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RD35 M44 Surgical differentia
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SURGICAL DIFFERENTIALS
BY
J. W. DRAPER MAURY, M.D,
R0CKEFEL1.KR INSTITUTE RESEARCH FELLOW IN THE LABORATORY OF
EXPERIMENTAL SURGERY
COLUMBIA u!NIVERSITY
NEW YORK CITY.
ILLUSTRATED.
published by
James T. Dougherty,
409 & 411 West 59th Street,
. - NEW YORK CITY. '■
1^04 '
Copyrighted, 1904,
J. W. DRAPER MAURY, M. D,
THEO. GAU8' SONS, Pbintebs.
42 Fbanklin Stbekt,
NEW YORK.
TO MY MOTHER.
PREFACE.
"Diagnosis" has for some time been accepted as meaning
"Differential Diagnosis." This term is too long for conveni-
ent iise and of the two words, clearness seems to demand that
"diagnosis" be dropped. This is offered as an explanation of
the title of this book.
The subject matter has been compiled with but a single
purpose. This is to present to students intending to enter the
competitive examinations of the New York Hospitals, a well-
tried scheme and its mode of application. It is not the actual
learning of surgical facts but their selection and grouping
which is most difficult to the student.
In the opinion of over one hundred graduates who during
the past six years secured hospital positions, the ability to apply
this scheme was the primary cause of their success. These
pages represent simply an effort to present as tersely as possible
the system which has proved so highly efficacious. It will
therefore be seen that no attempt to make a text-book or
book of reference has been thought of.
Ability to sketch rough outlines in place of giving
long word answers has always been very helpful in secur-
ing hospital positions. In recognition of this, forty graphic
illustrations have been introduced. They were made by Dr.
Chas. K. Stillman, a successful graduate of last year. Hav-
ing been made by a student they can be duplicated by a stu-
dent, for they have been drawn with studied simplicity and it
is believed, with accuracy. Except in three or four instances
they are entirely original; — I cannot too cordially thank Dr.
Stillman for his care, or endorse his work too highl}-.
Copies of some recent hospital examination papers have
been added, in the interest of stndents at Universities ontside
of New York City.
The Differentials have been made with care and by pains-
taking reference to leading text-books. It is feared, neverthe-
less, that many errors may be found. These Differentials have
been chosen with the intention of indicating the general broad
trend of to-day's hospital questions. The time for memorizing
special material for each examiner is happily past and with it
the value of the obnoxious "quiz compend.'" Examiners no
longer ask for narrow isolated facts but require the broad prac-
tical Diiferential.
Dr. Jos. A. Blake, Dr. Geo. E. Brewer, Dr. R. H. M.
Dawbarn, Dr. John Rogers and Dr. L. A. Stimson may
recognize in the text some of their own familiar aphorisms.
The author wishes to acknowledge the debt which he owes
these Teachers of Surgery.
J. W. Draper Maury.
September 1st, 1904.
CHAPTER I.
SCHEME.
A clear and uniform recitation scheme is essential to every
student of medicine. This is particularly true of those who
enter competitive hospital examinations.
For more general surgical diseases the same scheme may
be applied which is universally used in the practice of medicine.
-, T-A ( Simple — Such as is given in a modern gen-
1 — Definition j. '■ , ,.° . ^
( eral dictionary.
r Predisposing — Age, sex, race, color,
^ ,-, j occupation, social status, climate.
2 — Etiology ■{ r > , ^
I Exciting — Trauma due to r • i
1^ ^ \ violence.
o T-> i Gross.
3 — Pathology -'.-.,.
I Minute.
Subjective or I c o u i t
^ -"i o .- ^ r See Sub-scheme I
General Symptoms )
. o 1 Inspection
4 — Symptomatology < rw • ^- -ni^-
j Objective or ! Palpation
j Local Symptoms { Percussion
1 J Auscultation
5 — DiFf-ERENTiALS^^— (3.ee Sub-scheme II)
,. r^ o ( Immediate, mediate and
— Complications and Sequelae \ '
I remote
7- Prognosis \ Mediaff^^ \ ^^ ^^ ^'^^ and return of function
(Remote j of injured part
f J Nurse
I Medical V Feed
8 — Treatment -:j ) Stimulate
o -1 Pallative
Surgical r r> 1- i
^ ) Radical
SCHEME.
SUB-SCHEME I.
Many surgical lesions, however, require further detail
than .this familiar scheme affords.
In giving subjective symptoms, for example, it has been
found convenient to follow the course of a particle of food
through the body. All the patient complains of in the usual
surgical lesions is pain or disability. One or both of these
symptoms may occur in the
1, Mouth
2, Pharynx
3, Esophagus
4, Stomach
5, Small and great gut
6, Liver (Jaundice) or other
glands
7, Here the food enters the
blood from which indi-
rectly is derived the
T. P. R.
8, Heart
9, Lungs
10, Brain
11, Special senses
12, Peripheral nerves
13, Kidneys and G. U.
14, Extremities
SUB-SCHEME II.
1 — HisTOKic Differentials.
a. History of Tumor, Injury, Disease or Malformation.
Note. — T. I. D. as used in prescription writing, convenient way
to remember this.
b. History of previous Injury, Disease or Operation.
c. Age, Sex, Race, Occuption, Social State, Climate,
2 — Subjective Differentials.
a. Pain — Local and referred.
b, Disftbility
i\ Vomiting
d. Bladder
and Rectum
e^ Jaundice
/, T. P. R.
Ap j Important always to give the actual
/ figures. Never say elevated or de-
pressed.
120 is the danger line of the pulse.
Pulse has six characteristics: Force,
Frequency, Rhythm, Lengfth, Full-
ness, Compressibility. The first three
are determined by the heart, the
last three by the condition of the
vessel wall.
SCHEME. • 9^
f Central (vertigo, delirium, con-
. -^T . , ^ . , j sciousness, convulsions)
^ ' "^ V s s} p -j Peripheral (paresthesiae, special
1^ - sense)
h, Urinary symptoms.
[ Inspection
j Facies
3^ — General Physical J Nutrition
Differentials ] Glands
j Superficial and
[^ Deep Reflexes
[ Inspection
I Palpation \ Pressure
4 — Local Physical ) Percussion f pain
Differentials \ Auscultation
I Mensuration | Serous Sangui-
1^ Exploratory Puncture f nous Purulent
5 — Laboratory Differentials.
A^ Sputum
B, Stomach
r FreeH. CI. (N. = yV^)
(TZ, Chemical of contents \ Combined H. CI.
( Carbon Compound Acids,
b. Physical of contents — Color, sediment, odor, etc.
!Boas-Oppler
Sarcinae
Atypical Cells
[ X-ray (with Bismuth).
I K. I. in capsules
so characteristic of the "hobo" and of the worn out
cook. As Jacobi says: "What to do?" Make a boot of the
patient's own skin by cutting a circle around the leg, just dis-
tal to the knee. Avoid the important cutaneous nerves and
cut to the muscles. Tie the vessels as you cut, and on com-
pleting the section, suture the skin. This is called "Schede's
operation." It blocks every cutaneous vessel and forces the
circulation into the deep veins.
If the lesion be characterized by swelling of the distal por-
tion of the long saphenous and with dilatation and tortuosity
of the vessel in the upper part of its course, the tortuosities may
be excised and the upper segment treated by subcutaneous
ligation or by removal of small sections along the course of the
vein. For treatment of proximal long saphenous varicosity.
Fowler has devised a unique method. He ligates at a chosen
TREATMENT OF VARICOCELE. 41
point six odd inches distal to the saphenous opening and again
ligates between the opening and the first ligature. At this
point he cuts the vein and frees it enough to grasp it with a wet
towel. He then, by a sudden jerk, pulls the severed section
of the vein, hook, line, bob and sinker, clean out of the tissues.
Every one must remember the pictures in school text
books of physics which show Torricelli's famous experiment
in which he burst a tremendously powerful cask by screwing
a pipe into it and pouring w^ater in at the top of the pipe. By
this means and without a very high pipe, such a cask can be
blown to pieces. No wonder the veins dilate, for in getting up
upon our hind legs, we illustrate admirably the Torricellian
principle.
Varicocele. This lesion has until recently been treated to
a large extent by subcutaneous ligation. It is recounted of
a famous French surgeon, that on one occasion a patient called
at his office and the surgeon found him to be suffering from a
bi-lateral varicocele. Esculapius was about to go to the opera,
but hastily taking his needle, after injecting a little cocaine, he-
threw a ligature about the parts on both sides. The varicocele
promptly disappeared, but in six months time the testicles had
atrophied ! On discovering this, the patient bought a revolver,
went to the office of the surgeon and shot him dead. He was
arrested, tried and promptly discharged by a court on the.
ground of "justifiable insanity!"
Accidents similar to this have combined to put a quietus
on sub-cutaneous ligation for varicocele. It is contrary to the
spirit of surgery to work in the dark.
The open operation here as elsewhere is to be preferred.
Most surgeons advocate placing the incision as high as possible
so as to avoid cutting the tissue of the scrotum which is most
difficult to sterilize. The important points are to note the
vas deferens by its rat-tail like feel ; to remember that the three
arteries are so small that their pulsation can hardly be felt; to-
note that the offending veins are usually separate and distinct
from the normal veins of the vas ; to tie above and below ; to-
excise the included inch or more of the plexus and to make
an internal suspensory by approximating the cut butts together.
Hemorrhoids. The easiest way to treat these varicosities
42 TREATMENT OF HEMORRHOIDS.
efficac ously is to put an angiotribe on them for a few minutes.
This instrument is a giant forceps designed to exercise a pres-
sure of from one to 2,000 pounds to the square inch. The tis-
sues embraced in its jaws are compressed to the thinness of the
finest sheet of tissue paper. This treatment is particularly
suitable for the single external hemorrhoid, for it can be done
very conveniently under local anesthesia.
Many people dread a general anesthetic more than they
do an operation. For severe cases of internal hemorrhoids,
the suggestion by Tinker that the entire perineal region may
be completely anesthetized by using massive infiltration of a
half per cent, of eucaine in the neighborhood of the great
ischiatic tuberosity where the internal pudic and long pudendial
nerves course about the bone will be of importance in further-
ing the treatment of these cases. If prostrates can be painless-
ly enucleated by this method, surely hemorrhoids may be
similarly treated. (See illustration under Prostatectomy.)
The clamp and cautery is probably the favorite method of
treating hemorrhoids.
Another widely employed technic is to seize the apex of
the tumor with a blunt clamp, to circumscribe its base with a
sharp knife through the mucous membrane, to transfix it with
a needle bearing heavy pedicle silk; to cast a Staffordshire knot
•over the growth, to tie it so tightly as if possible, to kill the
nerve endings, and finally to cut ofif the apex as near to the
suture as is safe. This is known as ligation.
In the execution of this technic, the flaw is apt to lie in
the fact that it is almost impossible to tie the suture tight
enough to kill the nerves. If these live, for several days after
the operation, the surgeon had better leave the patient exclu-
sively to the nurse, for the pain makes the remedy worse than
the disease. Injecting the veins with irritants and escharotics,
■such as equal parts of tincture iodine, glycerine and phenol,
is widely practiced by quacks and constitutes, in the hands of
some of these men a useful, although admittedly dangerous
palliative treatment.
The Medical treatment of hemorrhoids is satisfactorily em-
braced by the four words, nurse, feed, stimulate and bidet.
Fig. 6, shows the veins of the face and neck. They are
NEVI.
43
frequently asked for in hospital examinations. The temporo-
maxillary sinus, when varicose, constitutes a very evil lesion,
its removal being extremely difficult.
wTT juqu/ar
*■ fi^t a„tCTSst
Fig. 6
Nevi. These dilatations occupy a mid -position between
the arteries and the veins, by virtue of their occurring either,
in the small continuations of these vessels, or else actually in
the capillaries which connect them. They have been con-
veniently divided into capillary and cavernous. The capillary
form is best known in the familiar "mother's mark." All
'^'mother's marks" are, however, not due to capillary dilatations,
some being caused by pigmentary deposits. These dilatations
are usually treated in one of two ways. They are either
excised, and the part is skin grafted, or else they are subjected
44 VENOUS ANASTOMOSIS.
to electrolysis. The negative needle of a galvanic battery is
run longitudinally its full length into the growth. The elec-
trolytic action destroys a number of cells in the near region of
the puncture. Productive inflammatory changes take place,
and as explained in Chapter II, the gap is presently filled with
granulation tissue. At no distant time this contracts, and,
clinically, where once was a disfiguring red blotch, will be
seen a fine white line. A multiplication and an irregular cross-
ing of these fine white lines eventually destroy the growth,
enough capillaries being left to preserve the normal skin color.
The technic is tedious to the operator and expensive to the
patient.
Cavernous Nevi are lesions which sometimes threaten life.
They have an evil habit of growing with such rapidity that
they may be difficult to differentiate from a rapidly growing
sarcoma. They occasionally yield, when inoperable by the
knife, to prolonged treatment by electrolysis. Bubbles of hy-
drogen can in these cases be seen, when the electrical action is
going on satisfactorily and when the needle is suitablv placed,
coursing at the rate of one or two to the second '♦through the
dilated and about to be destroyed veins.
Wyeth has recently devised a characteristically ingenious
and simple method for the treatment of these growths. It
consists in the introduction of boiling water directly into the
tissues, the water being boiled by a lamp held under a syringe
which holds half a pint to a pint. This process is much more
rapid than electrolysis, and it is safe if care be taken not to
introduce enough boiling water to cause necrosis. In other
words, not more tissue should be destroyed at a time than
can be taken care of by the phagocytes and the plasma, without
the necessity of the organisms pushing the devitalized ma-
terial out through the surface.
The knowledge of the paths by which the blood may
return when the portal system is obstructed is an important
aid in establishing many diagnosis. It is a frequent hospital
question and is therefore given. (From Gray)
(i) By anastomosis of mesenteric veins with superficial
abdominal.
(2) Of phrenic and gastric veins with those of Glisson's
capsule.
(3) Of superior hemorrhoidal, inferior mesenteric and
internal iliac.
(4) Gastric and esophageal with azygos minor.
(5) Left renal and intestinal.
CHAPTER IV.
NERVES, MUSCLES, TENDONS AND BURSAE.
Fig. 7.
LUMBAR PLEXUS.
Hif't"'^
From upper four Lumbar
Nerves.
The 1st Lumbar splits into
two; the 2d, 3d and 4th split
into four each.
The 2nd division of L,
and the 1st of the II. unite.
(Genito-crural)
The 2d division of II., and
1st of III. unite. (External
cutaneous)
The 3d division of II, and
2d division of 3d, and 1st di-
vision of IV. unite. (Ant.
crural)
The 4th division of II., the
3d division of III. and 2nd
of IV. unite. (Obturator)
The 4th division of III.,
and 3rd division of IV. unite.
(Accessory obturator)
The 4th of the IV. unite with V. (Lumbo Sacral Cord)
The Mnemonic for this is :
"If I get examined, all's over. Oh!"
The two most interesting problems in the surgery of
nerves are suture and transplantation.
According to very recent views, the outlook on suturing
a nerve many months after its section, is almost as good as if
the operation had been done immediately after the infliction
46 NERVE SUTURE.
of the injury. This is not in accordance with the older teach-
ing, which was that there is very little use in attempting to do
anything with a severed nerve, unless it can be operated on
immediately after being cut. This recently demonstrated abil-
ity of the nerve to re-establish its function, even if united long
after the reception of the primary injury, seems to show that
the much dreaded degeneration is not so grave as was formerly
supposed and suggests that function returns in some other way
than by the actual re-establishment of the axis cylinders. The
conclusion from these recent observations is that no case of
peripheral nerve injury should be refused operation simply be-
cause the opportunity to unite the divided ends comes at a
late hour. In any event, whenever the union is made and
whatever the process of repair, return of function, which may
be either incomplete or complete, comes at best only after
months of patient treatment with electricity, massage and
hydrotherapy; one and all.
Another conclusion, which is of very great importance is
this, viz. — no attempt should be made to unite the ends of a
divided nerve in case the wound is known to be dirty. Inas-
much as a moderate delay or even a prolonged delay appears
not to have the profound importance which was formerly as-
cribed to it, some surgeons now advocate postponing the
operation until after the active manifestations of the inflamma-
tory reaction have cleared away.
The attempt to replace a destroyed segment of human
nerve by grafting an equal length of animal nerve has failed.
So it did in the case of bone grafting. The body does not take
kindly to any form of graft, except skin graft ! Decalcified
bone tunnels, and a host of similar devices, the supposed pur-
pose of which is to keep the pathway open for the axis cylinders
to grow along, have also proved failures. They should proba-
bly therefore, be entirely abandoned and recourse had, in the
event of destruction of a segment of the nerve, to bone resec-
tion. This of course applies only to wounds of nerves on ex-
tremities, and although in the arm it shortens the "reach," this
is justifiable except of course among a certain class of athletic
gentlemen.
Transplantation has lately awakened a widespread interest,
NERVE TRANSPLANTATION. 47
because it appears that the possibilities before it are as yet only
half surmised. As has often happened before, supposed ad-
vantages of this technic may have been exaggerated.
The present status of transplantation, however, is such
that a thorough knowledge of how the technic is applied ; its
indications, and its limitations is desirable. So far, the most
important application of the principle has been made in cases
of paralysis of the seventh. The process is a simple one.
Given a case of facial palsy, what can be done for it? Ob-
viously it can be massaged, electrefied and hydrotherapized,
but as is well known, if the disturbance be centrally situated
absolutely no good will follow. Until very recently, it was
held that the centres of the cranial nerves differed widely from
each other. They certainly send out impulses having utterly
dififerent characteristics. The medullary centers have become-
peculiarly specialized, in that for example, one interprets hear-
ing, while another almost adjacent to it, controls the muscles:
of the tongue. The one is a higher class of work than the
other. How can it by any possibility be that one of these
little bunches of cells, after a short education, can assume the
functions of the other? Whatever be the answer, the fact re-
mains that if a portion of the hypoglossal nerve, as it courses,
in the neck toward the tongue, be grafted into a centrally
paralyzed seventh nerve, the patient v>^ill, under favorable con-.
ditions, regain facial control. When first done, it was not ex-
pected that anything would happen. As is sometimes the
case, however, the unexpected did happen and the control of
the muscles of the face was assumed by the center of the
twelfth. This center did its own work and that of the seventh
as well. What an interesting series of possibilities this
awakens. It is true that both these centers have to do primar-
ily, with the creation of motor impulses, but if such a switchings
of motor centers is possible, may it not untimately lead to a
swi-tching of the special sense centres as well? Will, for ex-
ample, the first nerve ever be made to assume the functions of
the second, thus giving sight to the blind?
MUSCLES.
A straiii is an injury produced by over-stretching a muscle.,
A sprain is also an injury produced by over-stretching a mus-
48 CONTRACTURES.
cle. Each of these may occur in the ligaments. The first
may be said to be disting-uishable only with a microscope, or
perhaps not even by such delicate means, whereas the second
is always accompanied by a macroscopic, or physical tearing
'of the fibres. Strains are more apt to occur in muscles than
sprains, which are usually seen in the neighborhood of joints,
the ligaments being torn.
Muscles are apt to undergo calcification. It is well to
note that this change differs from ossification. The one is a
dead process, the other a living. Ossification, while not so
common as calcification in the muscles, is not by any means
unknown. Rider's bone is a plate forming in the adduct or
longus and is frequent among the cavalry men. Drill
bone occurring in the deltoid muscles is occasionally seen
among infantry- men. These lesions are the result of chronic
irritation and are grouped under the general term of occupation
diseases.
