"„^ETT?'t^.T.?i^rir hX64055035 RD31 M912 Clinicallalksonmi RECAP >.'^ ■?.■ may attack and destroy nail and matrix, and involve periosteum, bone, joint, and tendon. There is no limit to its possible ravages, but for the avoidance of confusion, as I told you at the first, when the inflammation has passed beyond the region of the nail, I prefer to speak of it as felon and not as paronychia. Palmar abscess is the third subject to be considered to-day. To it felon and paronychia naturally and inevitably kad. It is a lesion of great interest, — in its pathology, its treat- ment, and its capacity for far-reaching damage. In it the infection usually starts in the palm, but it may begin in one of the fingers and spread to the palm. The methods of infection are therefore various, but perhaps the commonest method is that presented by the hard-working man whom I show you. He is a gardener. His hand bears heavy callosities, which have become so hard as to press upon and irritate the underlying soft structures. This bruising has caused a considerable blister, which has become infected from the overlying skin, and in turn has passed on its irritating properties to the deeper parts. As you look at the hand it appears every- where swollen — back as well as front. That puffy, reddened dorsum is swollen from oedema. If you were to cut into it, you would draw only serum and blood. But the palm shows a condi- ON MINOR SURGERY 77 tion quite different. It is not so greatly dis- tended in appearance as is the dorsum, for its deep structures, bound down by the dense palmar fascia, cannot greatly swell. The pain is there, however; and it is all the more severe because the fascia does so limit the swelling. In order to escape without our aid the pus must burrow up under the annular ligament, into the forearm, and that is what we fear. So you see the palm of the hand to be tense, brawny, but not greatly swollen. It is exquisitely sensitive to pressure. The pus must be let out quickly, and here again we are presented with a problem which is rendered interesting by reason of ana- tomical complications. No other region of the body contains so many and such diverse struct- ures compressed into so small an area. There is here a labyrinth of tendons, nerves, vessels, and fasciae — to say nothing of tendon sheaths, small muscles, and bones. All these structures are essential to the proper use of the hand — that wonderful piece of mechanism. We cannot go roughly slashing into it without crippling it, yet to get out the pus we must in a fashion slash. It used to be taught as a safe rule, and those who so taught were in the main correct, that when cutting into the palm you should make your incisions short, multiple, and parallel to the bones, thus avoiding, so far as possible, the 7^ CLINICAL TALKS delicate structures of the hand. That plan is not a bad plan — indeed, it is the one commonly followed still, but it has this disadvantage, that through these straight incisions the pus is sought somewhat blindly and with difficulty, and that the incisions tend to early closure, thus damming in the discharges and necessitating a second operation often. Moreover, such wounds heal with disabling scars, which are bound closely to the underlying parts and seriously limit mo- tion. My colleague. Dr. Brooks, has devised an incision which I prefer. The patient is now etherized. While his hand is held firmly out- spread I outline a semi-circular flap which in- cludes the whole of the palm practically. I enter the knife over the second metacarpo-phalangeal joint, as you see, and after sweeping round the palm I bring it out at the base of the thenar emi- nence; in other words, the flap is to be turned back on the thumb as a pivot. Rapidly dissect- ing away the skin, I have now exposed completely the palmar fascia. You see a little pus oozing through it at these three openings. I now en- large the openings with a blunt scissors and rapidly, without damage to structure, follow up and clean out all the cavities. You see I have had to deal with a really beautiful and well- exposed dissection of the palm, I have avoided easily the important arteries, nerves and ten- ON MINOR SURGERY 79 dons, for I have seen them; and I have searched out the burrowing pus far more thor- oughly than was possible by the old blind method. Now I disinfect carefully the whole hand. How about drainage and the after-treatment? Wicks are led out from all the pockets; a thin layer of gauze is spread over the whole exposed surface and the skin flap is laid back over the gauze. In the subsequent dressings, when neces- sary, the skin flap may again be turned aside and the depths of the wound may again easily be explored. Judging by experience, we should find the inflammation subsiding in a day or two, when the wicks gradually will be removed. By the end of a week the palm and the under surface of the flap will be covered with granulations. Then, if