but may be introduced through wounds. The lei)tothrix form is that most com- monly found in man. B.xciLLUS Mallei: — Cllanders or Farcy; a motile bacillus, growing on gelatine at body temperature, forming a whitish mass composed of chains and threads. On plate cultures pro- duces bright yellow colonies. ( )n potatoe a bright yellow surface g. owth which gradually takes on a peculiar fawn colour, ultimately becoming chocolate brown. Stains best with an alcoholic solution of methyline blue. It is most pre- valent amongst the equine species, in which it is associated with inflammation of nasal lymphatics. It is inoculablc to man. The disease gradually spreads until it becomes a gen- eral infection. Diagnostic Test: — 1. By inoculation of guinea pig and e.K- amining the purulent exudate from between the layers of the 244 SURGERY tunica vaginalis. After four days the bacilli are readily de- monstrated. 2. By the injection of Mallein, which when in- jected into a Silandered animal produces great local reaction, marked constitutional disturl)ances with rise of tempera- ture. (See also i)age 85.) B.\ciLr,us Sia'Tif.KMi.K 1I.k.\i<>kkii.\(;u .!•:: — An organism or group of organisms important to surgeon, which are de- scribed imder different names by dififerent observers. P.. of fowl cholera, Pasteur. \\. of rabbit septicaemia, Koch r.. of swine plague, Loettler. 15. of deer jilague of Iluepjje. It is a short bacillus with rounded ends, and is found in the blood and oedematous fluid of affected animals. Extremities of bacilli are stained by aniline colours, decolorized by Grams. The central zone always remains unstained. It grows best when sujiply of oxygen is restricted, as in the dee])er layers of the tissues. In a peptone solution of ordinary media, it produces indol. Drying kills; results, swelling of spleen and lymi)hatic glands, swelling and ecchymoses of nuicous membranes; acute oede- ma at point of inoculation and hemorrhage, and degeneration of small areas of nuisdes. I'acilli continue to increase after death. B-ACTLLis OF Ik'r.oNif I'lachk: — Recently described by Kitasato is similar to preceding, and is found in the blood, tissues, buboes and internal organs of infected patients. It may be single or in pairs, encapsulated, is slightly motile and grows best on blood serum at body temperature. The growth, which is yellow and moist, docs )iot pe])tonize the medium, tior does it licjuefy gelatine. Guinea pigs, rabbits, mice and rats are susceptible. It is especially propagated by mice and rats. By drying, moist heat 80°. and antisepsis, the bacillus is destroyed. Bacilli's Lactis Aerogexes: — Usually met with in the faeces cf children and in animals fed on milk. It bears the same relation to peritonitis as the B. coli does. It grows on gelatine, producing nail-shaped colonies. In milk sets up an energetic lactic acid fermentation and pro- duces gas (Carbon dioxide and water). SURGERY 2i- Bacillus Proteus Vulgaris: — Is one of the commonest putrefactive bacteria. It occurs eit'ier in oval forms or as distinct bacteria, with rounded ends; usually in pairs. Ther2 are numerous involution forms. Gelatine is liquefied, colonies yellowish brown, and eventu- ally the whole surface is covered by zoogloea masses. Al- thouj^h spores are never found, it resists dessication. May grow anaerobically. Inmumity on recovery. Surj^ically, it is important to remove the effete matter by the various emunc- tory channels, at rejj^ular internals, because Chcyne found that, although the tissues will resist a large number of bacilli, a minute dose plus the accumulated toxine will result in death, the accumulating toxines devitalizing the tissues, and produc- ing a favorable nedus for proliferation. * B.NCH.i.rs ( )ki)km.\tis Malig.m, or I'ibrion Septiquc : — Is found like the Tetanus B. in the soil, and also in the water which has stood in pools near such soil. It is a large bacillus, and occurs in chains or long filaments, the transverse divisions are not well marked; ends convex, ."^tains by Gram's; forms spores. Grows best in nutrient gelatine (plus 2 per cent, sugar), deep down in media which it liquefies, forming gas and giving oflf a characteristic odour. It is pathogenic to all domestic animals except cattle. In man it is accidentally met with. If it is injected directly into the veins, it is killed ofif. but if into the muscles or subcutane- ously, the disease is set up. Colon Bacillus: — Recent observations on the morpho- logy of colon bacillus, or rather on the colon group of bacilli, by Professor Adami, tend to show that the variety of the forms it may assume in its life history under various condi- tions is greater than heretofore described. The attenuated forms are specially interesting; diplo-cocci, diplo-bacilli, and chains of diplo-cocci, in addition to the well- known varieties, being seen in preparations from cultures crown under different conditions of temperature and iu various media. 