Muscular Contractures are of great interest and impor-
tance. Their treatment forms a large portion of the work of
the orthopedic surgeon.- They are of two distinct types, spas-
modic or relaxing and non-relaxing. Spasmodic contractures
are often called contractions.
The most practical way to dififerentiate contractures is
to give the patient chloroform. The first type is seen typically
in those cases where Nature endeavors to make splints out of
the organism's muscles, as for example, to protect a joint in-
flamed with disease from harmful motion. The rigidity of such
muscles is so great and the tone of the tension so constant
that it is often impossible, except under an anesthetic^ to tell
whether such a stiffness is of the transitory or permanent type.
Naturally, if transitory, when the element of pain, which symp-
tom calls this muscular tone into action, is obliterated, the mus-
cle relaxes, and the condition is seen to be spasmodic. Muscles
in a state of chronic tonicity are apt to become permanently
shortened. If no relaxation occurs a non-relaxing contraction
is demonstrated.
Myotomy or Muscle Section is indicated in non-relaxing
contractures. Familiar examples are, section of the sterno-
mastoid for spastic torticollis, or of the flexors and adductors
in late stages of coxitis. Tenotomy usually takes the place of
myotomy.
The fasciae are very liable to degenerative changes. As
elsewhere in the body, so in the fasciae fibrous tissue tends on
slight provocation to become very thickened, or sclerosed, as
it is called. It will be remembered that this process has been
described in Chapter II, as dry productive inflammation.
DUPUYTREN'S CONTRACTURE. 49
Cc
T-/r^//s
Fig. 8
One of the most interesting, as well as most common, con-
tractures of fasciae, is what is called Dupuytren's Contracture.
It occurs in the palmar fascia. It has nothing to do with the
tendons. It is a superficial lesion. It is infinitely more com-
mon in men. It is characterized by a gradual closing of the
fingers, which are held in a pathognomonic position as though
by bands of steel. As it is often bi-lateral, a central cause has
been suggested for it. Probably chronic irritation favors this
sclerosis, although it is by no means uncommon among men
who have done but little manual labor.
The figure shows that the hand assumes, (no doubt for the
convenience of ones memory), the well known position of
Papal Blessing or Apostolic Benediction. Were it not for this
obliging resemblance, it would be very difficult to remember
the fact that the lesion occurs almost entirely in the fascia lead-
ing to the ring and little finger.
Treatment. The open and the closed methods are advo-
cated. By the open, some cocaine is introduced and a longitu-
dinal section is made directly over the steel like band of fascia.
This band is tensed by traction on the closed finger. After a
little dissection it easily comes into view, is sectioned proxim-
ally and distally, and as much as possible of it is removed. The
subcutaneous method consists in making a series of sections
50
SENSORY NERVES, UPPER EXTREMITY.
of the tense band with a fine tenotome. It occasionally gives
good results, but as a rule is to be utterly condemned because,
as time goes on, more sclerosed tissue grows as a result of the
traumatism and irritation of the operation. Tenotomy is, to-
day, practically the only closed operation that has survived.
Fig. 9
z-^
TT~^CT of 0)770.7^
c)j[cy/o/Y^Dtyc6e.7)7)A^
t ; ,-j
; 'n V
C.KS
Fig. 10
51
DIFFERENTIAL.
Dupuytren's Con-
tracture.
Ulnar Section.
Median Section.
Burn
Contract-
ure.
History of Injury.
Absent.
Onset extremely
slow; begins lit-
tle finger.
Male.
Unable to let go
after takinghold
Sensation nor-
mal. No wast-
ing. Posture :
typical ; aposto-
lic blessing.
Cut near wrist us-
ually.
Cut near wrist us-
ually.
Disease.
Onset immediate. Immediate.
Sex.
Male.
Male.
Disability.
Unable ^ grasp
objects normal-
ly. Loss of sen-
sation as in Fig.
10. Atrophy of
hypothenar,
eminence mark-
ed. Posture:
typical; claw-
hand.
Small objects can
not be picked
up by thumb
and fingers.
Loss of sensa-
tion as in Fig. 10
Atrophy of the-
nar eminence
marked. Post-
ure: typical.
Ulnar flexion with
extension of
wrist and fin-
gers.
Burn of severe de-
gree.
Moderately slow.
Negative.
Depends on extent
and position of
the burn. If
nerves were de-
s t r o y e d , the
parts supplied
by them will un-
dergo the four
characteristic
changes cited
below. Posture:
atypical.
Note four important points in diagnosis of nerve section :
Atrophy, Paralysis, Anasthesia, Posture.
Note also that every nerve which crosses a joint supplies
filaments to all the soft parts as well as to the hard.
TENDONS AND TENDON SHEATHS.
Tendons are more freqtiently the scene of operative inter-
vention than muscles. This word is used advisedly instead of
interference, because the surgeon does not "interfere." The
•53 TENO-SYNOVITIS.
Tendon Sheaths are exquisitely delicate sacs much like dimin-
utive pleurae. They are subject to inflammatory changes, not
dissimilar to those which occur in the great sac. One charac-
teristic sign of pleurisy is the see-saw friction rub heard as the
patient breathes. It can sometimes be felt. Similarly, in the
small sac, dry inflammatory processes go on. The smooth
bearing surfaces usually so well oiled and presenting infin-
itesimal obstruction to motion, become dry and corroded.
On pulling the tendon back and forth after this change has
taken place, they emit a grating sound and transfer what is
called a fremitus to the hand. This is known as tenosynovitis.
It is usually an acute or sub-acute lesion, and it occurs fre-
quently in the tendo- Achilles. "Tender feet" who have over
indulged in walking often fall a prey to it.
Chronic teno-synovitis is present in most cases of tuber-
culous joints. It is characterized by an increase in the size
and number of the inflammatory particles characteristic of the
acute form. These may gradually grow until they finally be-
come detached. They are soft at firsfr but ultimately undergo
calcareous degeneration. After this they are known as rice-
bodies. Most of these formations contain in their center
tubercle bacilli. It frequently happens that the chronic form
of teno-synovitis as in the case of many other lesions, usually
originates in the acute. Obviolisly the chronic form is amen-
able only to operative treatment.
Tendons often have to be cut to correct muscle contrac-
tures. This is done subcutaneously. Repair of the part takes
place under Schede's moist blood clot referred to on page 25
Consequently great care should be exercised not to allow the
dressings to press out the blood clot, failure of which to organ-
ize means loss of function in the part.
A felon is an acute inflammatory process in the distal
phalanx of a thumb or finger. It begins on the palmar surface.
It is typically a periostitis, although the other soft parts, par-
ticularly the tendon sheath, may be primarily involved. Treat-
ment consists in section over the point of the greatest pain
through the periosteum. The indication for this section is
not the presence of pus but the symptom of pain.
Ganglion. . The lay name for this is weeping sinew.
BURSAE. 58
Ganglia are now thought to have no connection at all with the
tendon sheaths, but to take their origin from the synovial
fringe of the neighboring joint. They are therefore a form of
distention cyst. They may be treated by rupture subcutan-
eously or by aspiration or excision.
Tendon Transplantation, This is often useful in cases of
acquired paralysis of the extremities. It has been employed
more particularly upon the foot. It consists, for example, of
inserting a slip of the tendon of the peroneus longus into that
of the tibialis anticus. It is of value only in rare cases where
there is a healthy muscle near a paralyzed one.
BURSAE.
The lesions of the bursae are classed as occupation
diseases. They are the result of exudative and productive in-
flammation. Morphologically they are distention cysts caused
by long continued pressure. Child believes them to be essen-
tially protective rather than pathologic in nature. From hoary
antiquity we have inherited the following old classics :
House Maid's Knee or pre-patella bursitis ; Miner's Elbow;
rarely seen in this country, but frequently in England and
Wales, where the coal seams are so narrow that the men are
obliged to lie on their sides to use their picks. As they pick,
the elbow rotates back and forth on the Olecranon process
and the bursa enlarges. Coachman's Bottom. This, on ac-
count of the hard seats which the liveried flunkies of the British
nobility are obliged to sit upon, combined with their tight
pants, arises on the tuber ischii. It is rarely seen in this coun-
try because of adequate upholstering.
CHAPTER V.
LYMPHATIC VESSELS AND THEIR NODES.
Fig. 11
Shows the group of cervical glands typically involved in syphilis.
This figure is designed also to show the cervical triangles as
simply as possible.
ACTION OF THE NODES. 55
The relation of the lymphatic vessels to diseases in general
and particularly their influence upon the metastatic distribution
of carcinomata make them of very great importance surgically.
A thorough knowledge of the distribution of the lymphatic ves-
sels which drain the tongue, the breast and the uterus is a
sine que non for all, but most particularly for those wishing
to rank in a hospital examination. The character of the opera-
tions on these important parts is governed entirely by the dis-
tribution of the lymphatics.
The glands may well, for purposes of convenience, be
looked upon as nature's sieves. They protect the body from
germ infection and other dangers, and are therefore of great
surgical importance. They do not, however, bear as intricate
a relation to surgical pathology and treatment as the vessels.
The lymphatic vessels play a very important part in the
distribution of germ toxins as Avell as of the germs themselves.
The glands or nodes are thought to filter out the germs them-
selves much more efficaciously than their chemical products,
although it is well known that in passing through these bar-
riers of infection, the toxins are greatly moderated in their
virulence. Reciprocally the glands are enlarged and often per-
manently damaged. It is, however, in the protection of the
body against invasion of the actual germ bodies themselves
that the glands show to the best advantage. Their well known
splenic reticular structure seems to have been specially devised
to entrap the invading vegetable hordes. When a germ is
lodged in the gland, there is plasma enough and leucocytes
enough in this vascular organ to inhibit its development if not
actually to kill it very shortly after its lodgement. If the dose
of infection at the primary wotuid, supposing it to be on an
extremity, is not sufficiently great to entirely overwhelm the
lymphatic nodes, they will sieve out the intruder to the entire
protection of the general organism. If, however, the dose is
overwhelmingly large, there is naturally a limit to the number
of germs they can accommodate, and the result is that, like
sponges filled with water, they can take no more. The germs
then pass on and are swept either into the general vascular
stream where the great lymphatics join the veins, or into the
56 TERMINATIONS.
inner breast works as they might be called, of lymphatic nodes,
unless this last line of defense has already been passed.
This introduces the very important subject of lymphangitis
and lymphadenitis.
This is not an inopportune time to grind out these various
endings. Very few students know them, but it is a blessing
to realize that if the half dozen odd terminations are once
memorized and thoroughly understood, they can be applied
throughout surgical pathology.
For nerves, for the stomach, for tendons and so on down
the line, these terminations will be used.
Lymphangitis. "Itis" means inflammation of. Seen
also in appendicitis, gastritis, otitis, etc.
Lymphadenoma. "Adene" in Greek means a gland, so
that this termination means a lymphatic grandular swelling
devoid of inflammatory reaction.
L5anphadenitis. Here the two terms are combined. The
"itis" showing that the enlarged gland has undergone inflam-
matory change.
Lymphangitis. "Angi" in Greek means a vessel. This,
therefore signifies an inflammatory condition of the lymph ves-
sels.
Lymphangiectasia. "Ectasia" in Greek means dilatation.
Therefore this term as applied to the lymphatics means that
the lymphatic vessels are dilated.
Lymphangfiorrhaphy. "Rhaphy" in Greek means a line of
union. It is seen in the "median raphe," a term familiar to all.
Now raphe means also to sew. Whenever it is suffixed to a
word, therefore it means that the parts have been sewn to-
gether. For example, enterorraphy means a sewing of the gut.
This naturally is rarely practiced in the case of lymphatic ves-
sels, because they are too delicate to sew together, but at-
tempts have been made to suture the thoracic duct.
Lymphangiostomy. "Stoma" means mouth. (Kindly re-
member that this has nothing to do with stomach). Stomatitis
is an inflammation of the mouth. If you make a mouth on a
thing, it implies that you have made a hole in it for good. This
differs from a temporary opening, which will be considered in a
moment. If it were desired to make a fistula to drain the
DUCT LESIONS. 57
lymphatic duct, experimentally, for example, this would be a
lymphangiostomy. It will readily be noted that this operation
is not practically used on the lymphatic vessels, but it is intro-
duced here to show that theorectically all these terminations
can be applied at will to almost any organ. The familiar opera-
tion in which this termination is used, is one done on the stom-
ach and it is therefore called gastrostomy.
Lymphangiotomy. "Temno" in Greek means to cut. If
you cut into a vessel, you make an opening into the lumen.
Usage has determined that this term shall apply to a temporary
opening in contra- distinction to the one just considered in
which "stoma" is used, which implies the making of a perma-
nent opening. This is illustrated particularly well on the
stomach. A gastrotomy is done on a man who has swallowed
his false teeth. It is immediately closed by gastrorrhaphy. If
his esophagus is destroyed, however, he requires a gastrostomy.
Lymphangiectomy. "Ectomy" is derived from two Greek
expressions "ec" and "temno" "ec," meaning out, and *'temno,"
to cut. "Angi," here, as elsewhere, means vessel. Therefore
this long word means simply a cutting out of a lymphatic ves-
sel. In practice this is rarely deliberately done, the fine lyfn-
phatic vessels being removed with masses of other tissue.
The terminations are used very frequently to denote operations,
on other viscera. For example, neurectomy, is practised for
the relief of sciatica ; enterectomy, a removal of a section of
the enteron or gut is frequently done for strangulated hernia.
Lymphedema. From the Greek "Oidos," a swelling.
This means a transudation into the areolar tissue of lymph.
It is generally due to a blocking of the vessels. It is distinct
from venous edema in that it is solid.
Returning from this excursion into etymological fields, it
is interesting to note what definite relations lymphatic vessels,
bear to disease in general.
Filariasis. This is the general term for a series of symp-
toms which until quite recently were regarded as having separ-
ate entities. They are called into being by the presence of an
animal parasite called filaria sanguinis hominis, yvhich means
the thread worm of man's blood. It is 1-80 of an inch long.
The embryos are harmless, but the adults produce a train of
•58 LYMPHADENITIS.
symptoms, the like and diversity of which is not paralleled by
any other known organism. One of the most important of
this series is
Elephantiasis. This disease is rarely seen outside the
tropics. It is a productive inflammation, due to the presence
of the filaria in the lymphatic vessels. This occludes the vessels,
and ultimately they either burst or degenerate into solid strings.
So terrible is this disease in its ability to cripple and render
useless great numbers of men and women that immense prizes
of money await him who is fortunate enough to discover its
remedy.
Chyluria. This symptom is also produced by the filaria.
The urine looks like milk. The pathology is not yet under-
stood.
L5niiphadenitis is a commonly seen swelling of the nodes.
It is due, as already stated, to the snaring of pyogenic germs
in the meshes of the node and to the irritation of its paren-
chyma by their toxic products. The parenchymatous cells are
the cells which do the specialized work of an organ. They are
supported by the interstitial or frame creating cells which unite
to hold them in place. Six years ago, the pus producing organ-
isms were supposed by many to be confined to the three varie-
ties of the streptococcus and the staphylococcus, viz. — the
albus, the aureus and the citreous. This list has now been
lengthened to over thirty. The best way to remember it, is
to learn the germs that do not produce pus. Prominent among
these are the parasites of tetanus and diphtheria.
Lymphadenitis may be acute or chronic. It is not uncom-
mon in the groin. If a patient is found to have a swelling of
"the glands below Poupart's ligament, look for a sore on the
foot. If the cross bar of the lymphatic T is involved, look for
venereal infection. Acute lymphadenitis, particularly when the
inflammation is localized either in one gland or in glands which
are close together, is sometimes called bubo. Bubo is from the
Greek "Bonbon," meaning groin, but the term is also occasion-
ally used to denote an inflammatory condition in glands situ-
ated elsewhere.
The treatment is palliative or radical. If the infection has
T^een of such a degree and nature as to kill the gland, ice bags
LYMPHATICS OF FEMALE GENITALS.
59
and rest will do no good. These agents, however, should al-
ways be employed, and it is well to remember that in practically
all cases of acute inflammation, cold is indicated during the
first 36 hours and moist heat after that time. Moist is much
more efficacious than dry heat.
The radical method of treatment consists in free incision
and drainage. The after-treatment is very tedious. Attempts
to heal these lesions rapidly by the application of the principle
of Schede's moist blood clot have been successful. The technic
after opening and curetting is simply to swab the cavity out
with pure carbolic acid, douching it immediately with alcohol.
This stops further action of the acid. This method of treating
abscess cavities has recently been widely adopted by many New
York surgeons. It has been used with favorable results in
thousands of cases at the Hudson Street Hospital. After irri-
gating with the alcohol, the incision is tightly closed with
ZSody
G
CrviK
*/
iJukC
Uo^^
h»^
nJi
XrcL^ in. above Zygoma; 1>^ in. back
from external angular process.
Trephine for Brain Abscess. — ^ in. above External Audit. Meatcus;—
if not there, IX inches behind external audit, meatcus: X i^- below
R. B. L. (Cerebellar Abscess)
Trephitie for Lateral Sinus. — 1 inch behind Auditory Meatus; % in.
above R. B. L.
104
SENSORI-MOTOR AREA.
Fic. 20
V^^ VtA"
H
SigpT
A/OTo
r Sriicn
• SoUNT>
Fig. 21.
POSITION OF THE CENTERS. lO.S
Surgical hemorrhage generally comes from the anterior
branch of the middle meningeal artery. Its extent is deter-
mined by two factors; namely by the degree of laceration and
by the position of the wound. Not infrequently the middle
meningeal lies in somewhat more than a i8o degree channel
on the skull case. This amounts virtually to a canalization of
the bone by the vessel, and from it two interesting conclusions
result. First, hemorrhage must take place from an artery
which is enveloped by bone, but very slowly, if at all; and
second, the artery must be injured in almost every case of
simple linear fracture of the bone across its course. The rela-
tion of the dura to the tear is also a determining factor in blood
extravasation. Hemorrhage will naturally take place very
much more rapidly central, rather than peripheral, to this,
tough membrane. Cases of peripheral dural bleeding have been
known to occupy a week or more before symptoms became
marked. This is to be explained by the difficulty which the
blood experiences under the limited cardiac pressure in tearing
the dura from the bone.
The home-made method of remembering the position of
the centers in a sensory motor area is shown in the accompany-
ing figure. It demonstrates the body of a puppet upside down,
which is the position taken by the centers, as shown by the
companion figure. It demonstrates further that just posterior
to the fissure the sensory and the moior areas overlap each
other. This little scheme has long been used by Dr. Robert H.
Dawbarn in demonstrating his lectures on the brain.
The position of the anterior branch of the middle men-
mgeal is such that the first symptoms, after the recovery of
the unconsciousness produced by the primary concussion,
should, as shown by the puppets in the Figure be motor irrita-
bility of the face and arms.
BRAIN AND MEMBRANE INFLAMMATIONS.
There is no more favorable location for the growth of
bacteria than within the brain case. There are various ways
by which these germs obtain ingress. It may be convenient to.,
use Sub-Scheme III to give the causes of intra-cranial infection.
It may be brought about by T. I. D. M. of the parts.
Of tumors situated externally, epitheliomata may be taken-
106 CONTINUITY AND CONTIGUITY.
as representative. These, as nutritional advantages decrease,
break down and become infected. The drainage from such
ulcerating areas is apt to be by one of the Emissory Veins.