all looks clean and sound, we shall stitch the skin back into place and look for a rapid healing by a delayed first intention. To facili- tate the sewing back of the flap we usually pass these so-called provisional stitches at the time of the original operation. When the time comes they will be tied. For the first four or five days it is well to dress the hand and forearm in a large creolin poultice with a splint, but this may be abandoned soon for the gauze dressing with elastic com- pression and elevation. You will be surprised to see how useful and 8o CLINICAL TALKS comely a hand will result from all this. The scar will be there, of course, but it will not be especially troublesome, and the function of the hand will generally be much better than was the case when multiple linear incisions were used. Again, let me warn you, in closing, that in spite of what I have said of your flap at the thenar eminence you must never operate by rule of thumb. Broadly this operation is a good operation, but diverse conditions will present themselves. No two cases are alike, and while you must strive always to observe general principles, you must apply also a broader com- mon sense. LECTURE VIII BOIIS, CARBUNCLES Gentlemen: The treatment of boils may seem to you a very minor part of Minor Surgery, yet there are few curable conditions more trouble- some than furunculosis. Last winter there came to see me a man who is the chief of police in a neighboring town. He had upon the back of his neck two boils and the scars of half-a-dozen others. For four months he had been suffering from these pests, — in constant discomfort with a sore and painful neck; his sleep broken, his appetite impaired, and his health becoming undermined. On inqtiiry I learned that he had gone ten years without a day's vacation, and that for six months before the appearance of his boils he had been feeling run down and debilitated from that con- dition of faulty metabolism which we call muscular rheumatism. I gave him a simple cleansing wash for the neck and a course of aperient waters. I en- joined a two weeks' vacation and the follow- ing tonic: sulphate of iron 3ii, sulphate of 8i 82 CLINICAL TALKS magnesia 5vi, dilute sulphuric acid 5vi, syrup of ginger 5iv, water Six, — a combination which I borrowed from Dr. L. D. Bulkley, and have found very useful in such conditions. The dose is one teasponful in water after meals. To the boils I applied merely a soft protective cotton dressing. Ten days later the man wrote to me that his boils had disappeared and that he was feeling well. That case illustrates one of the most impor- tant points I have to make for you in this con- nection. It is the point I have so often made for you before. You must regard your patient's general condition. And boils are usually a manifestation of a general condition. They indicate some form of malnutrition aud must be treated on that basis. Billings' Dictionary defines a boil as "a pain- ful conical or rounded swelling of the skin, due to inflammation about a hair follicle, a Mei- bomian gland, or a sweat gland." That is a fair enough definition, and if you will turn to page 172 of your Warren's " Surgical Pathology" you will find the nature of the process ex- haustively described. The point of it all, so far as the clinician is concerned, is that the organisms normally present in the skin gain lodgment in some of the glands or ducts and then multiply. The active development of these colonies of bacteria produces small areas ON MINOR SURGERY 83 of connective tissue necrosis. This necrotic portion acts as a foreign body, and nature pro- ceeds to throw it off as a "core." The process of throwing it off gives rise to further inflam- mation, with the resulting pus formation and swelling. After the core is thrown off there remains a little pit, which must heal by granu- lation. So, you see, there are three stages in the life history of a boil, and each stage demands its appropriate treatment. There is the first stage, when we see only a small superficial pustule; the second stage, when we see a much larger mass — elevated, indurated, and painful, containing its core; and the third stage of a craterlike but subsiding swelling. Most commonly a patient comes to you with a well-developed boil in the second stage and, in the neighborhood, two or three incipient boils or pustules. If the case is a chronic one, make up your mind about the patient's general condition, especially as regards diabetes and rheumatism. This young man before us is a good example of what I am describing. He is a night watch- man, whose daytime sleep is disturbed. He is given to rather excessive whiskey drinking, and is feeling pretty well done up. He has a poor appetite, constipation, a furred tongue, and is a striking type of the tired man who is burning the candle at both ends. I need not 84 CLINICAL TALKS trouble you with details of general treatment in