246 SURGERY OMITTED FROM inX'ERATION, PAGE 59. Skin Grafting: — This is the method adopted in larg'e ulcer, 1. Revcrdin's method of skin grafting. This is applicable only where we have granulations. Asepsis is unnecessary. Tiny pieces of skin are placed here and there over the granu- lations, and Covered with silk isinglass. In a few days they seem to have disappeared, but the granulations in this area are spreading rapidly. This mtthod takes a longer time to heal skin, and is not so good as 2. Thiersch's method of skip transplantation. Asepsis is absolutely necessary, so scrape awiy all the granulations, and cut ofT the diseased skin at the edges. vShave ofif pieces ot skin three-quarters to one and a half inches wide, and la_y on, taking care not to go deeper than the epidermal layer ; this is recognized by being hard and dense with bleeding points. If any fat ])rcsent this points to true skin, which is not wanted; have adjacent pieces over-lapping. Special Forms of Ulcer: — i. Phagedena; rapidly spreading; occurring usually in venereal sores. Chronic or acute. Treatment: — Destroy the surface by caustic or cautery, and get acute ulcer healing well, except perhaps in syphilitic or debilitated subjects. 2. Exuberant Ulcer : — Treatment : — (a) If slight, apply Silver Nit. or Cu. Sulp, (//) If marked, shave it ofif, and apply pressure or cautery. 3. Painful Ulcer (nerve endings arc exposed). Treatment: — (a) Cut the nerve branch, {b) Chloral or Co- caine applied. 4. Rodent Ulcer: — This is an Epithelioma, growing from the sebaceous glands. 5. Decubitus: — From debility, but prevented by hardening the skin, and by scrupulous cleanliness. 6. Trophic Ulcer: — Pressure Poultice and stimulating the nervous system. ^%f' WK> ADDENDA To Irrigate Bladder. Warm solution of Boracic Acid. ■vV Thiersch's solution, Salicylic Acid gr. I. / \^ Biborate of Soda VI. Water oz. I. Bichloride of Mercury i-ioooo. External Irrigation. Carbolic Acid 1-20, 1-40, Bichloride of Mercury i-iooo to 4000. Irrigation of Joints. Bichloride 1-5000. Irrigation of Peritoneal Cavity. Boiled Water. Bichloride i-ioooo. Transfusion of Saline Solution. One drachm of Sodium Chloride to the pint of sterilized warm water. ( 1 '<4.^^ GENERAL INDEX. Abscess 50 Diafjno-is of ; Ililtcin's Metliod 51 Abdominal Injarics 100 Actinom) cdses 87 Acu ininciure 168 Addenda 247 Albuniinuiia 22 Amyloid Degeneration 22-52 Aneurism .4 3 1 35 Anorchism 216 Anthrax 84 Angina l,udovici .... I9 Antyllub Melhod 34 Armstrong on Append'citis 229 Arteries 24 Artificial Anus 94 Aveling's Trans-fusion Apiiaiatu'-". 30 Aseptic Technique 7 Bacteria in Wounds 6 " Anthracis 2^2 of Hubonic Plague 244 " Diphtheria; 241 " of Influenza 242 '' Lactis Aerogenes 244 " of Lustganen 67 " of Leprosy 241 " Mallei 85 '' Oedematis Maligni. . . . 248 '• J'roteus Vulgaris 245 ' ' Pyocyaneus 238 " of Kabies 241 " Smegma 241 " of Syphilis 241 '' of Haemorihagic Septi- caemia 244 " of Tuberculosis 240 " of Tetanus 242 " Typhi .'Nbdominalis ... 239 Bandagi ug 123 Bedsores 5765 Bloodletting 48 Bladder, Diseases of 186 Cystitis 188 Stone in 193 T, B. C. of , 100 Foreign Boi'ies in I91 Tumors of 192 Bones, Diseases of 162 Caries 166 Inflammatory Diseasesof .. . 170 Periostitis 162 Necrosis 169 Osteitis 164 Osteo Myelitis 165 Hrea'it, I 'iseases of 230 Solid 'I'umors of 233 Brushes 7 Burns Hi Bryant's Triangle 131 Callus 115-125 Callaway's Trst 152 Cancruni Oris 59 ( 'art)uncle 59 Caries 166 Castration 185-221 Cellulitis 19 Chancroid 72 Cholecystectomy 224 Cholecysiostomy 223 < holedochotomy 224 Cholelithotrity 224 Cholecystenterostomy 224 Cholelithiasis 225 Ciiarbon 84 Cloacae 1 69 Cold, Eflects of 48 (."ollapse 21 Colles' Law 85 Culototry 94 Contusions i Cryptdvchid Cystitis 1 88 Czerney Lembert 213 Davey's Lever 27 Degeneration, Lardaceous or Amy- loid 52 Diabetic Gangrene 59^3 Diagnosis of Fracture 113 iJigital Pressure 33 Dislocations 148 Astragalus 161 Carpal Bones 157 Clavicle 151 Klbow 1 54 Fibula 161 2S0 GEyPAlAL INDEX Foot 1 6 1 Hip 150 Knee 160 Lower J;iw .... 150 Metacarpal 157 Patella 160 Shoulder 152 Special 150 Semilunar Cartilage 160 Thumb 152 Varieties and Causes 148 Drainage 9 Dressings ,. 8 Duodenum, I'lcer of 22 Dusting Powder 9 Dugas' 'J'est 152 Dysphagia. 209 Ecchynioses i Ectropion Vesicae 186 Embolism-Fat 124 Erysipelas , 13-21 Treatment and Classification. 14-16 FIsmarch 27 External It rigation 247 Exstrophy lb6 Farcy S5 Fat Embolism 124 Fever 47 Hectic 52 Fistula 53 Urinary 179 In Ano 106 Fissure in Ano 104 Fractures I lo Classification and Varieties of iii Complications of. 123 Clavicle 146 Colles 145 Coccyx 1 29 Diagnosis of 1 13 Femur 130' 134 Fibula 139 Humerus li\2 Hyoid Bone 127 Leg 138 L'wer Jaw 126 Non-union , II7 Nasal bones 125 Patella 135 Pelvis 128 Potts 140 J99o 44 . los . 247 • 247 . 247 f 170 ,. 170 . 171 .. 198 • '53 I. • 52 . 44 .. 21.^ ,. 8 ,. 28 *> t ! I i \ •^*4Kitm,^ti ^U.:i^ OKNERAl. IXDKX 251 \ Liston's Aorlic Compress 27 Lithotomy 198, 208 Position 206 Lithotrity 197 Liver, Diseases of 221 Malignant Diseases of : Intestine 91 Rectum 108 Operation in 109 Liver , 222 Malgaigne's IIool