This is more apt to be the case if the lesion under consideration
is located upon the scalp, although the face, as show^n by the
figure, is not a region exempt from danger. Suppose drain-
age of the epithelioma to take place via the ophthalmic
vein. It terminates in the cavernous sinus, and from this great
blood lake infection travels into the brain by contiguity of
tissue. (See Fig. 13)
It is important to know the difference between travelling
by continuity and contiguity of tissue. It would be easy to
understand the terms if the words "of tissue" were usually
used, but they are not. If an inflammatory process begins in
the stomach, as an ulcer and an abscess developes in the con-
tiguous lobe of the liver, that infection is said to have reached
its destination by contiguity. The tissues were near to each
other, but they were not continuous. First, there were stomach
?ells, then interval connective tissue cells, then liver cells.
If, however, an abscess had formed in the wall of the
stomach, those products would have reached their destination
by so called "continuity of tissue," because they never were
obliged to pass out of the stomach wall.
Consequently, by contiguity, a panencephalitis might be
established in the case of the supposed ulcerated epithelioma.
Sarcoma of the Antrum is an example of a tumor in the
wall of the brain case, which, on breaking down, may cause
panencephalitis, localized intra-cranial abscess, or any form of
inflammatory change.
Tumors on the inner wall of the brain case, which cause
intra-cranial inflammation, are rare.
External Injuries. — Almost any injury which becomes in-
fected, and which is situated in the neighborhood of an emis-
sory vein, may cause the lesion under consideration.
Fractures are the next possibilities to consider, and after
injuries come the diseases.
Lupus. This disease is prone to ulceration, and the man-
ner of infection from it may be similar to that of epithelioma.
Otitis Media often affords an admirable illustration of
CEREBRAL ABSCESS. 107
how infections travel by contiguity of tissue. From the middle
ear, as has already been noted, the agents travel to the mastoid,
thence to tlie lateral sinus, producing typical phlebitis of the
internal jugular; thence, if the patient lives, to the dura, pro-
ducing pachymeningitis ; thence to the pia (always supposing
the patient to stand it), producing lepto-meningitis ; thence to
the cortex, producing cortical abscess ; thence to the enceph-
alon, producing pan-encephalitis.
Cerebral Abscess, then, may arise in a variety of dififerent
ways. It is not unlike abscesses elsewhere. It, therefore, pos-
seses the general characteristic that it may be due to a pure
or a mixed culture infection.
The best example of pure culture cerebral abscess is the
tubercular. About this abscess an interesting point of dif-
ference has arisen. The chronic, slowly developing, often mul-
tiple, frequently secondary, pure culture tuberculous abscess
causes typically a sub-normal temperature. Its antithesis, the
single, acute, rapidly growing mixed infection abscess which
bears no practical relation to the tuberculous form at all, cer-
tainly in its early stages, is characterized by a temperature of
from 103 to 105.
Park states that the temperature when raised is in pro-
portion to the degree of meningeal involvement. He says fur-
ther that a particular characteristic of the cerebral abscess is
its tendency to form about itself a pyophylactic membrane by
which the abscess becomes entirely capsulated. In fact unless
this membrane forms, the patient is almost certain to succvimb
in the acute stages of the abscess. Thus, "walling off" is of
vital importance in the brain.
It is not known why abscess tends to produce a sub-normal
temperature. If it were a usual accompaniment of intra-cere-
bral pressure, one would expect to find it a manifestation of
tumor ; but such is not the case. There can be little doubt that
whatever the cause of the subnormal temperature acute ab-
scesses, which undergo the encapsulation process, become prac-
tically the same as pure culture tubercle abscess. They are in
other words "cold" and should .naturally not be expected to
produce the symptom of elevated temperature. The conclusion
then is, that although probably a number of cases of abscess
108
CEREBRAL DIFFERENTIALS.
which in the past were described as mixed culture abscesses,
have in reaHty been pure culture tubercular formations. In
this case, a subnormal temperature has erroneously been as-
cribed to them.
One of the most frequently asked as well as the most con-
fusing differentials, is between cerebral tumor, abscess, tuber-
culous meningitis and typhoid. It is obviously of the gravest
importance for the patient that correct conclusions should be
reached early because of the fundamental difference in the
modes of treatment. In this differential, as in others, no at-
tempt is made to give all the smallest details which are in-
tended to be filled in by the reader. Furthermore, here as else-
where, it is not possible to be dogmatic without opening a free
path for justly unfavorable criticism. Whatever flavor of dog-
matism is present has been extracted from the most recent
text books on the subject.
DIFFERENTIAL BETWEEN
Cerebral Tumor.
Cerebral
Abscess.
Tuberculous
Meningitis.
Typhoid Fever.
History of Injury.
Not rare, especi-
ally in sarcoma-
ta.
Onset fairly rapid
Before 20 if tuber-
cle; 20 to 40 if
sarcoma.
Very severe. Con-
stant. Some-
times located
over lesion.
Worse in early
morning.
Frequently fol-
lows fracture
of skull.
Absent.
Disease.
Onset slow. Chill.
Onset slow. T.B.
elsewhere.
Age.
Active adult life.
Childhood.
Pain.
Severe. May be
localized.
Often worse at
night.
Absent.
Onset slow. Anor-
exia. Nosebleed
common.
15 to 30.
Headache often
absent.
109
DIFFERENTIAL BETWEEN.— Continued.
Cerebral Tumor
Cerebral Abscess
Tuberculous
Meningitis.
Typhoid Fever
Disability.
Depends on posi-
tioi:. May be
anywhere.
If protectile or dis-
tinctly "cere-
bral" in type
very important.
Because of fre-
quency in cere-
bellum, often
disturbances of
gait.
Stiff neck.
Vomiting.
Not infrequent, TVT ^ u . • ^•
but nausea rare, r""^ characteristic
Negative.
Normal.
Strong, 50, regu-
lar.
Bladder and Rectum.
Negative.
Temperature
96.5 to 100.
May be secondary!
to enteric T. B.
If so, diarrhea.
100 to 102. Even-
ing rise.
Pulse.
Strong. 40 to 50,
regular.
Strong, 60 to 70,
regular.
NERVOUS SYMPTOMS.
Vertigo.
Not common un-l
less in cerebel- Very common
lum.
Absent.
Delirium.
Late, if at all.
If present, abso-
lute.
Usually general
and early.
Apt to be earlier.
Early.
Unconsciousness.
Absolute. Less profound.
Convulsions. -
Not so common as r^
in tumor. Common.
Dysalimentation.
If present, of dis-
tinctly "gastric '
type.
Constipation o r
diarrhea.
100 to 102.5. "Step-
ladder".
Weak, 100 to 110,
may be irregu-
lar.
Absent, except
from gut or due
to weakness.
Early, late or ab-
sent.
Less profound.
Often intermit-
tent.
Very rare.
110
DIFFERENTIAL BETWEEN.— Continued.
Cerkbral Tumor
Cerebral Abscess
Tuberculous
Meningitis.
Typhoid Fever
Amnesic Aphasia.
Word- deafness,
common.
Rare.
Word - blindness,
common.
Often cannot
write. (Second
or third left
frontal)
Frequently pres-
ent.
Not so common.
Absent.
If in tempero-
sphenoidal,
common.
Motor Aphasia.
Absent.
Alexia.
Less common.
Absent.
Agraphia.
Rare.
Absent.
Absent.
Absent.
Absent.
Absent.
Apraxia.
(Loss OF Perception of Objects)
Occasionally pres-
ent.
Absent.
Paresis or Palsies.
Frequent.
Optic neuritis
common and of-
ten double.
Occasional.
Not so common
and apt to be
sinele.
Absent.
Special Sense.
Absent.
Absent.
Absent.
Absent.
LOCAL PHYSICAL.
Palpation.
Negative.
Very rarely local
tenderness.
Occasional local
increase in tem-
perature.
Not infrequently
local tenderness
Negative.
Percussion.
Absent.
Negative.
Absent.
Ill
DIFFERENTIAL BETWEEN— Continued.
Cerebral Tumor
Cerebral Abscess
Tuberculous
Meningitis.
Typhoid. Fever
Exploratory Incision.
Found to be oper-
able in only 5 to
10% of cases.
Unaltered.
In temporo-sphen-
oidal lobe or ce-
rebellum. Lo-
calized pus.
Pin-point tuber-
cles on mem-
branes. Exu-
date.
Negative.
Negative.
BLOOD.
Leucocytosis.
10,000 to 15,000. I 9000.
WiDAL AND Other Tests.
XT i- Positive to tuber-;
^^S^^'^^- I culin. I
Effect of K. I.
5000
Positive to Widal.
If gumma, mark- Negative
ed.
Negative.
Negative.
It will thus clearly be seen that a differential between these
four diseases, particularly if they are taken at a reasonably
early period of their development, is extremely difficult. The-
value of the laboratory findings cannot be over estimated, for
clinically there may be a very grave and discouraging absence
of facts.
THE SPINE.
If difiticulty has been experienced in localizing cerebral in-
juries, it has been much greater in the case of the cord. This
is obviously because the cord is concerned only with reflex ac-
tion and with transmission. These functions, are extremely
difficult to localize with any degree of accuracy. Precisely
similar lesions arise in the cord as in the brain and their causes
are in a measure identical with those affecting the higher cen-
ters. It often becomes necessary to establish a differential
between a supposed case of spinal hemorrhage, of bone pres-
112
SPINAL DIFFERENTIALS.
sure of transverse lesion of the cord, or of certain very rapidly
grov^fing tumors. In theory this may be possible, but in prac-
tice most unfortunately it is too true that a positive conclusion
can be reached only after exploratory incision. There are,
however, points of academic interest and these have been ar-
ranged as concisely as conflicting opinions of authorities allow.
DIFFERENTIAL BETWEEN
Spinal
Hemorrhage.
Bone Pressure.
Transverse Mye-
litis.
(Traumatic)
Sarcoma.
History of Injury.
Always present.
Always present.
Always present.
History of Disease.
Onset may be
slow. Symp-
toms increase.
Onset immediate.
Symptoms sta-
tionary.
Same.
Previous Disease.
Atheroma.
Negative.
Negative.
Sex.
Negative.
Negative.
Negative.
Temperature.
100 to 102.
Normal.
98 to 100.
Paresis and Paralysis.
Appear late. Mod-
erately slow in-
Immediate.
Immediate.
crease.
Absent.
Relatively very
slow. Symp-
toms increase.
Involvement else-
where.
30 to 40. (McCosh)
Normal.
Appear late. Slow
increase.
LOCAL PHYSICAL.
Inspection.
Often irregularity
of spine.
Same.
Same.
Negative.
LAMINECTOMY. 113
It will be seen that there are very few available data upon
which to base a differential of the spinal lesions. Brewer says
that a recognition of extra-dural and subdural hemorrhage is
surgically unimportant even if they do occur unassociated with
fracture or dislocation, because they cannot be clinically recog-
nized.
Laminectomy is the term used to designate the technic
which is used in reaching the cord. The danger of this opera-
tion increases very rapidly as it approaches the brain. The
chief matter of importance concerning it is that if indicated at
all it should be performed immediately. It is interesting that
this rule, which was formerly supposed to hold good for in-
jured nerves, has recently been demonstrated, as already cited,
to be fallacious. (See chapter on nerves.) That this does not
hold true in the case of the cord is undoubted, for degenerative
processes of a destructive nature are pretty definitely proven to
be well under way thirty-six to forty-eight hours after the cord
has been injured, and by some authorities before then.
CHAPTER X.
THORAX.
Fig. 23
The Compleinental Sinus
is shown as the higher of the
two areas mapped out on the
lower region of the Thorax.
It is that space intervening
between the lower border of
the lung and the line of Re-
flection of the Pleura and is
filled with Pus in non-en-
cysted empyema.
The Costo Phrenic Sinus
lies just below the comple-
mental and its inner and
outer boundaries are formed
respectively by Diaphragm
and Thoracic wall. This
Sinus is the seat of Costo
Phrenic Abscess.
The following table, in part
compiled according to Hunt-
ington will be found useful.
J>.^^r^,^._^'
complkme-n tal and supplemental
Sinus.
Comply-
Lower Pleural menial
Line. Limit. Lunr/. Sinus.
Sternal— Upper VII. Kil), Upper VI. 2 ciu.
Paraslerual — Middle VII. " Lower VI. 20111.
Mammary — Lower VII. •' Ui^iiier VII. 2 cm;
Axillary— IX. " Lower VII. Gem.
Vertebral— XII. " " XI. 2.53 cm.
This shows a longitudiual elevation
through the centre of Fig. 22. Con-
sult Deaver's anatomy for further
data.
Note thai the greatest depth of the
Complemental Sinus is in the axillary
line.
The Costo Phrenic Sinus naturally
is bounded above by the Lower Pleural limit and below by the attachment of
the diaphragm to the Ribs and Rib-Cartilages, (See cut of diaphragm in
chapter on hernia. )
DIVERTICULAE. 115
The surgery of the thorax has been stimulated very much
by the perfection of methods for artificial respiration pending
the opening of the chest cavity. Prominent among these is
one devised by Matas of New Orleans. It is so constructed
that it automatically supplies the required amount of air. This
obviates the danger of the variable dosage which the excite-
ment of a major operation was almost certain to engender
when the old instruments were used.
The Esophagus, partly because of its great importance and
its unfortunate liability to disease, besides the fortunate fact,
that although passing through the thorax, its whole extent can
be reached without opening that cavity, has been the object
of more surgical intervention than any other organ in the chest.
One of the most interesting lesions which can befall this
tube is the formation in it of Diverticulae. The causes of these
diverticulae can easily be enumerated by reference to Sub-
scheme III. They arise as a result of twelve possible condi-
tions, viz. — Tumor, Injury, Disease or Malformation within the
lumen, in the wall of the lumen and without the lumen, or in
other words in twelve possible positions. The accompanying
radiogram, which was recently made by Dr. Cole at Roosevelt
Hospital, shows the nature of these diverticulae very beauti-
full}^ The outline was made clear by causing the patient to
swallow about two ounces of carbonate of bismuth. The
esophagus, on account of its being, collapsed antero-pos-
teriorly, appears in this side view as a line.
These diverticulae are often the result of stricture.
Dunham has recently shown that almost every stricture
which is of such nature that the patient is not prevented by it
from swallowing water, can be passed by allowing a thread to
float in the water and by then swallowing the liquid and the
line. In strictures of the deep esophagus, which are beyond
the reach of external esophagotomy, and as a preparator}/- to
Abbe's Fish Line Treatment, this demonstration is of great
importance.
The Italians have been the pioneers in Cardiorrhaphy. As-
tonishing success has met efforts to suture the heart wall. It
depends upon the introduction of interrupted sutures which are
ticfl duriny diastole.
116
ESOPHAGUS.
^^O/D BOA/£
ESOPHAGUS
Fig. 24
ESOPHAGEAL DIVERTICULUM.
(author's case)
Given off opposite the 6th cervical vertebra. (The patient coughed
up bismuth for two weeks after this radiogram w^as made.)
TREATMENT OF EMPYEMA. 117
Of operations which necessitate a trans-pleural route, by
far the most frequent are those for the relief of empyema.
They may be enumerated as follows: (i) Paracentesis, (2)
Resection of One or More Ribs, (3) Estlander's Operation, (4)
Schede's Operation. (This last might be spelled "Shady" for it
is highly doubtful if the patient survive it), (5) Fowler's Oper-
ation.
If the collection of fluid in the pleura be localized and of
such extent as to produce a bulging ;• a condition uncommon
but not by any means unknown, the needle should, after most
scrupulous sterilization, be driven in over the most prominent
part of the swelling. If, however, as is more frequently the
case, the exudate is not loculated. a point of election for para-
centesis is just below the scapula. This of course is a very
movable point, but it is usually understood that the arm is in
a position past full abduction from the body. This raises the
lower scapular angle somewhat and carries it toward the axilla.
The needle should not enter lower than the eighth intercostal
space, and when it is withdrawn, a piece of zinc oxide adhesive
plaster should be clapped over the wound before the patient
has time to suck air in through it by making a respiratory
effort.
Now suppose the pumped out fluid to have been a simple
straw-colored liquid, which is shown by laboratory examina-
tion, to have the characteristics of an exudate. This treatment
will, in a very large percentage of cases, be curative. Occa-
sionally, however, either because of infection introduced at the
time of operation, or because of a contamination of the exudate
through internal sources, the patient's condition will not im-
prove except in so far- as he becomes more comfortable at once
from the relief of pressure. The temperature, in-stead of re-
maining normal or falling from the slight rise which occasion-
ally accompanies simple pleuritic exudation, either maintains
that slight rise regularly, or else creeps slowly upward. What
is to be done in the face of these conditions?
Obviously drainage is indicated. Some very excellent au-
thorities have said that adequate drainage is to be had through
an intercostal space. Dr. A. A. Moore has devised an ingen-
ious little instrument for so draining these pus cavities, partic-
118 ESTLANDER'S TECHNIC.
ularly in little children. The general consensus of opinion,
however, is that it is better surgery in every case to resect a
rib, rather than to attempt intercostal drainage. Ribs regen-
erate very rapidly and, the resection entails a remarkably small
amount of shock. On a "stiff" it is demonstrably impossible to
do a sub-periostial resection, but this is simply because the
membrane in the "stiff" is normal. In the case of a chronic
empyema, however, the periostium is very apt to have become
somewhat thickened on account of contiguous productive in-
flammatory change. The section of rib, consequently, in these
cases, shells out with comparative ease from its enveloping
membrane. The intercostal vessels and nerve, below, are not
seen if the periostium be split directly over the anterior long
axis of the bone, nor are the smaller vessels, which are located
at the upper margin.
Now suppose the rib resection and the introduction of the
usual drainage tube to have failed. What is the next step to
be taken? Obviously it is necessary to establish freer drainage.
The condition will now have become decidedly chronic, a
greater or lesser area of the lung having retracted. The me-
chanics of the proposition therefore become simple. A con-
stantly discharging abscess is in one respect like nephritis in
that the body in each condition loses highly nutritive albumin-
ous fluids. The cavity has to be obliterated, in order to stop
this steady drain of pus. It resolves itself into either bringing
the lung out to meet the chest cavity or of dropping the chest
wall upon the permanently collapsed lung. Obviously it is bet-
ter for the patient if the lung can be forced out, but this cannot
be done in all cases.
Estlander's Operation is based upon an acknowledgment
of defeat. It is therefore not indicated until every means, such
as blowing water into James' Bottles and other attempts at pro-
ducing artificial emphysema have been tried. Furthermore, it
is not likely that any serious attempt to collapse the chest wall
will in future be made until Fowler's technic, shortly to be
spoken of, has been tried. If employed as thoroughly as is rec-
ommended by its distinguished inventor, there must be very
few cases in which it will fail to obviate the necessity of doing
either an Estlander or a Schede. Suppose, however, Fowler's
FOWLER'S TECHNIC. 119
technic to have been unsuccessfully employed. One should not
at this stage think of doing a Schede, but would naturally turn
to the more conservative Estlander technic. He advises
(Brewer) "the removal of portions of several ribs according to
the size and shape of the underlying cavity, but without dis-
turbing the thickened parietal pleura."