his case except to say that I shall stop his liquor, and give him a course of Carlsbad salts, with five grains of Blaud's pill before his meals. Look now at the back of his neck. Here on the right side is a conical swelling the size of a silver "quarter." It is reddened at the center, where it is beginning to break down and soften, but everywhere else it is indurated. It is very tender to the touch, painful on pressure, and he says it "feels sore all round." To the left of it are these three little pustules, with red- dened areolae, each about half the size of your little finger nail. In the first place, as regards these incipient boils, let me tell you with much assurance that they may be aborted. The old-fashioned method was to poultice the back of the neck and bring the whole crop to a head. Don't do it. There are scoffers who will tell you that boils cannot be aborted. I doubt if they have tried faithfully any method. Here are two methods. You may prick the little pustule and wipe out the minute cavity with a probe dipped in pure carbolic acid. That often will suffice, but I have not found it so successful as the hypodermic injection of very small quantities of some strong antiseptic. In the first place I cleanse this neck with soap and water and alcohol. Then I inject five or six minims of cocaine, in four per cent ON MINOR SURGERY 85 solution, under the infected areas. Now into this ansesthetized zone, along the cocaine track, I inject, under each pustule, two minims of pure styron, — an ancient but efficient bal- samic antiseptic. I prefer it to carbolic acid, because more thoroughly it permeates the affected tissues. The result of this injection is to destroy the active bacteria and to convert the infected area into an aseptic eschar. The immediate result, so far as the patient is con- cerned, is that the sense of burning and discom- fort disappears in a few minutes; without fur- ther sensation the eschar will be thrown off and the little wound will heal up. Remember to use cocaine before these injections of styron, for the styron used without such preliminary treat- ment causes a few moments of very severe pain. I am satisfied from a fairly wide experience with this method of aborting boils that it will usually be found successful. A young man came to me last winter who had pustule after pustule appear on his neck for a period of sev- eral weeks. Before I saw him, one of them had got ahead of us. It ran a severe course and had to be opened and curetted twice. Into the other incipient furuncles, — perhaps a dozen or more, as they appeared from week to week, — I injected styron and checked them at once. Finally with tonics and general treat- ment the malady subsided. 86 CLINICAL TALKS There is another method of treatment which our next patient illustrates. He is a medical student who kindly offers himself for our in- struction. Two months ago he had a slightly septic finger, which healed without trouble, but he became "run down " and developed a crop of boils on his left arm. They were treated by his friends and the surgeons in various dispensaries, where he kept at his work. They were opened, injected, poulticed, time after time, but continually recurred until he became discouraged and his life became a burden. I had seen him several times, but was unable to check the process, and there seemed to be noth- ing for it but to send him away on a long vaca- tion. About ten days ago when he came here to consult me I determined to take a leaf from the book of my friend Dr. Burrell and try the effect of a carefully applied Gamgee dressing. At that time the forearm had on it three incipient boils and the healing scars of a half-dozen others. The arm was carefully disinfected, wrapped in absorbent gauze, and put up, from fingers to shoulder, in our wadding and mill- board apparatus with firm compression. A sling, of course, completed the equipment. That dressing was put on one Friday and remained undisturbed until the following Tues- day. I then removed it, to find the arm clean ON MINOR SURGERY 87 and shrunken, the little red boils shriveled, and the old scars practically sound. As you see to-day, the patient is entirely well, no new trouble having appeared in the past week. I shall now allow him the free use of his arm. That was an interesting experiment, and cer- tainly it shows in a most striking manner the ever-present value of our familiar first principles — support, immobilization, elevation. When a boil has developed fully, or "come to a head " as the saying is, the treatment is very simple and obvious. There is then no special interest in it. You must open it and clean it out. Cocainize it first, of course, by one or two deep injections along its borders. You may make a conical incision or, what is better, you may excise a little cone at its apex, about half as large as a silver dime. This excis- ion will usually bring with it the core. Then scrape the cavity clean and drain it with a bit of gauze. For a day or two a creolin poultice will be a great comfort to the patient; after that, until the wound is healed, our cotton dressing is convenient and comfortable. One little note here — never plaster a cotton dress- ing down with adhesive strapping. It is dirty and ineffective, compared with collodion, and the taking-off process is painful. The collo- dion dressing may always easily be soaked off with alcohol. 88 CLINICAL TALKS You will be told of sundry other methods of dealing with boils. One man will pin his faith to internal medication and ointments and an- other to poultices and the knife, but the fact is that you must treat each individual lesion according to the indications of the case. When you have had one or two boils yourselves you will have had a valuable lession. Here, as elsewhere in the practice of our art, remember that " He jests at scars that never felt a wound." When we come to deal with carbuncles, we have a quite different problem on our hands — ■ different in the extent and gravity of the proc- ess, but not so very different in its causation and development. Let me ask you in the first place to look at these two patients, who present us with car- buncles in two stages. The first patient, a woman, has here below the occipital protuberance, and above the line of her hair, a conical swelling about the size of a silver dollar. As I part the hair and expose the swelling you notice that its apex has an excoriated look and that there are three little craters from which a drop or two of pus may be squeezed. The little mass is brawny to feel and is quite deeply seated. Take it as a whole, however, it resembles closely a boil, and ON MINOR SURGERY 89 you might readily mistake it for one. It is a carbuncle in its early stages. In comparison, the process in this man is much farther advanced. It is in the common location on the back of the neck, on the left side, below the line of the hair, and to look at appears to be as large as the top of a small tea- cup; when you come to handle it, however, it is found to be deeply seated, with a widely indurated base nearly as large as your palm about it. It is flattened at its top and has a half dozen little craters from which pus oozes and bits of white sloughs protrude. That is a large carbuncle beyond any mistake. Both patients are debilitated — the woman from a week's pain and discomfort, the man from nearly three weeks of a similar experience. Both cases are uncomplicated, so far as we can ascertain. The urines are free from sugar; both patients are in their prime and of previous good health. If you have a properly developed curiosity you will ask, What is a carbuncle and wherein does it differ from a boil? Billing's Dictionary defines carbuncle as "A circumscribed inflammation of skin and subcutaneous connective tissue, terminating in a slough." More than that, it is usually a gangrenous inflammation. It begins on the skin as does a boil, but it spreads much deeper 90 CLINICAL TALKS and, as you would expect, it is produced by the staphylococcus pyogenes albus and aureus. Do not confuse this process with anthrax, as did Billroth and the older pathologists. An- thrax has many of the appearances of car- buncle, but it is far more rapid, it has a wide reddened zone about it, it has not the charac- teristic elevated flattened surface, it is nearly covered with a gangrenous eschar, and it is caused by the bacillus anthracis. Our characteristic carbuncle begins then as a superficial skin inflammation about a hair follicle or gland, and works rapidly downwards along the columnce adiposcB into the connective tissue: there it spreads rapidly, involving other columncB and other glands, pressing upwards all the time, elevating the overlying skin, find- ing numerous points of exit and causing exten- sive necrosis of the connective tissue which it involves. It is usually a local process, but very rarely it may destroy the dense aponeuro- sis of the underlying muscles and extend widely to other structures. When we find it in its usual seat on the back of the neck we need not fear it greatly, for tough structures limit it below, but when situated in regions of greater vascularity and more delicate composition, as on the cheek and lip, it may spread rapidly, cause serious disfigurement, and even threaten life. ON MINOR SURGERY 91 Now, gentlemen, let me say a very decided word about treatment in these two cases before us. There is but one method for you, and that method is nearly always sure and final, — excise the carbuncle. Don't dally with applications and poultices or even with the old-time deep crucial incisions. They mean delay, if not extension, of the process. All this necrotic mass in each case has got to come out. If you poultice or incise you do not prevent a loss of substance — substance has already been lost. It is far better thoroughly to excise it at