Schede's Operation (Brewer) "consists not only of remov-
ing the ribs but also the parietal pleura. He advises 'a large U
shaped incision, beginning near the junction of the second rib
and costal cartilage, extending downward and backward to the
tenth rib, then upward to the axillary border of the scapula.' "
Fowler's Operation. It was noted some time ago that if,
during the execution of one of these throracoplastic operations,
the visceral pleura was cut, the lung promptly expanded be-
neath it, so that the simple line of incision could, as one
watched it, be seen to develop into an opening shaped like a
bi-convex lens. It must be remembered that after the establish-
ment of chronic empyema, the visceral pleura has promptly
lost all its delicate physiological functions and, because of its
extreme thickness (sometimes amounting to as much as a quar-
ter centimeter) has begun to act as an ever tightening con-
strictor around the lung. The evil effects of a productively in-
flamed capsule of any organ cannot be overestimated ; its
agency in producing lesions of the kidney will be spoken of
later.
Cutting the blanket-like pleura was destined to afford re-
lief of a measurable but inconstant type. The technic some-
what resembled the subcutaneous section of the fascial bands
in Dupuytren's contracture, which, although giving temporary
relief, eventually made the contracture worse by the subsequent
increase of the scar tissue.
Fowler was the first to note that the treatment of the
pleura should be the same as the treatment of Dupuytren's
fascia, viz. — that it should be removed as entirely as possible.
He therefore advised that it be freely incised and ripped from
the lungs. Obviously this should be done early, before dry
productive inflammatory (sclerotic) changes have taken place
in the lung. After the unfortunate establishment of this con-
130
MALIGNANT DISEASE OF BREAST.
dition, there is no relief for, nor means of obliteration of the
pus cavity, save by dropping the chest wall in upon it as pro-
posed by Schede.
(2crom,o
n.
^a e. j <2;
Fig. 25
,,7* Tnamma
This is an adaptation from a most beautiful cut in Eisendrath's
Clinical Anatomy. It shows the breast quadrants and their
lymphatic drainage. It also shows the very important rela-
tions of the internal mammary artery.
(Used by courtesy of De. Eisendrath)
THE BREAST.
Since a small fraction over one-half of all favorable cases
of carcinoma of the breast can be permanently freed from the
disease, it is indeed a pity that more do not reach the surgeon.
An eminent authority has divided women into three
DEGENERATION OF BENIGN GROWTHS. 121
classes. Forty-five per cent, of them are so frightened at the
possibility of having- a tumor in their breast that they are per-
petually running to their physician, or at least to the person
who poses as such — for confirmation or refutation of their sus-
picions.
Another forty-five per cent, are so badly frightened that
when they find a tumor in their breast, they conceal it from
everybody and not a soul knows of it until it is a rotten mass
heralded by its stench.
The remaining ten per cent, are sensible about the matter.
Immediately on discovering a small tumor they put themselves
under the care of a competent surgeon.
Of the first class, almost the entire number, because of
their dread of the knife and their willingness to submit to every
"ism" and "no-knife treatment," fall in discouragingly great
numbers into the hands of the charletan and of the ignorant
but well meaning practitioner of "isms." Thus it is that prob-
ably not over twenty per cent, of tumors of the breast of a
malignant character are ever subjected to suitable treatment.
So hazy is the border line between an adenoma and a car-
cinoma of an inactive type, that it is impossible to say, when
the one may fade into the other. The changing of a benign into
a malignant growth may be likened to the peeling off from a
sweating hand of a pair of moist kid gloves. The fingers turn-
ing inside out, reverse their direction. That is all, from mor-
phological evidences in any event, which takes place when in
a wart or mole, the fingers of which have been extended toward
the surface and engaged in no malevolent work, some unknown
agent suddenly reverses them and they reach out hungrily and
malignantly into the subjacent tissue. So subtile is this change
in these most simple, superficial little growths that Keen has
gone so far as to counsel the removal of every wart and mole
from one's body. If this be advised on the opinion of so high
an authority, how great indeed must be the danger to which
we are all exposed through these apparently harmless but very
common growths. Furthermore, how much greater must be
the danger of malignant degeneration taking place in the more
complicated, more vascular and less freely observable tumors
of the deeper parts.
The appended figures represent an effort to show graphi-
132
BENIGN AND MALIGN CHARACTERISTICS.
cally some of the major differences between an adenoma, a car-
cinomaand a sarcoma.
Fig. 26
( /y/=-.»? St^^.l-^^^ )
Fig. 28
PROPHYLAXIS OF MALIGNANCY. 123
Treatment of Carcinoma. The treatment of mammary
carcinoma is determined absolutely by the distribution of the
lymphatic drainage. The mortality rate from the radical opera-
tion would be very much lower were it not for the unfortunate
fact that the upper inner quadrant drains largely into the an-
terior mediastinal glands and indirectly into the liver. Fortu-
nately, however, the most extensive drainage is into the axil-
lary and supra-clavicular groups. (See Fig. 25.)
Thus it is that the position of the growth, particularly if
it be a small one, determines the extent of the operative inter-
vention. If, for example, the outer upper quadrant alone is in-
volved, it may be deemed conservative to remove no more than
the axillary glands with pectoralis major and minor. If, how-
ever, as is too frequently the case, the growth when operated
upon has invaded other quadrants of the breast, the supra-clavi-
cular and in some cases even the anterior mediastinal glands
are taken out. The first calls for a resection of the clavicle ; the
second, for a resection of a portion of the sternum. The immedi-
ate mortality of the operation is of course higher if the medias-
tinal glands are attacked, but the chances of permanent cure, if
the patient survive the operation, are enhanced.
Prophylactic after-Treatment of Malignancy.
This is a convenient point at which to consider the after
treatment of all forms of malignant disease after they have-
been removed. The argument in general is this, that if certain
agents about to be described are curative, as they have posi-
tively been shown to be, of malignant growths, when superfi-
cially situated may these agents not have a protective power in
preventing the secondary development of malignancy after the
tumors have been removed by the knife? It is accordingly the
custom of some surgeons to treat their cases according to the
terms of this argument. Some of the treatments referred to-
are :
(i) The X-Ray. Both the curative and prophylactic power
of this agent are generally recognized. . The chief danger and
difficulty has been the indiscriminate use of the rays by ignor-
ant or unscrupulous operators. Such men yield to the tempta-
tion to advocate radio-active treatment in the case of deep-
growths, where the knife only is indicated.
124 PROPHYLAXIS.
(2) Finsen's Light. This was originally obtained by con-
centrating the sun's rays through huge water glass lenses, the
circulation of the water cooling the rays sufficiently to prevent
their burning. It is now obtained chiefly from electric lights.
Action depends on the unknown power of the violet and ultra-
violet portions of the light. The work done by these rays is
accomplished by vibrations which do not appear to us as color,
because of their being situated ultra or beyond the violet side
of the spectrum. They are too rapid for sight-perception. The
chief function of the Finsen rays probably is in the treatment
•of Lupus.
(3) Static Spray. This is simply the discharge from a
powerful static machine applied to the part from a metal point.
The erythema produced is similar to 'that of the X, and the
Finsen Rays, but the curative properties are more limited.
(4) Radium. This remarkable element possesses curative
powers similar to those of the X Ray. They are stated by
Abbe to be ten times less potent. It has, in addition to its
therapeutic properties the remarkable ability to retard develop-
mental processes. Abbe has shown that seeds, if exposed to
radium radiations, are retarded in their growth proportionately
to the time of exposure, and he has further demonstrated that
meal worms, which ordinarily complete their cycle of develop-
ment in about three months, if exposed to radium, remain meal
worms ; refusing for an indefinite period to manufacture their
■cocoons.
(5) Starvation. This treatment has been elaborately
worked out by Dawbarn, and he has conclusively shown that
in certain forms of sarcoma it is of distinct value and possibly
so in the case of other malignant growths. The principle is to
cut off as much nutrition as possible without causing the
healthy parts to slough. Its most favorite site for employment
is after the removal of sarcomatous growths from the region of
the antrum or lower face. The technic consists not in ligation
but in actual excision of the great bulk of the arterial and ven-
ous supply.
The treatment then of malignant disease as exemplified in
the breast, consists of early removal, followed by prophylactic
treatment. This may be by prolonged exposure to Radio-activ-
ity or by Starvation.
CHAPTER XI.
STOMACH AND GUT.
^ranches fy
OTa,vchcs to
Ca.rcCtt.
Fig. 29
CELIAC AXIS.
This drawing represents the stomach as a transparent body through
which can be seen the pancreas and its arteries. To draw the
Celiac Axis draw the lines 1, 2 and 8 (see small cut to right and
below the main one.) Then join 1 to 8 and 2 to 3 in the manner
shown. Subdivide the terminations of the lines 1, 3 and 8 and
compare the result with the large sketch.
126 GROSS PATHOLOGY OF ULCER.
It is Utopian to look for the last days of proprietary diges-
tants, but it is conservative to say that in future there will be
more stomach lesions treated by the knife than by purgative
pills and predigesting powders.
We eat well but not wisely hence the stomach has many
minor woes. Aside from these, the most interesting and most
vitally important, because of its relation to carcinoma, is
GASTRIC ULCER.
The etiology of the condition is unknown, but it probably
has much to do with repeated traumata of the mucosa. The
pathology presents characteristic phenomena. The ulcer is ty-
pically, a punched out area in the mucous membrane which
may sometimes be seen through the serosa as a whitish region.
It is white, partly because of anemia — the nutrient vessel which
can usually be found leading to the center of the ulcerated re-
gion, is very often thrombosed or plugged — partly because of
the formation of scar tissue, which is here made with unusual
rapidity.
W. J. Mayo states that probably fifty per cent, of cases of
gastric ulceration are complicated by a similar duodenal lesion.
Until quite recently duodenal ulcers were supposed to have a
rather constant relation to burns and other skin lesions. The
ulcer bearing- area of the stomach is rather strictly (80 per
cent.) localized on the posterior gastric surface, near the py-
lorus ; the ulcer bearing region of the duodenum is limited to
the first portion of that gut. It would therefore seem that there
is some physiologic or anatomic factor which renders this four
or five inches of what is practically a funnel particularly prone
to ulceration. This, though ignorance of its true cause, must
at present be termed spontaneous.
There are other regions of the alimentary canal which are
prone to ulceration, but these ulcers are of a distinctly different
type, tubercular, typhoid and the like. There is no other region
in the entire gut so liable to idiopathic ulceration as this short
pyloric funnel. Before attempting to give any differential
tables, it should be stated that a positive diagnosis in most
lesions of the abdomen is possible only after exploratory in-
cision and often not even then. On account of the juxtaposi-
DUODENAL RELATIONS. 127
■f^am "Py/ort/s +o
9aHT.Vuuacn,.7 a-^t,^
CorriTnofy ■9/7e KXuQ'f-
Fig. 30
Relations of 1st part of Duodenum.
Qui
l/tnm Cava
Uym-f-mr.
CoJoyt
Fig. B1
Relations of 2nd part of Duodenum.
128
ULCER-BEARING PYLORIC FUNNEL.
(Xhove. 'pa-ncrcaf.
(^<^-7>»T,^„„e*lr.
Fig. 82
Relations of 4th part of Duodenum.
tion of the gall bladder and its ducts to the duodenum and the
stomach, lesions of these parts are apt to be confounded.
Duodenal Ulcer because of these studies is coming into
great prominence and the time probably is not distant, when,
instead of reference being made to gastric or to duodenal ulcer,
separate and apart from each other, efforts will centre on the
demonstration of ulceration in the ulcer bearing pyloric funnel
already referred to. Nevertheless, it is still stated that duode-
nal ulcers have certain distinguishing characteristics. They
are so vague, however, that Brewer states it to be impossible
to differentiate the pyloric ulcer. No attempt will therefore
be made to do it.
Duodenal ulcers are said to occur in two per cent, of bad
burns. This percentage was much higher in the pre-antiseptic
days. They may also follow frost bite, erysipelas, pemphygus,
septicemia and eczema. Their possible exciting etiology may
be (i) Septic emboli; (2) Destruction of blood cells; (3) Ab-
sorption of toxins from cellular degeneration ; (4) Nerve irri-
tation. They may appear from four to six days after the burn
or injury.
DIFFERENTIAL BETWEEN
129
Carcinoma of
Pylorus.
Ulcer of Pyloric
Funnel.
Gall Stones of
Common Duct.
Chronic
Cholecystitis.
Absent in early
stage.
Onset always
slow. Progress-
ively worse.
Cachexia.
Gastric ulcer or
primary carci-
noma elsewhere
Over forty.
Male.
History of Tumor.
Rarely present. Absent.
History of Disea.sk.
Onset more rapid.
Characterized by
exacerbations.
Onset abrupt.
Acute exacer-
bations.
Previous Disease.
Chlorosis. Typhoid fever.
Age.
Under forty.
Female.
Mid-adult life.
Sex.
Female.
Occupation.
Negative.
Change from an
active out-door
to a sedentary
• one, as seen in
the case of emi-
grant servant
girls.
Commonly ascrib-
ed to indolence
and over-eating
but by a recent
continental
writer thought
to be due to the
opposite.
Pain.
to 3 hours after
eating. Charac-
teristic. Grind-
ing. Rarely be-
gins at night.
Chronic dyspepsia
Progressive
weakness.
Ch a r ac t eristic.
Acute. Relation
to eating, direct
and immediate.
Rarely begins
at night.
Remittent. Se-
vere. Shoulder.
No relation to
eating. Typic-
ally begins at
night.
Disability.
Intermittent dys-
pepsia. Acid
eructations.
Low grade chron-
ic d ysp ep sia,
frequent.
Frequent.
Onset slow.
Chronic course
with exacerba-
tions.
Chronic duodenit-
is.
Mid-adult life.
Female.
Negative.
Intermittent. Less
severe. Only
with exacerba-
tions. Usually
begins at night.
Dyspepsia,
mittent.
ous".
inter-
"Bili-
130
DIFFERENTIAL BETWEEN.— Continued.
Carcinoma of
Pylorus.
Ulcer of Pyloric
Funnel.
Gall Stones of
. Common Duct.
Chronic
Cholecystitis,
Bowels.
Negative.
Uncommon, ex-
cept in exten-
sive involve-
ment produ-
cing pressure on
the duct.
Normal.
Occasional "tarry "
movements.
Constipation.
May be "clay"
movements.
Jaundice.
Absent.
Absent.
Negative.
A b s en t , except
under similar
conditions,
which are rarer
than in carcino-
ma.
A very character-
istic symptom.
Temperature.
Variable.
Characteristically
intermit tent.
Chills and
sweats, 98 to 103
NERVOUS SYMPTOMS.
Delirium.
Absent.
Absent.
Negative.
Not infrequent.
Paresthesiae.
Constipated.
Frequent during
exacerbations.
Present during ex-
acerbations. Ir-
regular: 98-103.
Occasionally dur-
ing exarcerba.'
tions.
Itching of skin. Occasional itching
Urine.
High-colored and
stains linen.
Same during ex-
acerbations.
Evidence of ca-
chexia.
GENERAL PHYSICAL.
Inspection.
Pallor and pro-
nouned anemia.
Yellow.
May be yellow.
LOCAL PHYSICAL.
Inspection.
Possible tumor, l^'^^f^^ ""^ ^"Jno tumor.
Probable tumor..
131
DIFFERENTIAL BETWEEN— Continued.
Carcinoma of
Pylorus.
Ulcer of Pyloric . Gall Stones of
Funnel. Common Duct.
Chronic
Cholecystitis.
Palpation.
May feel tumor onj
deep respiration I Q
Tenderness nearP^™^-
mid-line. •
No tumor. Ten-
derness at "Rob-
son's" point.
BLOOD.
Leucocytosis.
About 60%, 8,000.
About 20%, 10-
000 to 12,000.
About 20%, 20-
000 to 40,000.
(Cabot)
Depends on de-
gree of cachexia
About 20'/^., 10,000
to 12,000.
Usually absent.
Hemoglobin.
One-half have lessl
than 50% (Cab- 70 to 80%
ot) I
URINE.
Indican.
Very frequent. Absent.
Absent.
Ffxes.
Undigested food
particles.
Evidences
blood.
of
Absence of color-
ing matter.
Exploratory Incision.
Tumor usually at
pylorus or on
lesser curvature
Ulcer 50% in first
part of duode-
num remainder
on posterior py-
loro-gastric wall
Tumor.
Stone often lodg-
ed im ampulla
of Vater.
May be marked
during exacer-
bation.
70 to 80%
Absent.
Coloring matter
may be absent
during exacer-
bation.
Dilated or atro-
phied diseased
gall-bladder.
As in the case of the breast, probably the most interesting
as well as the most vital, question in the surgery of the stomach
is the problem which bears on the relation of a carcinoma to
a gastric ulcer. In the breast it is frequently a benign tumor,
that is to say, a growth not traumatic in origin, which under-
132 SURGERY OF THE STOMACH.
goes the degenerative malignant change. There are, however,
many examples to show^ that the chronic irritation arising from
mild, low grade infection, as often occurs in frequently fissured
nipples and similar apparently insignificant lesions have a very
important bearing upon malignant degeneration. In the
stomach, benign tumors are rare, the source of malignancy tak-
ing its origin almost entirely in the bed of old inflammatory
lesions (ulcers). Chronic irritation then plays ^ most import-
ant part in the stomach and this is further exemplified by the
very fact that carcinoma of the stomach is much more frequent
in men than in women. Men eat too much and eat too indig'es-
table substances. There is probably some connection between
these two facts.
Pain, dyspepsia, acid eructations, loss of weight, vomiting ;
these are some of the symptoms which, singly or in combina-
tion, bring the patient to the surgeon's observation. Every one
of these sufferers has been subjected to all conceivable and to
many inconceivable forms of treatment. They have been
bathed in boiling and sprayed in ice cold water. They have,
for hours at a time, knelt with their buttocks on high and their
heads on low. They have suffered great iron balls to be rolled
and tumbled over their tender belly walls. They have con-
sumed thousands of dollars worth of drugs. They are at last
coming to their own ! ,
The symptoms above referred to arise directly from the
inflammation of nerve terminations as in the case of ulcer, or
indirectly, as in the case of carcinoma and other diseases which
produce pyloric obstruction, through a stretching of the parts
and a necessity arising for them to do work for which they
were not built.
Surgery applies to the stomach the simple common sense
methods that she utilizes elsewhere. She puts inflated parts
at rest and establishes drainage.
The surgery of the stomach is easy to understand and
there can be no possible misconception about it if these two
simple facts are remembered.
What, for example, is the surgical treatment of ulcer of
the stomach? Put the part at rest. Since the ulcer is usually
located near the pylorus, if this funnel be put out of use, the
TWINE-TRIANGULAR STITCH.
rss.
•ulcer will heal. Consequently one of the most frequently em-
ployed technics for the treatment of ulcer (Robson, Moynihan
and others) is Gastro-enterostomy.
Fig. 33
Gastro-enterostomy made by the twine-triangular stitch.
(Columbia Surgical Laboratory)
This deservedly popular operation serves the s-econd in-
dication, viz. — that of establishing drainage just as admirably
as it does the first. For this reason, it is employed in the treat-
ment (palliative in the case of carcinoma, as are many surgical
operations) of Pyloric stenosis. All the great and little evils
from which a case of pyloric carcinoma suffers are done away
with as though by magic through the execution of gastro-en-
terostomy. The technic is simple. The jejunum and the
stomach may be brought into communication by ligature and
section : by Murphy Button ; by the the Tv/ine-triangular stitch
(see Report from Columbia Surgical Laboratory, 1904.)
134
REST AND DRAINAGE.
Other methods are used for the relief of these lesions of
the stomach, but they must always be based on the simple
proposition of rest and drainage. Finney's pyloroplasty is ac-
knowledged to be the best of these. See Brewer's text book.
Fig. 34
POSTERIOR RELATIONS OF STOMACH.