once. Take as our best example the man with the large inflammation. He is etherized, for the operation is a considerable one, and the knife is carried cleanly and completely around the carbuncle, outside of the necrotic area. The blade bites down to the underlying fascia and the whole sloughing mass is dissected out. The bleeding is checked, the cavity packed with absorbent gauze and the wound left to granulate. When you look at the size of it you will exclaim perhaps that here is a need- less sacrifice of tissue and that the resulting scar will be enormous. You will be surprised, in the course of two or three weeks, to see how the sound parts have come together, and how trifling, after all, will be the evidence left of the great wound. You will be interested also to hear the patient's own account of himself to- 92 CLINICAL TALKS morrow. The old incisions gave but little relief at the time; the excisions are followed by an almost immediate reaction; and when next this man comes in I expect to hear from him that he has passed a good night, has eaten a hearty breakfast, and is practically free from pain. The woman I shall treat in similar fashion, but the resulting wound will be small and she will experience little inconvenience except from the loss of some of her back hair. Don't coquette with a carbuncle. Cut it out as you would a cancer, and you will neVer regret it. LECTURE IX BUNIONS, INGROWING NAILS, CORNS, AND WARTS Gentlemen : I have chosen for the subject of this exercise a Httle collection of seemingly trifling lesions; but to the victims they are not trifling and they are very often maltreated. Bunion is a condition so frequently associ- ated with hallex valgus that I am prompted to call your attention to an etymological jest. Hallex valgus, an extreme deformity and out- ward displacement of the great toe, was for centuries called hullux valgus. As such you will find it described in all the books on sur- gery. So far as I know, Dr. Robert H. M. Dawbarn, of New York, was the first to point out the error, and that was only last year. The word hallex is itself archaic. It means literally a scoundrel; and you shall search your diction- aries to find, at last, "Allex (hallex) in Isid. Gloss, est pollex pedis." However all that may be, bunion is a good Greek word. A bunion is an inflamed bursa, situated usually to the inner side of the meta- tarso-phalangeal joint of the great toe, and if 93 94 CLINICAL TALKS it becomes inflamed it makes trouble. Folk who go barefoot or wear sandals do not have bunions, but if you put a foot into an ill-fitting boot and crowd it forward, the great toe will feel the impact and be thrown outward across the second toe. Sometimes the deformity is so extreme that the great toe appears to be at right angles to the axis of the foot. When this deformity takes place, as you can readily see in the man here under inspection, the toe is partially dislocated at the metatarsal joint, and upon the knuckle so formed comes the constant pressure of the side of the boot. Here lies the bursa over the knuckle and, as a result of the pressure, it becomes irritated, thickened, and inflamed. You see the condition is a compound one, both bone and bursa being involved. In this present case we have an advanced stage of the disease, and the operation which I shall now do will illustrate the anatomy. I make a sweeping crescentic incision about the dorsal side of the joint, and this flap, which is four inches in diameter, I turn down upon the sole of the foot. The exposed bursal sac I next open and dissect out. You see it is dis- tended with a flocculent fluid, and, as I ex- pected, there is at its base a little opening, which leads directly into the joint. This has illustrated for us a point I intended to make ON MINOR SURGERY 95 for you, namely, that you are never safe in operating hastily upon a bunion, for you can- not always tell beforehand whether or not it may communicate with the joint. Every surgeon has had patients come to him from ignorant "com doctors," who have attempted to pare off one of these bunions, with a result- ing opening of the joint and a severe septic arthritis. I hope it is needless for me to point out to you that our operation is being done under the strictest precautions. Following up the sinus, I lay open the joint, of which the ligaments are so relaxed from the inflammation that their function is destroyed, the phalanx being in a state of subluxation. The joint cavity contains some of the fluid that we saw in the bursa and the articulating surfaces are roughened and diseased; in other words, we have shown that apparently simple thing called a bunion to be an extensive dis- ease of bursa, joint surface, and bone. There is no possibility of success from palli- ative measures in this case. The toe cannot be straightened even with the joint laid open. You can all see that the only thing to do is to excise the end of the