The Greater Curvature has been lifted upward and to the left.
This accounts for distorted (diagrammatic) shape of the stom-
ach. Note that head of pancreas is not in relation.
Gastrostomy. — Occasionally because of impassible stric-
ture of the esophagus, a permanent opening has to be made in
the stomach through which the patient may be fed. A similar
SURGERY OF TYPHOID ULCERS. 135
Opening occasionally has to be made in the colon through
which the patient may in case of permanent obstruction or des-
truction of the rectum evacuate his bowels. There is no truer
example than that found in a study of Gastrostomy and Colos-
tomy, of the axiom that to succeed, an operation must imitate
nature as closely as possible. She has passed through the ab-
dominal wall a tube which for all practical purposes is similar
to the rubber tube used in gastrostomy. It is the spermatic
cord. It traverses the abdominal wall by an intermuscular
course. The length of the canal is constant and the relation of
the muscles to it is always the same. The most effectual means
of establishing a permanent opening into the stomach or the
colon is based upon the principle that it should be made as
nearly like the inguinal canal as possible. That is all there is to
these so called valve or telescoping operations ; they simply im-
itate nature.
Surgical treatment of typhoid ulcers. As about 8,000 peo-
ple a year die in the United States alone of perforation or
hemorrhage from typhoid fever, it is 'obviously an important
matter to reach a means of treating this vital condition surgi-
cally.
In a very high percentage of cases the lesion takes place
within the last 24 inches of the ilium. The symptoms of per-
foration classically are pain, sudden and sharp attended by col-
lapse, but unfortunately there are too few cases that follow the
classical picture. It has been suggested as a palliative method
that some coagulable jelly-like material should be injected into
the gut somewhat as engineers sometimes put oatmeal into a
leaking boiler. Increased assurance in the opening of the abdo-
men under local anesthesia will undoubtedly do a great deal to
help this rather discouraging situation. .
APPENDICITIS.
There is not an unmixed joy in being a new woman. She
has appendicitis just about as often as her brother. Formerly
he had it four times to her once, but now that she bicycles cen-
turies, plays golf and basket ball, she has in more than one
sense become his equal. This seems to be rather convin-
136 TOXICITY RAISED BY PRESSURE.
cing that violent exercise has a good deal to do with the et-
iology of appendicitis.
It has been noticed that prolonged and violent bicycle rid-
ing, for instance, has in an unusual number of cases been fol-
lowed by an acute attack. This suggests that overaction of the
psoas in the case of an appendix which droops down into the
pelvis by bringing it thousands of times in harsh contact with
the pelvic brim gives the disease its first start.
The suggestion that women are usually so less liable to
appendicitis than men because of the greater blood supply to
the organ in the female has probably been shown to be erron-
eous by the facts already cited. Vascularity it is now believed
has little or nothing to do with the etiology.
Stricture of the organ is usually present. It is easy to con-
ceive that stricture here will act just as it does elsewhere, viz. —
for example in the urethra. Some variation in temperature,
some unusual germ activity, or some unknown conditions may
be s\ipposed to start the elements of a simple exudative inflam-
mation. It is known that the bacillus coli is practically ubiqui-
tous. It has been found in the gut of birds killed far out at
sea. It is therefore in most cases a resident of the appendix
throughout the length of its lumen. What happens after the
inflammation begins? The stricture swells and distal to it there
is shut in by the obliteration of the lumen, a little lake-like area
which, if not already full of fluid, rapidly fills after its closure.
The fluid is rich in food stuffs and it is at 98.6, the temperature
most favorable for the development of pathogenic germs. It is
inevitable that the colon bacilli propagate. Among the prod-
ucts of their metabolism are gases. These together with other
metabolic outputs are created more rapidly than the dilated
and engorged vessels of the part can carry away. Pressure in
the little lake results. The effect of grovnng germs under pres-
sure is a very constant one. Germs producing substances poi-
sonous to man, when put under pressure are more dangerous
than otherwise. Germs which, like the colon bacillus, are harm-
less to us under the usual conditions of pressure, become viru-
lently poisonous when this is augmented. Thus is explained
the great virulence and the remarkable local destructive power
of the fluids contained within these appendicular sacs.
137
DIFFERENTIAL BETWEEN-
Appendicitis.
Right Sided Sal-
pingitis.
Right Ruptured
Ectopic.
Acute
Cholangitis.
History of Tumok.
Very frequent. Frequent.
Absent.
Onset slow, belly-
ache.
Constipation and
previous at-
tacks.
Male, 3 to 1.
History of Disease.
Onset fulminat-
ing ; very severe
Onset slow; pelvic
cramps.
pelvic cramps.
Previous Disease.
Absent.
Onset acute ; belly-
ache.
Gonorrhea.
Often previous
pregnancies.
Female.
Sex.
Female.
Social State.
Typhoid.
More frequent in
female.
Single.
Begins at navel
and radiates to
McBurney's
point.
Very frequent.
Prostitutes.
Married.
Pain.
Begins in pelvis.
May be referred
down right leg.
Most severe of all.
Localized in pel-
vis or referred.
Negative.
Severe. Often re-,
f erred to Rob-
son's point.
Infrequent
Absent.
101 to 103.
Full, 120 usually
regular.
Absent.
101 to 103.
Vomiting.
Very rare.
Jaundice.
Absent.
Temperature.
).5 to 99.
Pulse.
Same.
Weak, 140 to 160,
irregular defi-
cient, short and
compressible.
Frequent.
Frequent.
101 to 103.
Full 120 regular.
^138
DIFFERENTIAL BETWEEN— Continued.
Appendicitis.
Right Sided Sal-
pingitis.
Right Ruptured
Ectopic.
Acute
Cholangitis.
GENERAL PHYSICAL.
Inspection.
Flushed, anxious
asthenic, febrile
look.
"Often tumor.
'Board like" ab-
domen. Vaginal
negative. Press-
ure pain at Mc-
Burney's point.
Very limited area
of flatness.
,000 to 11,000
means (A) mild
case. (B) very
severe case. (C)
Abscess walled
off. Increasing
1 e u c o c y t osis
may be only
evidence of dis-
ease. (Cabot)
20,000 to 80,000
not uncommon.
0.9
Same but often to
a less degree.
Pale, sweaty, pros-
trated, asthenic
look.
LOCAL PHYSICAL.
Inspection.
Possibly tumor.
Absent.
Palpation.
Rigid right side
but less marked
than in appendi-
citis. Vaginal
tumor. Pain in
lower right a b-
d o m i n a 1 seg-
ment.
Diff^use moderate
rigidity. Vagi-
nal; boggy, se-
vere pressure
pain. Abdomen
filled with fluid.
Often negative.
Percussion.
Flatness in flanks
disappears on
turning patient
on side.
Same as salpin-
gitis.
Absent.
Moderate rigidity >
tenderness i n
upper right ab-
dominal seg-
ment.
Limited flatness
tip of ninth rib.
BLOOD.
Leucocyte Count.
Same as appendi-
citis, but less
marked.
16,000 to 18,000.
20,000 to 30,000.
0.9
Color Index.
0.5 to 0.6
-Abscess found at Abscess of right
caput coli. tube.
Exploratory Incision.
Free blood in
periteneal cav-
ity.
0.9
Dilated gall blad-
der.
OCHSNER'S TREATMENT. 139
The blood has come to be a most efficient aid in diagnosing
■appendicitis and in differentiating it from certain other condi-
tions. It is readily seen that the appendix, the tube and the
gall bladder are organs, which although occupying different
positions in the abdominal cavity, have nevertheless almost
identical anatomical structure. It is probable that no disease
develops either in the tube or in the gall bladder except by
stricture formation. As in the case of the appendix drainage
is interfered w^ith and the distal parts of the organ become shut
off so as to form practically a culture tube for germs. These
will not make trouble so long as there is no pressure and in
the presence of unrestricted circulation. In the face of such
resemblances it is natural that the blood should not give much
differential information between these three conditions. It
should be remembered that it is not so much a question of the
amount of pus, but the degree of tension under which it is pent
up which determines the amount of leucocytosis. A gum boil
under pressure will often give a count of 20,000.
Whereas the presence of leucocytosis is, in many cases
very variable, there is a list of diseases which are definitely and
constantly characterized by its absence. They are as follows:
(Cabot) (i) Typhoid, (2) Malaria, (3) Grip, (4) Measles, (5)
Rotheln, (6) Mumps, (7) Cystitis, (8) Tuberculosis— all forms,
including miliary and tuberclous peritonitis.
In typhoid and miliary tuberculosis the leucocytes are
often diminished.
Leucopenia is a diminution of the number of white cells.
It is present not alone in tuberculosis and typhoid, but to a less
degree during stages of most of those infectious diseases which
are not characterized by leucocytosis.
The treatment of appendicitis is the most difficult of the
usual problems presented to the surgeon. There are two dis-
tinct schools, the one advocates operating when the diagnosis
is made; the other, except in chosen cases, advises subjecting
the patient to a special form of treatment prior to operation.
This is known as Ochsner's Treatment. It consists in giv-
ing the patient absolutely nothing by mouth, not even water;
in administering enough morphine to relieve pain ; in never
giving any form of purgation whatsoever. The object is to
140 INVAGINATION OF APPENDIX.
apply the surgical principle of putting the inflamed part at rest
and of allowing nature to "wall off" the abscess. It is said that
so successful has this treatment been in some cases that ab-
scess formation has even been prevented by it. Its use is justi-
fied, however, as distinctly insisted upon by Ochsner, only
after a thorough understanding of its contra-indications.
Probably the most popular method of removing the ap-
pendix is by that first suggested by Dawbarn. He has always
thought that the hole left after removal of the organ is exactly
similar to that created by a bullet and should in all common
sense be subjected to similar treatment. It is therefore more
surgical to throw a purse string suture around the stump prior
to cutting off the organ and to invert it into the gut by trac-
tion than to use pure carbolic or the actual cautery to destroy
the mucous membrane that the parts may heal.
THE COLON.
The colon has recently become the subject of special sur-
gical interest, because of the necessity of treating some of the
chronic diarrheas and dysenteries (particularly the amebic
form) by surgical intervention. These forms of colon inflam-
mation were first brought prominently into notice by soldiers
who came home from Cuba and the Philippines. No form of
internal medication served to relieve the condition and many
of them died. Thirty to forty movements a day were not un-
common, and that, in spite of the most active medicinal treat-
ment. In these desperate cases it was suggested to do a right
sided colostomy with adequate spur-formation.
The advantage of the spur is that it turns every particle
of fecal material on to the surface and thus allows the distal
portion of the gut to be sterilized and kept clean. Its disadvan-
tage is that, unless established by some procedure as recom-
mended by Bodine, in which case it can be broken through with
a Paquelin cautery, it necessitates a secondary and often a
very severe operation. The spur then is indicated in all con-
ditions where radical treatment has to be applied distally to it.
It is not indicated in those cases where an opening is made, as
for instance in strangulated hernia, simply for the relief of in-
"MARSUPIALIZATION" 141
tra-enteric pressure. The importance of the inter-muscular
operation in this connection has already been discussed.
Weir, when the pertinence of the surgical treatment of the
colon became manifest, suggested with custornary ingenious-
ness, that instead of bringing the colon to the surface and thus
doing an ordinary colostomy, the appendix should be utilized
to connect the colon with the outer world. Twelve to twenty-
four hours after the appendix had been made fast in the ab-
dominal wall, its tip was to be nipped ofif and disinfecting irri-
gation fluids squirted through it into the colon and rectum.
This technic will not shunt the gut contents to the surface as
in the case of the spur operation, but for amebic dysentery it
serves the purpose equally well. When the enteritis is cured
presto ! a hot iron shall be thrust into the lumen of the appen-
dix, thus closing the colostomy and incidentally doing away
with the appendix. This method has been widely used and has
been called Weir's Marsupialization. (The marsupial has a
pouch in which its young are carried. The term and principle
are sometimes used in surgery.)
THE RECTUM.
Fissure^ Fistula and Hemorrhoids are the three most com-
mon lesions of the rectum. They cause untold suffering and
unless relieved are the very type of chronic injury which is lia-
ble to malignant degeneration. It is therefore of very great
importance, not only for the relief of immediate pain and dis-
comfort which they cause, but for the more far reaching dan-
ger to which they subject the patient, that they should be in-
telligently treated. One of the most favorite differentials is
between these three ills. It will be noted that the most im-
portant differential point is the time of occurrence and the
character of the pain. It is usually possible to make a differ-
ential on the history alone and this is often convenient.
142
DIFFERENTIAL BETWEEN
Fissure in Ano. Fistula in Ano.
Hemorrhoids.
Early
Malignancy.
Absent.
Onset sudden.
Negative.
Absent.
History of Tumor.
Present.
Disease.
Onset slow. Onset slow.
Previous Operation.
Not infreqtaent.
Injections.
Pain.
Intermittent.!
Sudden, knife-
like. Last only Discomfort only.
10 ^seconds after
bowels move.
Remittent.
Heavy, drag-
ging. Severe for
two hours after
bowels move.
Disability.
Afraid to have a Cannot hold gas
movement. and fluid.
Weak from loss
of blood.
Present.
Onset very slow.
May follow hem-
orrhoid removal;
Not characteristic
Weak from be-
ginning cachexia.
INTESTINAL OBSTRUCTION.
This is probably the most frequently asked of all hospital
questions. It is therefore worth while to condense it into a&
short a space as possible. It is
Acute: Chronic.
Causes Acute.
Intussusception (acute). Bands. Volvulus. Foreign bod-
ies, gall stones and enteroliths. Internal hernia
(Meckels diverticulum and abdominal fossae.)
Causes Chronic.
Impacted feces, strictures (benign and malignant)..
Intussusception (chronic.)
INTESTINAL OBSTRUCTION. 143:
Pathology Acute.
Above obstruction equals gas.
Below obstruction equals empty.
At' obstruction equals ulceration, perforation, periton-.
itis.
Pathology of Chronic.
In and above equals hypertrophy.
Below equals empty and atrophy.
At obstruction equals same as acute.
Symptoms of Acute.
Same as acute strangulated hernia. ■ •
Pain, sudden and diffuse.
Collapse.
Tenderness, little or none.
^T •,• ( High — early, billious.
Vomitmg i T i ^ i i
'=' i Low — late, fecal.
Constipation absolute (obstipation.)
Tympanites.
Hiccough.
Peristalsis (if walls thin).
Increasing dysuresia.
Pulse rapid and feeble.
Temperature and tenderness from peritonitis only.
Great prostration and emaciation if last long enough..
DIFFERENTIAL.
Does Obstuction Exist?
History of Hernia in unusual places.
History of feces or foreign body.
Save and inspect urine, feces and vomit.
Examine for concretion, bile, bloody and mucous dis--
charge.
Examine for external hernia; uneven abdominal disten-.
tion.
Rectal examination for invagination, feces or stricture.
Palpate and percuss abdomen for tumor, tenderness,,
tympanites. (Do not put hand sound or measured'.
enema in rectum).
il44 INTESTINAL OBSTRUCTION.
Differentiate from Gastro-enteritis.
Early state Meningitis.
Biliary and renal colic.
Peritonitis.
Appendicitis.
Pyosalpinx.
Gastric ulcer.
Acute Cholecystitis.
Where is Obstruction?
SMALL GUT.
Obstruction High — Symptoms.
Violent onset.
Early collapse.
Early and persistent vomiting, bilious rarely fecal.
Tympanites absent or limited to epigastrium.
More or less dysuresia.
LARGE GUT.
Obstruction Low — Symptoms.
Onset slow and mild.
Increase in violence of symptoms.
Collapse late (except in volvulus).
Tympanites first in colon, then
Vomiting.
Abdomen more bulging on side than center.
Obstruction in Jejunum or Ilium — Symptoms.
Eliminate duodenum, colon and rectum.
Course moderately rapid.
Vomiting fairly early.
Tympanites later.
Abdomen more distended at center than at side.
What is Obstruction?
Acute Invagination — Symptoms.
Child.
Elongate tumor on left side felt via anus.
Tenesmus and bloody discharge.
Local pain.
Sudden onset.
INTESTINAL OBSTRUCTION. 145
Bands — Symptoms.
History of previous peritonitis.
Tuberculosis elsewhere.
Local pain.
Volvulus — Symptoms.
Old males. • ' '
Localized tympanites.
" tumor.
" pain.
Usually left iliac fossa in sigmoid. Note. Worst of all.
Foreign Bodies — Symptoms.
History false teeth.
Biliary colic.
Constipation.
Palpation.
Internal Hernia — Symptoms.
Local pain and tenderness over the abdominal fossae.
Chronic Obstruction — Symptoms.
Includes symptoms. of impacted feces.
Tumefaction in colon.
Rectal examination for feces.
Old people.
Young girls.
Stricture— Symptoms,
History of dysentery. ■'
Symptoms of visceral malignancy.
Old people.
Chronic Invagination — Symptoms.
History stricture or tumor.
Tumefied colon, not compressible.
Mucous and bloody stools.
Tenesmus.
146 INTESTINAL OBSTUCTION.
Treatment of all Forms.
Lavage.
Opii.
No cathartics.
Enemata.
Spoon out recti! m.
No tubage of colon.
No puncture of intestine.
Uniform and continuous abdominal pressure.
Laparotomy.
Enterotomy.
Enterectomy.
Enterrorhaphy and anastomosis.
Colostomy.
CHAPTER XII.
LIVER, SPLEEN AND PANCREAS.
The surgery of the liver centers on the relief of disorders
of its secretory passages. So called gall stone colic is probably
(Brewer) not due to gall stones at all, but to spasmodic con-
traction of the inflamed ducts pressing on the nerves.
The Gall Bladder is directly connected with the surface of
the body and so is the liver. They are therefore, in common
with other organs situated upon the surface of the body, sub-
ject, first, to superficial invasions by germs and animal paras-
ites, and second to the particular form of malignant degenera-
tion to which the surface is liable, viz. — Carcinoma. Bacterio-
logically speaking, the inner and outer body surfaces are dirty.
As the liver and pancreas are the most deeply situated of these
superficial organs, it is appropriate here to show a diagram
which proves this somewhat surprising hypothesis.
It is simply a question of remembering
that there are two surfaces, an outer and an
inner, and these organs together with the
parotid gland, the hepatic gland and certain
others, are located on the inner surface.
The Liver is occasionally the seat of ab-
scess. It has to be differentiated from sub-
phrenic abscess, which is a collection of pus
immediately beneath the diaphram, due usu-
ally to gastric ulcer; from costo-phrenic ab-
scess, which is a collection of pus in the
costo-phrenic sinus, a sketch of which is
shown in Chapter X, and from empyema.
Note that an important factor in this differ-
ential is the effect of respiration upon the
discharge of the pus after exploratory incision.
Figure of barrel show-
ing inner and outer
surface.
148
DIFFERENTIAL BETWEEN
Liver Abscess.
SuK- Phrenic Ab-
scess.
Costo-Phrenic
Abscess.
Empyema.
Previous Diskask.
Duct, cystic or
duodenal infec-
Amebae.
Pus may flow
faster during in-
spiration (dia-
phragm goes
down.)
Gastro - duodenal
ulceration.
Thoracic
tions.
infec- Pneumonia or
Pleurisy.
Exploratory Puncture.
I P n e u m o coccus :
Pyogenic organ-
isms.
T. B. ; Strepto-
or S taph y 1 o-
coccus.
Same.
Incision.
Same.
Pus may flow
faster during
expiration (dia-
phragm goes up)
Same.