metatarsal. This I do, accordingly, with the chain saw, and find that the normal line of the great toe now can easily be restored. The rest of the treatment follows naturally. Bleeding is checked, and the deep 96 CLINICAL TALKS parts over the joint are closed with buried cat- gut sutures, in order that the false joint at which we aim may have a firm lateral support. Those deep buried stitches are very essential for success. The skin flap is then stitched into place and the toe is held in its new straight position by a light tin splint. Over all is wrapped firmly a wadding and mill-board dressing to the knee, and the patient is put to bed. By the end of the week I shall take the dressing down and hope to show you a soundly healed wound. This case was an extreme one. Hallex val- gus has been its conspicuous feature, but here are a couple of simpler cases which admit of simpler treatment. Both have a slight out- ward bend of the toe and an inflamed tender bursa or bunion on the inner side. This first patient, the woman, has a toe which is easily pulled back into place. I shall content myself, for the present, with ordering a proper pair of broad, square-heeled laced boots, with straight sole on the inner side. Over the bunion I fit this piece of felt, cut like a large corn plaster. That will protect the bursa from pressure, and the properly made boot will allow the slight deformity of the toe to correct itself. These cases are frequently associated with a breaking- down of the longitudinal arch of the foot and a consequent flat-foot, but that is another story. ON MINOR SURGERY 97 Our second patient, the man, has a hallex valgus and a bunion similar to the woman's, but the toe is not so readily pulled into place. For him I have had a hard rubber spoon splint arranged. The bowl of the spoon has a handle at either end. When the padded bowl is laid over the bunion, the upper handle extends along the side of the foot and the lower along the toe. Now with the upper handle strapped into place I pull the toe inwards toward the lower handle and so correct the deformity. By his wearing this simple apparatus for a few weeks, and by the fitting of a proper boot, I hope permanently to correct the deformity. Another crippling affection of the foot is ingrowing toenail. This also is a disease pe- culiar to civilized peoples who are boot wearers, and is not seen in those who go barefooted. Years ago an old army surgeon told me that he had no trouble with ingrowing toenails among his men after he had taught them how properly to trim their nails. They were to cut them straight across instead of making a rounded corner. I have found that simple ma- noeuvre to be a valuable prophylactic measure. The common seat of ingrowing nail is on the outer side of the great toe. As with bunion, it is due to ill-fitting or tight boots. This young woman illustrates the usual story. About a year ago she noticed that the outer side of 98 CLINICAL TALKS her toe began to feel sore. It was red and tender. To relieve the discomfort she trimmed the nail down on the side. That answered well enough for three or four days, but by the excision of that strip of nail the pulp was given so much the greater latitude for bulging in- wards. It continued to encroach upon the nail, became irritated and eroded by the rough nail edge, took on the characteristics of a chronic ulcer, and threw out exuberant granu- lations, which now overlap that side. You see that the part is exquisitely sensitive to pressure, and that a little pus exudes from under the granulations. Nothing short of an operation is to be done. Here palliation will be useless. There are two or three operations of value. I will tell you of two of them and then do a third. Cotting's operation was devised by a well- known Boston doctor, recently dead. It con- sists of passing the knife, at right angles to the plane of the nail, into the pulp, and shaving off the whole of the soft parts together with a narrow sliver of nail on that side of the last joint of the toe. The wound is left to granulate and a contracted scar instead of normal pulp is the result. Ingrowing nail cannot occur again there, for there is no pulp for it to grow into. The operation is radical and effective, but leaves the patient with a sore toe for weeks. ON MINOR SURGERY 99 Then there is a similar operation which con- sists of cutting out a "piece of pie" as it were from the pulp and sewing up the hole. In this patient's case I prefer to do a good old operation which has the advantage of' simplicity. The toe being cocainized, I seize the nail deeply and firmly with a strong pair of plying forceps, and twist it out entire; then I curette off the granulations. At the end of several months, when the new nail has grown out, the wounded pulp will have healed and shrunk, and the patient will then be as though no trouble had ever been. The operation is simple, the laceration is slight, and the