The liver, on account of being on the surface, is occasion-
ally, as already said, the subject of parasitic invasion. Liver
abscess may be grossly divided according to the three zones
in which it is most prone to occur.
Frigid Zone or Echinococcus Cyst. The Echinococcus as it
occurs in man is the asexual form of the tenia echinococcus of
the dog. It is a moderately small tape worm.
The Laplanders live in such intimate relations with their
dogs that their food habitually becomes contaminated with the
animal's feces. Consequently in Lapland and throughout the re-
gion where dogs are largely used for transportation purposes,
man is very frequently the subject of echinococcus infection.
The cyst formed by this parasite is characterized by multilo-
cular formation, having daughter and grand-daughter cysts.
Torrid Zone or Ameba Cyst. In the Torrid Zone, the
ameba of dysentery abounds. Not infrequently it finds its way
from the gut into the liver. The result is the amebic or dysen-
teric abscess characterized by being single and by a rather
strict localization to the southern climes. (See Chapter XV^I.)
Temperate Zone or Pyemic Cyst. The Temperate Zone is
not exempt from its peculiar abscess. We do not live in close
CLASSIFICATION OF CYSTS. 149
communion with our dogs, or suffer from amebic invasion.
Amebae are frail and require the bad hygiene and torrid heat
of the tropics. We have with us, however, as steady compan-
ions, many pyogenic bacteria. Any one of these may make
the characteristic Temperate Zone or pyemic abscess.
These abscesses or cysts of the liver suggest a classification
of cysts. Cysts may be conveniently divided into
(i) Retention.
(2) Distention.
(3) Tubular.
(4) Glandular.
(5) Parasitic.
(6) Dermoid.
The only way to get hold of this classification is to apply it.
It will be noted that a cyst is often to be described by using
a combination of these terms. For example, it is either reten-
tion-tubular or retention-glandular, as the case may be. Take
a Glactiferous Cyst for instance. That is caused by pent up
milk in the milk ducts. Now the mammary gland secretes a
fluid which is intended to come to the surface. Cysts of it are
therefore retention cysts. This is because what was intended
to come out, is retained. The Glactiferous Cyst therefore, be-
cause the milk is retained in tubes, is a retention-tubular cyst.
Distention cysts, on the other hand, occur in regions where
the secretion is not intended to come to the surface, as for ex-
ample in the case of a bursa. Cystic change in this is called
bursitis. It is a distention cyst. These occur also in the duct-
less glands, as in the ovary or thyroid. They may therefore,
as in these two latter cases, be called distention-glandular cysts.
A distention-tubular cyst obviously cannot well exist. The
echinococcus cyst is an excellent example of the parasitic cyst,
which is here meant to mean an animal parasite.
Some of the more common animal parasites of man in
addition to the echinococcus are described in Chapter XVI.
SPLEEN.
(J)n account of the vascularity of this organ, practically all
that can be done to it is puncture or removal. Puncture is con-
fined to obtaining from it specimens of central blood in which
150
RELATIONS OF PANCREAS.
certain forms of parasites, unwilling to circulate in the peri-
pheral blood, are resident.
Excision or Splenectomy, while a formidable operation,
is the only possible chance for patients suffering from splenic
pseudo-leukemia. Spleiiectomy is also the only possible means
of treating idiopathic splenic enlargement.
Banti's disease, a condition of splenic enlargement, asso-
ciated with hepatic cirrhosis, is another condition for which
splenectomy is undoubtedly indicated. Other conditions which
may call for removal are : rupture, wandering spleen, cysts,
tumors and malarial hypertrophy.
PANCREAS.
Tv-ferio-T tTl'-ScnferK: Vein,
•Superior Wcsevft-ri-z l/C/ri,
Fig. 36
RELATIONS OF PANCREAS.
(Seen from the front)
J{J. o^.
PANCREATITIS. 151
Much of the recent surgery of the abdomen centers upon
the pancreas. The diseases of this organ have a very intimate
relation to those of the liver and bile duct. Acute pancreatitis,
both hemorrhagic, suppurative and gangrenous, is one of the
least understood abdominal lesions. It may arise from ordi-
nary germ infection, just as in the case of other organs, but
there is a rather constant relation of biliary duct disease to it,
which makes it seem probable that in many cases, at least, tin's
is a powerful predisposing, if not actually an indispensable
cause.
Acute hemorrhagic pancreatitis is characterized by the
usual evidences of intra-abdominal inflammation ; rigidity, ten-
derness, distention and very severe pain. On account of the
depth of the organ a definite tumor rarely appears. The con-
dition cannot be diagnosed except on exploratory incision. In
its later stages it is differentiated by exclusion — because of the
appearance of their characteristic symptoms — from perforated
duodeno-pyloric ulcer ; from appendicitis ; from acute intestinal
obstruction ; from peritonitis ; from acute cholecystitis ; from
pyonephrosis. The difficulty, however, of waiting for differen-
tial points to arise is that unless relieved in its early stages,
acute hemorrhagic pancreatitis usually kills in a very few
hours. The recognition then of acute hemorrhagic pancreatitis
depends only upon exploratory incision. The moment the ab-
domen is opened, white patches are seen throughout the omen-
tum and in the mesentery. They vary from the size of a pin's
head to large irregular masses. They are the so-called areas of
fat necrosis. The origin of this fat necrosis is not 3^et under-
stood but it is supposed by some to be due to the liberation in
the abdominal civity of the fat splitting ferment of the pancreas.
The objection, however, to this theory is that fat necrosis has
been seen in these cases occuring in fatty areas where it seems
improbable that the ferment could have reached it. The sub-
ject is therefore subjudice. The gland when exposed is found
to be spachelous and as the shock of removal would certainly
kill the patient, all that can be done is to see that adequate
drainage is established.
Chronic pancreatitis or the development in the organ of
dry productive inflammation, is an interesting and not infre-
152
AMPULLA OF VATER.
quent disorder. Even more than the acute form it has a rela-
tion to interference of the gall duct circulation. Opie has
shown that in many cases there exists in the ampulla of Vater
a gall stone which, too large to pass out through the papilla,
is yet large enough to net within the ampulla as a ball valve.
It is clear that when the ampulla is blocked, the bile must
pass directly up through the pancreatic duct into the pancreas.
The patency of the accessory ducts (Santorini) of the pan-
creas are of obvious importance in safeguarding the individual
from chronic pancreatitis arising in this way. If present they
maintain adequate pancreatic drainage.
DIFFERENTIAL BETWEEN
Chronic Pancrea-
titis.
Chronic Gastro-
Duodenal Ul-
ceration.
Chronic Chole-
cystitis.
Liver Carcinoma
History of Tumor.
Rare.
Onset characteriz-
ed by rapid loss
of weight.
Possible.
Frequent.
Disease.
Onset follows Onset often cha
symptoms of
acute ulcer.
racterized by at-
tacks of colic.
Unusual.
Onset slow and
marked by in-
creasing ca-
chexia.
LOCAL PHYSICAL.
Palpation.
May be feeling of
deep resistance
Negative.
Tumor near pylo-
rus.
Tumor tip of 9th
rib.
LABORATORY.
Chb;mical of Stomach Contents.
Liver below carti-
lages and may
be nodular.
Excess of HCl and
blood.
Usually excess of!
Carbon Com- Same,
pound Acids. |
"Clay" stools due
to exeess of fat.
Tumor of head
of pan cr eas
grossly indistin-
guishable from
Carcinoma.
Feces.
'Tar" stools.
'Clay' stools due tol
absence of color- Normal,
ing matter. |
Exploratory Incision.
m e 1 1 Dilated gall blad-i
Tumor of pylorus derusullly filled Usually multiple
of similar type. ^^.^j^ ^^^^>^__ I - ^
CHAPTER XIII.
GENITO-URINARY.
Custom has more or less extensively welded these widely
differing branches. There is less reason for their union in the
light of to-day than there was in the past. They are further-
more badly confused with the term "venereal."
THE KIDNEYS.
These organs are reached by one of three general incisions.
Probably, the most common extends along the outer border of
the erector-spinae, from a point half an inch distal to the last
rib (to avoid wounding the diaphragm, see Fig. of this muscle
under hernia) to a point at the level of the iliac crest. The
incision may then turn (Konig) and sweep transversly around
the trunk in the direction of the umbilicus as far as may be
necessary. This incision affords the best view obtainable of
the kidney and is indicated for the major operations as well as
(the first part of it) for minor.
The second incision starts at the same point and runs
parallel to the twelfth rib one-half inch from it (diaphragm)
for a distance of eight or ten centimeters.* This incision is a
useful one for minor work and has the advantage of lying in
the direction of the spinal nerves which are therefore much less
likely to be injured than if its course lay across them.
The kidney is also reached by a transperitoneal route. A
ten centimeter opening is made at the outer border of the
rectus, having its lower limit about on a line with the umbil-
icus. When the small guts are cleared away a right angle tri-
angle is seen, bounded above by the transverse colon, exter-
nally by the ascending or descending colon, according to the
side operated, and internally by a retracted mass of small guts.
On deep retraction, the floor of this triangle will be seen to be
white. This is the perinephritic fat. The retro-peritoneum is
* The two systems are purposely confused.
154
RENAL RELATIONS.
'^/Cf/,* /tT/e/^
''y
UEveL of
~ 'JEZDona.) —
LBvSt-a-f
"iTT'"' LarnBAK . ^"^'^ ^^"=^'
cy
Fig. 37 — Anterior Relations of Kidnevs.
tik^
Fig. 38 — Posterior relations of Kidneys.
fit (fhi- /^'cfni y-
DIFFERENTIAL.
155.
incised in the line of the original skin cut and the kidney cap-
sule is brought into view. This incision has certain advantages
claimed for it, but it is objectionable because of the danger of
soiling the peritoneum if pus be found. It, furthermore pro-
duces greater shock than the posterior incisions.
Nephropexy. This is a sewing of the kidney to the poster-
ior abdominal wall. It is for the relief of floating kidney.
This disorder is characterized by a prolapse of the organ
distal to the umbilical plane of the body. A great many kid-
neys are so relaxed in their attachment, due presumably to con-
genital over-development of the fatty capsule, that they wander
at will as far down, at times, as the pelvis. This does not
signify anything except in the presence of symptoms and unless
these exist to a constant and incapacitating degree, the case
should not be operated upon. The symptoms referred to are
often of a vague and indeterminate character, making a posi-
tive diagnosis of the condition, except for the ability to feel the
organ, a difficult one. It has to be differentiated from recurring
appendicitis, nephralgia and nephrolithiasis. It may well be
said that in order to do this, all that is necessary to do is to
palpate the patient's side. This is true, but there are numerous
people walking around to-day supposed to have gastritis and
innumerable other diseases, who really have a floating kidney,
and on the contrary, many who actually have such a lesion as.
recurrent appendicitis, are prowling around with kidney pads
on their back. This shows the value of following some care-
fully planned scheme for differentiation.
DIFFERENTIAL BETWEEN
Prolapsed Kidney
Recurrent Ap-
pendicitis.
Gastritis.
Nephrolithiasis.
History of' Tumor.
Often present.
Intermittent, oft-
en severe, re-
ferred.
Generally dyspep-
sia or dvsuresia.
Possibly present.
Absent.
Pain
Intermittent, al-
ways severe, lo-
calized.
DiSAKILITY
Interval period
grows shcjrter.
Absent.
„ -...11 I Intermittent, very
Remitten, less ^^^^^^ referred'
severe, localized | ^^ genitals.
Chronic dyspepsia
Complete during
attack.
156
DIFFERENTIAL BETWEEN.— Continued.
Prolapsed Kidney
Recurrent Ap-
pendictis.
Gastritis.
Nephrolithiasis.
Vomiting.
Very frequent.
Frequent.
Typical in the
morning.
LOCAL PHYSICAL.
Palpation.
Bi-manual, fee llRight sided rigid-
organ below na-i ity, — may be tu-
vel. Little or no' mor. Pressure
tenderness. j pain.
Diffuse pressure
pain only. No
tumor.
LABORATORY.
Motor Power of Stomach.
K. I. appears in
urine late.
Blood freezes at
normal tempera-
ture.
-Negative.
Normal.
Normal.
Negative.
Very late.
Cryoscopy.
Normal.
X Ray.
Negative.
Rare. Nausea
from pain.
No tumor. May
be localized
pressure pain
along course of
ureter.
Normal.
Apt to be raised.
Positive.
CRYOSCOPY.
Among numerous other aids to diagnosis which have re-
cently been developed in the study of renal disease, one of the
most interesting is cryoscopy. In the normal individual, the
blood freezes at a very constant temperature.
This point varies so little, in the absence of renal involve-
ment, that it may, for clinical purposes be considered con-
stant. The ftmction of the kidney is to separate from the blood
certain solid products of metabolism. These are removed at
the same rate at which they are manufactured and thus the
^saline elements of the blood, which are the factors determin-
ing its freezing point, are kept in constant relation to the
plasma. If, however, the function of the kidney is impaired,
SEGREGATION METHODS. 157
this relation changes. One of the most convenient methods of
determining the degree of change which has taken place is to
test the freezing point of the blood. Of course if the kidneys are
diseased and there are more salts in the blood than there nor-
mally should be, the freezing point will be lower, because, as
is well known, salt water requires a lower temperature to freeze
it than fresh.
One would expect the converse to be true, viz. — that the
diminished amount of solids in the urine should show in the
same constant manner and by the same cryoscopic method as
in the case of the blood. In the opinion of Bevan, however,
who with his assistant has probably done more of this work
than anybody else, the cryoscopic testing of the urine has no
value whatsoever. He looks upon this test as applied to the
blood, however, as having very far reaching and important sig-
nificance. His limits he states to be between 0.51 in a case of"
anemia and 0.78 in a case of aneuria.
The X-Ray has been used very widely in the diagnosis of
nephro-lithiasis. The technic has been so far perfected that it
is now stated (Bevan, Leonard, Blake and others) to be pos-
sible to establish a positive or a negative diagnosis of stone in
the kidney, pelvis or ureter more certainly by this means than
by any other. It has largely superseded Kelly's waxed tipped
bougies, which were ureteral probes dipped in wax and then
passed without touching anything, directly into the ureter. The
distance to which they could be shoved up determined the
position of the impacted stone and a microscopic finding of,
scratches on the wax proved that it had come in contact with
the stone.
Ureteral Catheterization has not taken such a prominent
position as its early exploiters believed it would. This is prob-
ably because of two reasons. First, the great difificulty in
catheterizing the male, second and all-important the fear of
carrying infection up from the bladder. It is a means, however,,
of obtaining urine from one kidney.
Urinary Segregation is a method which, while probably
more objectiona]:»le to the patient, is fraught with less danger to
him.
Harris' Segregator is an instrument for obtaining the urine
158 ARE THERE TWO KIDNEYS?
of the two kidneys separately. It is an ingenious device by
which a tent-like structure is inserted into and opened out in
the rectum. The apex of the tent is directly under the trigone,
which it lifts up. The ureteral openings then discharge into
two little lakes, one on either side of this ridge in the floor of
the bladder. Two fine separate tubes are carried by the in-
strument in such manner that the ends dip into the center of
these ponds of urine. Separate bulbs pump these ponds dry,
the urine being poured into separate bottles. Up to date this
is the most satisfactory means of obtaining separate urine from
the two kidneys. Moynihan reports that a new French in-
strument which unfolds a diaphragm in the median antero-
posterior plane of the bladder is reliable.
The importance of positively separating the urine cannot
well be overestimated. In the first place, it is probably the
most practical method of determining that more than one kid-
ney exists. Before removing a kidney for any reason whatso-
-ever, the point must always be definitely settled that it is not
the sole and solitary organ possessed by the patient. The ac-
cident of removing the kidney has happened to a large number
of able operators. Formerly there existed good excuse on the
ground that there was no way of assuring one's self except by
making a counter-incision. This, the chance — one in a great
many thousand — did not seem to justify. It is most interesting
from a pathological standpoint that, contrary to what one
would expect, these patients who have suffered removal of their
sole kidney and therefore are destitute of any renal excretion
whatsoever, live usually from a week to ten days!
Renal Sepsis. Infection of the kidney and its pelvis may
occur in one of two ways. A frequent source of germ invasion
is from below. This is sometimes known under the old term
of "surgical kidney." The infection passes upward from the
l^ladder or ureter and is distributed among the tubular ter-
minations. The other method is by deposition of germs in or
about the glomerular tufts. They are carried here by the blood.
This is therefore a pyemic process.
Clinically these two methods of infection are indistinguish-
able for their manifestations are the same. Historically they
may differ. On section of the kidney, however, if too much de-
generative process has not taken place, they can readily be dif-
DECORTICATION VS. CAPSULE SECTION. 159
ferentiated by the presence of round cell infiltration and per-
haps of germs in the regions already referred to. Whatever
the source of the infection, the treatment is free incision and
drainage.
More interest has recently centered in the results of treat-
ing chronic parenchymatous nephritis surgically than in the
more fully understood cases of acute renal suppuration. With-
in the past year a large number of patients suffering from
chronic parenchymatous degeneration of the kidneys have been
subjected to the so-called Decortication Operation. This tech-
nic in itself is simple enough, consisting as it does in executing
the first part of the technic usually employed for nephropexy,
viz. — a longitudinal central splitting of the inner capsule.
The effects of this operation in a certain number of cases
have unquestionably been, to say the least, remarkable. Dr.
A, H. Ferguson showed such a case at the recent meeting of
the American Surgical Association. The high standing of this
operator and the unquestioned integrity of his pathological ex-
aminations, which were made by the ablest experts and upon
which the pre-operative diagnosis was based, renders it im-
possible to deny that there is a place for the surgical treatment
of chronic parenchymatous nephritis.
It has been claimed that the good accruing to the patient
arises from a development of a new and a large blood supply
to the organ. This, however, seems to have been an erroneous
supposition for Emerson, as a result of extensive experimental
observations made at the Columbia Physiological Laboratory,
has been able definitely to prove that, in animals at least, renal
decortication is not succeeded by the development of an ad-
ventitious blood supply to the kidney. It has been noticed
that as much good may result from a simple section of the
capsule, with or without an accompanying nephrotomy, as has
been observed to arise from a thorough decortication. In the
absence of proof that increased blood supply arises after this
operation in man ; in the presence of positive demonstration
that such blood supply does not arise in animals, and on ac-
count of the fact that improvement is noted after a variety of
operations in which the capsule is not torn off, it is probable
that improvement results from an increased nerve stimulation
rather than from an increased blood supply.
160 SIGNIFICANCE OF BLOODY URINE.
The ureters occasionally have to be sectioned and re-united.
This operation is called Uretero-ureterostomy. Various de-
vices have been employed, among others a small button and
a diminutive hammer. The button, in a measure resembles
Murphy's intestinal button and the hammer serves the pur-
pose of juxtaposing the openings while suture of the serous
coat is in progress. The union of this tube at any point is
easy, so that throughout its length it enters more or
less widely into operative technics. The treatment of the ter-
minal extremity of the tube, however, is a very different con-
sideration. It will be discussed under the bladder.
Robert F. Weir used to say that blood in the urine meant
in a very large proportion of cases one of three things. Stone,
Tuberculosis or Malignancy. This affords an admirable illus-
tration of the easy applicability and the accuracy of the Sub-
Scheme for giving "Causes of." Hematuria is necessarily not
the only symptom of these three important diseases, but Weir
ingrafted that teaching on thousands of students to the lasting
good of the public. *
THE BLADDER.
The importance of this reservoir centers largely upon its
close relation to other pelvic organs. In the female it is very
apt to be involved secondarily and by contiguous infection pro-
cesses in malignant diseases of the uterus. It is thus often
necessary to resect the bladder very widely. It possesses a
remarkable power of regeneration, excellent bladders having
been created from a dilatation of an incredibly small portion
of mucous membrane left behind and sewed into a bag at time
of operation. This is an illustration that nature produces or-
gans as they are needed, but it is rare indeed that she is able
to do so in the adult human being.
Another important surgical consideration is the point of
entry of the ureters. Just as in the case of the inguinal canal
and the duodenal opening of the duct of Wirsung, so here na-
ture has made use of the inter-muscular course. For from two
to three centimeters the ureter passes between the coats of
the bladder before it pierces the mucous membrane. It can
readily be seen that malignant; tubercular disease or injury
* An important differential is between Nepliro-litliiasis, Nephro-
tuberculosis, Nephro-malignancy and Nephralgia.
IMPORTANCE OF URETERO-VESICAL VALVES. 161
might make necessary the removal of so much of the ureter
that the ends could not be juxtaposed. The problem then
arises what to do. Even in view of the very extensive work
which has been done in an effort to answer this question more
satisfactorily than it was formerly answered, it is safer for the
patient that the entire kidney should be removed rather than
that any attempt be made to leave it in. This necessitates
caring for the secretion by grafting the ureter either to the
surface of the body or into the sigmoid.
Madyl was the first to suggest the desirability of preserv-
ing the uretero-vesical valves. He advocates cutting out a
square of the bladder wall of sufficient size to more than in-
clude these valves, and a transplantation of this segment di-
rectly into the sigmoid at such a position that a convenient
uretero-ureterostomy can be made between the proximal and
distal ureteral ends. Some cases operated upon by this technic
have been surprisingly successful. It is astonishing howtolerant
the sigmoid will soon become of urine, and the qviantity which
it will hold is so great that under favorable conditions, the in-
dividual need not void it more frequently than is habitual.
This operation, it will be noted, converts the patient into a
bird in that the urine and the feces are both disposed of
through a common opening or cloaca (great sewer).
Unfortunately even with Madyl's technic, the uretero-ves-
ical valve is usually so impaired that infection from the sig-
moid soon passes it, ascends to the kidney and kills the patient.
This is why it is probably more conservative surgery in such
cases to do a primary nephrectomy. A third important rela-
tion to the bladder which has a definite bearing upon the sur-
gery of the organ is that of the prostate. This gland if re-
moved through the supra-pubic region can be reached only
after anterior and posterior section of the bladder wall. The
type of prostatic treatment instituted in a given case, there-
fore, has an important bearing on the bladder. As will be
explained, however, in the chapter on the prostate, this rela-
tion is coming to have less importance every day.
Stones occasionally form in the bladder. A great majority
of them grow after the manner of a snow ball, by rolling round
and round in the bladder. There has to be a beginning or
162 TESTICULAR DIFFERENTIALS.
center for the concretionary mass ; this may arise from
bodies introduced from without or may come down in the
form of small agminations of crystals from the kidney.
Bladder stones (Brewer) may be composed of
Uric Acid; smooth, round, dark brown.
Ammonium Urate ; lighter in color.
Calcium Oxalate ; very hard, dark brown or black, nodular
rough surface.
Phosphatic; white and friable.
Composite Stones.
Cystine j
Xanthine '
Positive diagnosis of stone can be made only, either by
touching it with a metal sound; by seeing it through the cysto-
scope, or by the X-Ray.
Blood in the urine, if not from the kidneys, frequently
comes from the bladder. The most common cause of a bloody
discharge from this organ is the so-called papillomatous tumor.
It is a benign, pedunculated, highly vascular growth, not un-
common in young people and always to be thought of in con-
nection with hematuria. The important dififerential point be-
tween this condition and the three renal causes of hematuria
already cited is the — presence or absence of vesical irritability.
THE TESTICLES.
Syphilis and tuberculosis attack these organs with about
equal frequency. The diseases, therefore occasionally have to
be differentiated from each other as well as from the more
common gonorrheal infection. Practically the testicle cannot
be invaded without a certain amount of sympathetic involve-
ment of the epididymis. This is fortunate, since without the
epididymis as a guide, a clinical differential would be difficult
to make. In syphilitic involvement the enlargement is almost
always at the globus major. In tuberculous invasion the en-
largement is in the globus minor. The syphilitic lesion there-
fore is proximal to the tuberculous. The gonorrheal lesion
also usually occurs in the globus minor, differential between
this disease and tuberculosis being based upon history rather
than physical examination.
GROSS PATHOLOGY OF PROSTATE. 163
For those who liave been sterilized by gonorrheal infection
of the vas deferens and epididimis it will be comforting to
know that the occluded vas has recently been cut proximal to
the stricture and grafted into the testicle with good functional
result,
THE PROSTATE.
If, as Osier says, pneumonia is the friend of old age,
chronic prostatitis is its bitterest enemy. A very well-known
authority on this subject recently stated that the mortality
from catheter life should be placed at one hundred per cent.
Even ardent advocates of this ancient method of treating the
chronically enlarged, obstructing prostate, are obliged to con-
fess that the average duration of life under the catheter is net
more than four or five years.
Freyer (Lancet, July 23d, 04) states that the prostate is in
reality composed of twin organs of apparently purely sexual
function. This twin formation is seen typically among some
of the lower vertebrates, and it is always found in man during
the first four months of life.
it is evident from this that instead of calling the organ the
"prostate" we should speak of the prostates.
There are two moot points in the gross pathology of these
organs. First, as to the so-called "capsule." Second, as to the
so-called middle lobe.
Freyer likens the two organs to an orange. He states that
the analogy would be complete if an orange segmented into
two halves, instead of into many small pieces. Imagining such
an orange, the true prostatic capsule is analagous to the delicate
coat which envelopes fhe edible portion of the orange. The
"false" capsule, or what is usttally known as the "capsule,"
corresponds to the thick rind of the fruit.
The "middle lobe" does not exist as a thir-d division of a
single organ, as it is usually described, but is in reality simply
the over-folded, upward-protruding margins of the two lateral
lobes or two prostates, as they evidently should now be con-
sidered.
More revolutionary work has been done on the subject of
prostatectomy in the last year than in any other department
164 PERINEAL PROSTATECTOMY.
of surgery. There are consequently almost no text books
thoroughly up to date on this new surgery. The contributions
of Young, Sims, Goodfellow and Tinker presented in
1904, to the Surgical Section of the American Medical Asso-
ciation ofifer the matter in such a new light and withal in such
an authoritative light, that it may be looked upon as almost
entirely remade.
Together^ they reported over one hundred and fifty cases
of perineal prostatectomy in which there had occurred the
astonishingly small mortality rate of less than three per cent!
This is an utterly different teaching from that of recent text
books, which quote mortality rates of from fifteen to twenty-
five per cent.
Tinker's contribution to the subject is of the utmost impor-
tance. He has demonstrated that prostatectomy may actually
henceforth be relegated to the domain of minor surgery! Old
men, victims of advanced arterial sclerosis, often do not take
kindly to a general anesthetic. Tinker injects the long puden-
dal and the internal pudic nerve, where they course around the
tuberosity of the ischium, as shown in the figure, with massive
infiltration anesthesia after the method of Matas. His patients
suffer no pain whatsoever ; they complain simply of being,
wearied by their cramped position on the table.
One of the most remarkable facts in connection with this
subject of perineal prostatectomy is that the patients are al-
lowed to get up and walk about their rooms in from twelve to
thirty-six hours. They suffer no discomfort in so doing and
prevent the possible development of hypostatic pneumonia.
The consensus of surgical opinion, as shown at this meet-
ing, is that the perineal operation is the technic of choice ;
that the gland should be removed under local anesthesia, and
that the operation should be done as early in the course of the
disease as possible.
Bottini's Operation. This technic has been given rather
wide attention here recently on account of the work of
Young and others. Two years ago Young utilized it almost
to the entire exclusion of any other technic and obtained very
good results by so doing. He has, however, since that time
done over fifty perineal prostatectomies.
Thus the man who was perhaps better able to judge the
LOCAL ANESTHESIA OF PERINEUM.
16^
advantages and limitations of the Bottini technic than any-
other in this country has given it up in favor of the perineal
operation.
fi'''
^,77/*"'*
Fig. 39
This figure illustrates the relation of the Inferior Pudendal and the
Internal Pudie Nerves to the Tuberosity of the Ischium. It
shows the ease with which they may be anesthetized in this
situation.
It also shows the structures emerging from the greater Sacro-
Sciatic foramen above and below the pyriformis; viz.:
Int. Pudic Vessels and Nerve.
., ( Gluteal Vessels.
Above - o /^i 4. 1 TVT
Sup. Glutea Nerve.
Below
Nerves to Obturator Inter-
nus and Gemelli.
Sciatic Vessels.
Sciatic Nerve.
Inferior Gluteal Nerve.
CHAPTER XIV.
FRACTURES AND DISLOCATIONS.
One of the differences between the treatment of fractures
now and the former methods of treatment is that the fracture
is set in a permanent dressing as soon as it is diagnosed. There
are, of course, exceptions to this, but as a rule the "Fracture
Box" has been discarded.
Fractures and dislocations, which were formerly spoken of
as compound or as simple, are now referred to as open and
closed.
Open fractures and dislocations are always to be kept as
surgically clean as possible ; they have, therefore, a certain dis-
tant relation to pathology. Especially slender has the thread
become which unites the art of treating fractures to the science
of medicine since the introduction of the X-ray.
A great many new and undoubtedly more comfortable
dressings have been introduced, but in general any dressing is
good if it successfully concludes the treatment of the case. The
solitary indication is that a given dressing* must reduce the de-
formity and hold it reduced.
Fractures cannot be reduced and held reduced except the
anatomy of the part be properly understood. One of the most
interesting and instructive fractures, from a purely mechan-
ical standpoint, is that of the femur. There are three planes
in which force is exercised to produce the characteristic de-
formity. This fracture exemplifies so well the principle long
taught by Stimson that the distal-fragment should always be
put in line with the proximal. Leave the proximal fragment
to take that position which the conflicting planes of muscle
force will throw it into, and by as simple a contrivance as pos-
sible put the distal fragment in line with this. Hold it
there, and the result will uniformly be good. Attempt, how-
ever, to force the proximal fragment into line with the distal,
and the result will uniformly be bad.
* Dressing here is used in a general sense.
LINEA ASPERA.
ur,
The position taken by the proximal fragment of the femur
depends entirely upon the length of that fragment. This is
easily explained. The three groups chiefly concerned are the
adductors, the flexors and the abductors or external rotators.
When the fragment is short, as for example, if the break occurs
from five to seven centimeters distal to the lesser tuberosity,
all the muscular attachment of the second and third group is
inserted upon the proximal fragment. Only a part of the ad-
ductor insertion is upon this piece of bone, for it extends
Fi<;. 40
This shows the linea aspera pulled out sideways.
throughout the entire linea aspera. (See cut of muscles.) In a
fracture, then, situated at the point just mentioned, the posi-
tion taken by the proximal fragment is that of external rota-
tion and abduction with flexion. As the line of fracture occurs
further and further distally, the pull of the adductors becomes
greater and greater, for the reasan already referred to, until
at length the adductor and the abductor pulls balance. What
efifect upon the flexion of the fragment has its lengthening?
Obviously the longer it is the more it is enshrouded by the
Heavy vasti muscles and the leverage of the lengthening piece
rapidly becomes so great as to obviate all evidence of flexion
in the fragment. This occurs at about the same time that
abduction and adduction balance each other. It is at a point
about midway on the thigh. This explains the figure, which, it
168
DIFFERENTIAL OF FRACTURE.
Th^ec /J'sy'^ Chdjr
will be noted, calls for a Nathan R. Smith splint until the
fracture reaches about the mid point of the bone.
Success follows a strict adherence to
the principle that whatever the direction
of the proximal fragment, the distal
fragment must be made to follow it.
The dressings suggested in the figure
are by no means the only ones which
will fulfill the required condition. They
are only examples of dressings suited to
the supposed conchtions.
The Etiology of Fracture* Direct
Force. This is the most frequent cause
of fracture, particularly of short bones
and of flat bones. An exemplification
of it is fracture b}^ a cart-wheel having
passed over the part.
Indirect Force. This form of violence usually breaks the
long bones. For example, the ribs are often broken, but they
rarely give way at the point of application of violence. It is
true that they may be crushed in by a very heavy blow upon
the chest wall as of a hammer or a club, but the usual history
of this fracture is that pressure was applied on- two opposite
sides of the body to such an extent that it was flattened until
the ribs gave way at a point 90 degrees from the application
of the pressure. Such forms of injury are often inflicted on
brakemen caught between cars. Another example of this type
of injury is seen in the bending and bursting or equatorial
fractures of the skull which occur at 90 degrees from the point
of application of the pressure.
Muscular Violence. Except in the olecranon and in the
patella, which are really nothing more than sesamoid bones,
this cause of fracture is rare. Baseball pitchers do, however,
occasionally break a long bone.
The Differential of Fracture rests upon :
(1) History of Injury, (may be very slight indeed).
(2) Pain.
(3) Disability: Lost or limited power.
^
DIFFERENTIAL OF FRACTURE. 169-
!a. Displacement and loss of contour.
b, Angular deformity.
c, Swelling, ecch)'mosis, blebs.
C rt, Bony irregularity.
,^. . , \ b, False point of motion.
(0) Palpation , ^^ Referred pain.
[ d, Linear pain. (Important)
( L\ Extension painless; compression painful,
I /, Rigidity.
i Bone.
g. Crepitus < Blood.
( Tendon.
(This sign is the least valuable of all)
(6) Compare with opposite side.
(7) Mensuration.
(8) Tendency to recur.
(9) X-Ray.
The details of these signs are as follows:
Probably the most important is
Pain. This is not peculiar to fracture at all, but, as already
stated, is an invaluable diagnostic point in many diseases. For
that reason, the giving of an anesthetic, while undoubtedly of
great value, has this hmitation upon it, that it takes from the
surgeon this very important natural sign-post Avhich points
to something wrong. The importance of establishing a diag-
nosis without an anesthetic is well seen in the case of early
inflammatory lesions of joints where pain is often the only
symptom.
The pain of fracture has several important characteristics.
First, the ordinary subjective pain incident to the injury.
Second, the referred pain. This is, of course, an objective
pain and is elicited by the surgeon pressing upon uninjured.
regions. For example, if a fractured rib is suspected, pressure
over the two ends of the rib will often cause the patient to cry
out. On being asked where it hurt, he will frequently point to
the neighborhood of the axillary line. Another good example
of referred pain is occasionally to be seen in Pott's Fracture,.
where pressure on the fibula, ten or twelve centimeters above
the ankle, or pressure on the tip of the outer malleolus will
cause the ];)atient to cry out. He will refer the pain to the
•170 SYMPTOMS OF FRACTURE.
usual point of fracture, viz. : four or five centimeters above
the malleolus. This objective referred pain of bones is en-
tirely different from the "referred pain" of nerves, which is
■entirely subjective.
Third, and very important, is linear pain. This is consid-
ered by many surgeons as a pathognomonic sign of fracture.
It is well elicited by pressure along the course of the bone
with the butt end of a pencil. The zone of tenderness will be
found in typical cases not to be broader than a pencil butt.
This pain is very sharp, and, when present, is of the greatest
value. It is always present when bones near the surface are
fractured.
Fourth, compression pain. This form of objective pain is
of value in differentiating fracture from dislocation. If the
distal extremity be pulled from the proximal, in the case of
fracture, the two sharp ends of bone which grind into each
other and into the neighboring soft parts will be separated
and the injury that they are causing will be stopped. Conse-
quently the patient will at once experience relief. If, on the
other hand, the proximal and distal portions are pressed to-
gether, the injury done will be increased with a corresponding
increase in the patient's pain. Dislocation is just the reverse
of this. In it the soft parts are torn and the hard parts are
intact. If you pull upon the distal fragment, it stretches the
torn soft parts and it hurts the patient. Pressing the fragments
together, however, has a negative effect.
Ecchymosis and Blebs, when present, if they can be posi-
tively shown not to have been caused directly by the primary
injury, are of pathognomonic importance. If, for instance, a
person is thrown from an automobile and lands upon his
shoulder, it hurts more or less for a' number of days, but no
further positive evidence may be forthcoming. Perhaps after
three or four days there will appear a little subcutaneous
hemorrhage in the neighborhood of, usually somewhat internal
to, the acromion. The fact, that this was not there before shows
that it is not the black and blue bruise of the primary injury,
but that it is due to blood which has escaped from a broken
bone and which is slowly finding its way to the surface. These
blood extravasations follow the fascial muscular boundaries
HOW TO LOCATE THE TROCHANTER.
171
more or less and are widely influenced by gravity. Thus it hap-
pens that the ecchymosis of a Pott's fracture is often found
over the calcaneum just distal to the tip of the external malleo-
lus. Probably in some cases the direction of the blood ex-
travasation is more or less determined by the periostium. It
would be safe in the supposed case of automobile accident
referred to above, to say, upon the appearance of an ecchymosis
as described, that the patient had a fractured bone.
Blebs usually form somewhat later than ecchymosis. They
are an equally important sign of fracture.
Because the X-rays are not by any means always avail-
able, as, for example, in country practice, Blake considers that
they should be held in secondary importance for the diagnosis
of fracture.
Fracture of the Neck of the Femur. Nothing can be done
with this condition until one is familiar with the landmarks.
In a child or in a slender patient, it is easy to get one's fingers
upon the great trochanter. In a big fat woman, however, it
is no easy matter unless the exact position of the trochanter
in its relation to a prominence which cannot be covered with
fat is kn,own. This is the anterior superior iliac spine, and the
following method is a handy one to enable the surgeon to place
rfi-
,1^ ■r'
Fig. 42
173 COMPARISON WITH SOUND SIDE.
the tip of his index finger upon the tip of the great trochanter^
or rather to place it -where it ought to be without reference to
the fatness or the leanness of the patient.
Put the patient flat upon his back. Stand by the side
opposite to the injury. Place the fifth metacarpo-phalangeal
joint of the hand which is nearer the patient's head upon the
anterior superior spine of the injured side. Put the hand in a
transverse plane of the body, and if the patient be an adult
and the surgeon's hand be of usual size, the tip of the index
finger will be found to lie directly upon the tip of the great
trochanter.
Very naturally it is not often necessary to resort to this,
method, but as the great trochanter is the all-important land-
mark in determining hip injuries, and since in very fat women
with unusually small bones, it is sometimes difficult to Hnd,
the technic may occasionally be of service.
Bryant's Triangle. This is found by dropping a vertical
line from the ant. sup. spine when the patient lies flat on his
back. The line passes to the table. A second line is drawn
at right angles to it from the tip of the great trochanter. This
it will be noticed is just about in the line of the pants pocket,
and in an adult is about five centimeters in length. The hy-
potenuse of Bryant's Triangle extends from the tip of the great
trochanter to the anterior superior spine. It is of no diagnostic
value whatsoever, and there is no practical use of completing
the triangle, the important side of the triangle being as already
stated, the one which lies where the seam of the pants ought
to be. When the length of this line is determined, it should
be compared with the length of the corresponding line on
the well side before any significance can properly be attcahecl
to it. Comparison with the sound side is very important in
this and in every other fracture. Individuals may vary very
widely from the standard, but they are usually bilaterally
symmetrical. In other words, the standard for the patient is
not the hypothetical one in the examiner's mind, but the actual
one, represented by the patient's uninjured side.
Obviously, if there be a fracture of the neck of the femur,
this side of Bryant's triangle will either be very much reduced
in length, or else it will actually be a negative quantity the
COLLES' FRACTURE. 173
tip of the trochanter having passed above the line dropped
from the anterior superior spine.
Nelaton's Line. This is a somewhat more difificidt meas-
ure to make because one has to find the most prominent part
of the ischiatic tuberosity. In very fat people this is difficult
•or almost impossible to do. Nelaton noted that a line drawn
from the anterior superior spine to the great tuberosity of the
ischium should normally pass through the top of the great
trochanter. If the tip of the trochanter lies proximal to this
line, there is a fracture, unless, owing to the peculiar construc-
tion of the individual, a similar condition exists on the unin-
jured side.
Colles' Fracture. This is called the "back door fracture."
In the old days of New England, the housewives used to throw
their dish water out the back door on the path to the out-
houses. Walking on the same path an hour after, when the
dish water had frozen, they frequently slipped and fell. They
usually fell backwards, and putting their hand behind them to
save their buttocks, they broke a wrist. Passengers attempt-
ing to walk on board ship during a storm often fall in the same
way. Banana peels on city pavements often cause this frac-
ture.
There are two interesting points to remember about Colle's
fracture. First, almost any form of treatment seems to work
well if thorough reduction be accomplished at the start. Un-
less this be done, and it is surely most certainly accompfished
under an anesthetic, no form of treatment will give a good
result. The disability arising from improper reduction con-
sists in the patient not being able to close the fingers. This is
due to an inclusion of the extensor tendons in the callus. The
second point of interest about the fracture is that it is the
only one at which pressure at the point of fracture is permis-
sible. A pad is usually placed in this position to aid in pre-
venting" recurrence of the deformity.
Fracture of the Clavicle. The most successful mechanical
contrivances are those which follow nature's mechanisms as
closely as possible.
Erricson, who invented the marine propeller, is said to
have had the idea suggested to him while lying on his back
174 MORPHOLOGY OF THE GIRDLES.
one fall day under a maple tree. He saw that the seeds, as
they fell, spun slowly round and round. He conceived the
notion that if a piece of metal were fashioned in the shape of
the seed and its wings, it would drive a boat.
One of the most remarkable characteristics of medieval
architecture was the flying buttress. Shooting off from the
sides of the main building, these delicate structures seem so
frail as to be for decorative purposes only. Yet they are so
proportioned that they support enormous weights. The pelvic
and the shoulder girdles of man are interesting examples of
flying buttresses. In the pelvis, adaptation to the upright
position and other factors favoring ossification have caused
that greater girdle morphologically to depart widely from the
buttress, but the principle of transmission of the body weight
through the pelvic bones remains the same. In the shoulder,
a more perfect resemblance to the flying buttress has been mor-
phologically preserved. The clavicle and the scapula are the
integral portions of the buttress.
Fracture of the clavicle, therefore, is of particular interest
since its successful treatment depends upon a recognition of
its function, which is to hold the upper extremity out from
the body against the pull of the torso-humeral muscles and
against gravity. After clavicular fracture these forces tlirow
the distal fragment (shoulder) downward, forward and in-
ward. The proximal fragment by muscular traction is dis-
placed upward. Any form of treatment is satisfactory for this
fracture if it holds the distal fragment in a position directly
opposed to this, viz. : upward, backward and outward.
Fractures of the Skull. Breaks in the bone-case of tKe
cranium are always confusing. They may for convenience
of description be divided, first, into those which are distin-
guishable by their appearance. They may be depressed or
linear. The first is caused by the application of blunt force,
and is therefore direct. The second may be direct or indirect.
If the fissures are multiple and radiate from a common
center, the fracture is sometimes called stellate.
Depressed fractures have to be differentiated from the
circumscribed swelling which often accompanies severe local-
ized scalp injuries. This is done by palpation. The examining
EQUATORIAL AND POLAR FRACTURES. 175.
finger in case of the bone injury is felt to pass over a sharp-
edge which is not raised at all into a depression. In the case
of the scalp injury, there is a similar depression and a similar
ring around it, .but the finger is felt to rise as it passes over
the ring before it enters the depression. This rise is the dif-
ferential between the two.
Indirect Fractures of the skull are not thoroughly under-
stood. They are the so-called Bending and Bursting fractures
and fractures by Conte Coup,
To understand these, even if imperfectly, it must be re-
membered that when a blow is applied to the side of the head,
it is, mechanically, as though an almost corresponding force-
had been applied directly at the opposite pole. This force is.
furnished in obedience to Newton's law that bodies in motion
tend to stay in motion and bodies at rest tend to stay at rest.
Given a skull, then, struck on one side, the opposite side of the
skull being still, has a very decided tendency to remain still.
The necessity of overcoming this tendency not to move puts
pressure upon the brain-case. You then have a condition just
exactly the same as if you had put the head between the jaws
of a vice.
From this point on it is not so difficult to understand how
the bending and bursting or equatorial fractures, as they may
be called, and the contra coup or polar fractures may occur.
Squeeze the jaws of the vice together and fracture will
very likely occur along the line of the equator, or in other
words at 90 degrees from the points of application of the pres-
sure. These are the poles. In a vice, the pressure applied on
one side is entirely counterbalanced by the resistance of the
opposite jaw. It does not move at all. The side of the skull
which corresponds to the resisting side of the vice does move
just as soon as the inertia is overcome. Perhaps it is for this
reason that equatorial fracture does not always occur, but that
the break is sometimes found to be at a point 180 instead of
90 degrees from the pole where the force was applied. For
further explanation of these fractures see Stimson's "Fractures,
and Dislocations."
It is important for legal reasons to remember that a skull-
case may be very widely broken without exhibiting any grave
176 TREPHINE INDICATIONS.
early manifestations. It is not the broken bone, but the result-
ing brain injury or infection which may cause death.
Fracture of the Anterior Fossa is often characterized by
sub-conjunctival hemorrhage, by bleeding from the throat
and by paresthesia of the first nerve.
Fracture of the Middle Fossa is characterized by a dis-
charge through the ear of cerebro-spinal fluid. That a given
discharge from the ear is cerebro-spinal fluid and not blood
serum, is determined in two ways. First, its quantity. This
is often incredible. It may, in 24 hours, saturate a pillow ; run
through a mattress and drip to the floor. Second, by its power
to reduce such a mixture as Fehling's solution.
Fracture of the Posterior Fossa. The signs in this case
are not distinctive and they appear late. There may be swell-
ing and ecchymosis over the region, but the presence of symp-
toms of cerebral injury, with an exclusion of anterior and
middle fossa involvements, are more important features than
the local ones.
Trephining or Bone Flap Operations are two methods
frequently employed, either to reach the brain and its mem-
branes or to treat fractures and their complications. The
indications for trephining are :
(i) For disinfection of bending and bursting fractures.
(2) Disinfection of circumscribed fracture with splinter-
ing of inner table.
(3) Clear cases of local pressure in simple fracture.
(4) Removal of foreign bodies.
(5) Arrest of bleeding (middle meningeal) and removal
of extravasated blood.
(6) Occasionally in simple depression. (There is a dis-
cussion as to this point.)
(7) Disinfection and evacuation of pus which appears
after injury.
(8) Cerebral abscess.
(9) Occasionally in traumatic neuroses.
(10) Tumors and neuralgias of the fifth nerve. (From
Stimson's lectures.)
Pott's Fracture. An interesting characteristic of this
break is that it is often mistaken both by the surgeon and by
WHAT CONSTITUTES POTT'S FRACTURE ? 177
the patient for a sprain. It is not uncommon to see men whose
rough work renders them more or less indifferent to minor
injuries, walking around with a well-developed Pott's.
The history of such cases is as follows: By jumping from
their truck, or in some similar exercise of their usual duties,
they "twist their ankle." The pain may be severe, but they
continue to work. What is the gross pathology of the part
at this stage? There is a fracture of. the fibula four or five
centimeters above the external malleolus and there is a begin-
ning tear at the lower extremity of the tibio-fibular ligament.
The tibia transmits a considerable portion of the weight of the
body to the fibula. Part of this weight reaches the fibula at
the tibio-fibular articulation above, and part of it is trans-
mitted by the interosseous ligament. As soon as the fibula
is broken, all the weight that is transmitted normally to the
bone by two agents has now to be carried by one. The natural
result of this unusual strain on the tibio-fibular ligament is
that it tears and that a separation of the two bones results.
As soon as this is accomplished, whether or not the del-
toid ligament has ruptured, or the tip of the internal malleolus
has broken, as often happens in place of the ligamentous tear,
the injury may be denominated a Pott's fracture. This is based
upon an acceptance of the holding (Stimson) that the exist-
ence of any two of the three characteristic lesions, fibula break,
interosseous Hgament tear and deltoid tear shall constitute
a Pott's fracture.
The patient furnishing this pathological picture usually
finds his way into a hospital about this time. He says h'e has
a "badly sprained ankle." Upon what data is it possible to
prove that it is not sprained, but broken ?
Inspection. — Foot is "spayed;" in other words, a position
of extreme plano-valgus. There may be (late) ecchymosis
over the calcanium on the outer side of the foot.
Palpation — False point of motion is a very important and
characteristic sign of Pott's. It is obtained by putting the
thumb and linger in the position of a stirrup and determining
whether the astragalus moves back and forth in its mortice.
Eliminate normal motion between the tarsal joints.
By pressure on the tip of the external malleolus the frag-
178 MODERN TREATMENT OF PATELLAR FRACTURE.
ment may sometimes be made to rock. Referred pain may
sometimes be obtained by pressing on the shaft of the fibula
high up. Linear pain is usually very sharply marked. It is
sometimes localized almost to a line. Find it with pencil butt.
The treatment is dorsal flexion with plantar inversion.
The reasons for this are obvious. The ankle is often so much
involved that it becomes permanently stiff. While walking, at
the termination of a tread, dorsal flexion is marked. There-
fore, unless the patient is to certainly develop a flat foot after-
wards, there must be marked dorsal flexion. Flat foot is the
most dangerous sequel of Pott's. The disability suffered from
it is often complete. It arises from constant thump during
walking on the ball of the foot. This was never intended to
bear such weights, and the inferior calcaneo-navicular liga-
ment soon gives way under the strain. This, of course, only if
the ankle becomes stiff.
Blake has shown that the treatment of patellar fracture is
best accomplished by a careful stitching, with an absorbable
suture, of the lateral ligaments of the patella. The important
point is to place the stitches very close to the bone, in a line
extending from it. This method gives much better results
than the older one of utilizing silver wire, which inflicts dan-
gerous traumatism on the parts at the time of operation. Such
traumatism is an undoubted factor in favoring infection, and
should therefore be avoided.
DISLOCATIONS.
Thumb dislocations are of three types. Stimson lays
special stress upon their importance.
Incomplete dislocations are really subluxations. They can
be produced and reduced at will.
Complete dislocations are those such as are commonly
seen on the baseball field.
Complex dislocations are generally produced by attempts
to reduce the complete form. They are characterized by a
button-holing of the head of the metatarsal bone between the
tendons of the flexor brevis. It can be relieved only by open
treatment.
The law for the treatment of dislocations is that the de-
ALLJS ON DISLOCATIONS. ITQ
formity should be increased and the head of the bone be car-
ried back over the same course through which it made its exit
from the socket. The object of increasing the deformity is to
relieve the muscular tension and relax the part. That explains
in large measure the complicated steps of Bigelow's method.
Allis has shown that, given a knowledge of the gross pathology,
the reduction of any ordinary dislocation should not be at-
tended by difficulty. Essential conditions to success are, first,
complete anesthesia, and second, absolute immobilization of
the proximal part.
Dislocations of the hip and shoulder resemble each other
in that the head of the bone in each case almost always tears
the capsule at its lower boundary. It is weaker here than
above, undoubtedly because it is not necessary for it to give
as much support to the head of the bone.
If, as is rarely the case, the head of the humerus simply
slips through a tear in the capsule and journeys no further,
this dislocation is sub-glenoid. If, however, as is usually the
case, it does make an excursion in the tissues, it almost always
migrates toward the coracoid process. This sub-coracoid
dislocation is the common one. Under the impetus of extra-
ordinary pressure the head sometimes journeys past the cora-
coid to a position beneath the clavicle. This is known as the
sub-clavicular form. It is rare. Occasionally the head, instead
of coming forward, is forced backward, but this also is rare.
The differential scheme for fractures should be applied to^
every variety of bone-break. It cannot be done here.
CHAPTER XV.
TUMORS, HERNIA AND MALFORMATIONS.
A tumor is a solid swelling not the immediate result of
inflammation.
Cysts are swellings not the result of inflammation, but
they are not solid. In the case of certain malignant growths
such as epitheliomata, there can be little doubt that they are
occasionally the indirect result of an inflammatory process.
This frequently arises from chronic injury.
Benign tumors owe their interest chiefly to two condi-
tions. First, they often cause inconvenience and occasionally
death from simple pressure. Second, they tend constantly to
undergo malignant degeneration.
The borderland between benignancy and malignancy is
vague. This must continue so long as we remain ignorant of
the causes of malignancy. All benign tumors are not so far
removed from the malignant forms as others, and on the other
hand some of the malignant tumors, also near to the zone
which separates the two groups, are not far removed from the
benign.
Bland-Sutton's charming book deals most interestingly
with this question, as with the entire problem of tumors, in a
wonderfuTly interesting and simple manner. He approaches
the subject by the only standpoint from which it can possibl}^
be understood, viz. : that of comparative pathology.
Granting, then, that there are certain tumors on both
sides of the fence, about which nothing positive can be said,
it may be justifiable, first, to give the general characteristics
of malignancy, and, second, to attempt to differentiate between
a benign and a malignant tumor, always remembering that
the differential may fall flat because of. the benign tumors
having assumed malignant characteristics.
MALIGNANT CHARACTERISTICS. ISi
CLINICAL SIGNS OF MALIGNANCY.
(i) Rapid growth. !
(2) Pain.
(3) Position.
(4) Adherence to skin.
(5) Ulceration.
(6) Redness and heat.
MICROSCOPIC SIGNS OF MALIGNANCY.
(i) Infiltration of surrounding tissues.
(2) Arrangement of cells.
(3) Arrangement of blood vessels.
(4) Character of blood vessels.
(5) Character of cells.
The applications of these differentials are seen in Figs. 26
27 and 28.
Aberration from normal developmental lines gives rise to
the so-called terratomata and to congenital cysts. The best
description of the origin of these cysts which are relatively
very common is to be found in Bland-Sutton's hand book.
Carcinomata occur on the surface of the body. There is
an inner and an outer surface. Diverticulae of the alimentary
canal such as the liver, the pancreas and the parotid gland lie
upon the inner surface of the body. For this reason, and fur-
ther because they are actively functionating glands, sarcoma
in them is rare. They are characteristically attacked by car-
cinomatous degeneration. (See Fig. 35.)
Sarcomata occur within the body.
Sarcomata of bone are frequent and are interesting. They
are of two types, the central and the periosteal. There is a
very great deal of difference in the treatment of these two
types. This is because the central sarcomata are probably
(Bland-Sutton) to be ranked with myelomata. These are
tumors on the border line between malignancy and benignancy,
built of tissue identical with the red marrow of young bone.
It is thus of great importance to the patient whether the tumor
be centrally or peripherally located, for whereas in the first
case cure almost certainly results from a simple curettage, life
182
HERNIA
in the second case can only be occasionally prolonged by dis-
articulation of the bone.
McCosh (Annals of Surgery, Aug., 04) states that con-
trary to the usual belief Sarcoma is most common between the
30th and 40th year. This is based on a careful study of ninety-
eight cases, and is at interesting variance with the generally-
accepted teaching that sarcomatosis is a disease of early life.
'/z ^IctefhQCfeQj opnin,^
Arises
Fig. 44
DIAPHRAGM.
Ensiform
Last 6 Ribs and tlieir Cartilages.
Arcuate Ligaments.
Lumbar Vertebrae.
Internal Arcjiate Ligament. — Continuous witli outer side of correspond-
ing crus and from outer side of body of 1st Lumbar, arching over tlie
Psoas, to front of transverse process of 2nd Lumbar.
INTERNAL HP:RNIA. 183
External Arcuate Ligament.— ^\-on1 of transverse process of 2nd (with
slip from 1st lumbar vertebra), to apex of last rib, arching over qua-
dratus lumborum.
Right Crus.—Yxon\ bodies and intervertebral substance of 3 or 4 upper
lumbar vertebrae.
Left Cms. From bodies, etc., of upper two lumbar vertebrae. The
tendinous portions of the crustae converge in the mid-line to form an
arch (for Aorta, Vena Asygos Major and Thoracic Duct). The
Fibres from the right pass in front of those from the left— they cross-
open out— and recross after forming opening for esophagus, finally
uniting with central tendon.
^. , ^ r^ . -^ \ Sympathetic.
Right Crus transmits -^ Q^^^^g^ ^nd lesser Sphlanchnics.
y ,, r- , ., ( Left Sphlanchnic.
Left Crus transmits -j ^^^^ Azygos Minor.
Central Tendon.— '^xiusiied. immediately below the pericardium istrifoil in
shape. Right leaf the larger.
Aortic Opening.— In mid-line in front of bodies of vertebrae and hence
behind diaphragm. Transmits Aorta— Vena Azygos Major and
Thoracic Duct.
Esophageal Opening.— Formed, by double decussatior; of the Crura.
„ ., ( Eso-pha^us.
^ Transmits -j pj^^^^^^^rastric Nerves, (left in front)
Foramen (2uadratum.—V\SiCe6. at junction of right and middle leaflets.
Transmits Lnferior Vena Cava.
Points of Deficiency.— ^^a-ces of Larray: One on either side of slip to
Ensiform. (Pus or Diaph. hernia)
Another between attachments to 11th and 12th Ribs.
Brevier defines hernia as a "protrusion of an organ from
the cavity in which it is normally contained." By far the most
frequent form of hernia occurs through the potential opening
of the inguinal canal. The saphenous region is also a frequent
site for external hernia.
Internal hernia, while uncommon, occurs with sufficient
frequency to make a differential of the utmost importance. It
has already been touched upon while considering intestinal ob-
struction. The usual sites for internal hernia are as follows:
( 1 ) Foramen of Winslow.
(2) Aortic, esophageal and other openings and weak places
of the diaphragm. See figure showing this muscle.
(3) Duodeno- Jejunal .
(4) Cecal fossae.
(5) Sigmoid.
(6) Preperitoneal hernia.
184 IMBRICATION METHODS.
There are two important. points m the technic of repairing
external herniae. The first is the use of absorbable sutures and
the second is imbrication. This latter is the most recent ad-
vance which has been made in the treatment of hernia and is
well exemplified in Mayo's technic for the treatment of ven-
tral hernia and in Andrew's modification of the Bassini. An-
drews accomplishes what Halsted endeavored to do. Hal-
sted's operation, by which the cord and its appendages were
placed on the outer surface of the external oblique, did not
work well because the skin gave insufficient protection to the
cord. It is obvious that a stronger abdominal wall may be
made by uniting the three muscles rather than by having them
split by the cord. Andrews accomplishes this tighter union,
and, in addition, successfully protects the cord. He transplants
it to the outer surface of the wound just as in the Halsted
technic and then imbricates or folds fibres of the external
oblique over it.
In a large direct hernia, Blake sews the rectus to Pou-
part's and closes the internal oblique over it.
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