result- ing incapacity of very brief duration. A simple vaseline and gauze dressing is all that is re- quired. I must say one word, and an important word it is, about palliation in the incipient cases. Palliation means properly fitted boots and the packing of cotton under the nail. If you pack skillfully you may so treat a pretty bad case. Few men do so pack. Don't roughly and quickly thrust in the cotton. You will grievously hurt your patient and you will not get the cotton in. With the patient's foot on your knee, take a strand of absorbent cotton, lay it by the side of the nail, use the back of a narrow-bladed knife, and gently and patiently with a succession of pushes insinu- loo CLINICAL TALKS ate the cotton under the edge. The patient will experience prompt relief. Repeat the performance once a week until you establish a cure. I feel almost as though I should apologize to you for saying a few words about such trifling things as corns and warts, but you will be asked to treat them and you may be at your wits' end for a remedy. A few months ago a young fellow from the college in Cambridge came to me complaining that he had run several splinters of wood into his foot when walking barefooted on the ' 'float " at the boathouse. He had pulled out two splinters half as long as his little finger, but a third had been healed in and caused him constant pain in walking. I examined the foot and could distinctly feel the foreign body, as large as a medium penknife blade, deep under the skin at the base of the second toe. There seemed no reason to doubt the presence there of a splinter. I made an incision deeply into the foot and went down for nearly an inch through a stratum of tough callous, until I reached normal tissue. There was no splinter there. The seeming foreign body was nothing but a great callus, which I excised, and so cured the lad of his painful foot, — but I had learned my lesson. This callosity was of the nature of a corn, ON MINOR SURGERY loi which is made up of a circumscribed excessive development of the epidermis and of a central portion or core. The cqre extends quite deeply into the tissues, in the form of an inverted cone, the base being directed outwards, appear- ing on the surface as a rounded area, the apex of the cone resting on the papillary layer of the corium and causing pain when pressed upon. In this case I performed a radical cure in the only manner which is possible, namely, by excision. Nothing else will do it. The "corn doctors" do not wish to cure. Their palliative measures merely relieve pressure for a time, but the patient returns repeatedly for further treatment. After all, few patients will consent to so radical a measure as excision, especially with the prospect, if they are not careful, of a fresh com developing about the site of the scar. So the sufferer comes back again and again to parings and plasters, and will continue so to do as long as boots are worn and com doctors abound in the land. Finally, as regards warts, there are several facts which you should bear in mind about them. There are four principal varieties: The ordinary homy warts of children (Verruca Vulgaris), the smooth multiple warts on the faces of old persons (Verruca Senilis), the little wormlike warts which we see hanging from the I02 CLINICAL TALKS lids (Verruca Filiformis), and lastly, venereal warts (Verruca Acuminata). There is reason to suppose that all these varieties are due to some infecting organism, though this is not definitely proven. The common wart of chil- dren, seen mostly on the hands and fingers, may appear and disappear in an inexplicable manner. It is composed of a papilla contain- ing a vascular loop; this is covered by a very much thickened horny layer, which in turn is covered by an hypertrophied rete. The little boy before us has three such horny warts on his fingers. One I pare down with a sharp knife and touch the base with the nitrate of silver stick; the second, after paring, I touch with nitric acid; and to the third I apply this mixture of salicylic acid, the important ingre- dient of most of the patent "wart cures." It contains salicylic acid, 5ss; cannabis indica, extract, gr. v; flexible collodion, §7i. This is painted on the wart twice a day for five days until the growth becomes necrotic. The finger is then soaked for fifteen minutes in hot water, when, if all goes well, the wart will drop off. The soft flat warts of elderly persons are permanent and are not especially disfiguring, but they have this important fact connected with them, that they may become epitheliomata of a malignant type. The patient may pick at one until it bleeds, or he partially dislodges it, ON MINOR SURGERY 103 when he finds that it does not heal; that the Httle ulcer, so formed, spreads, and that he is concerned with a troublesome sore. When you see such an affair, cut it out first, and then let the microscope settle its exact nature. Those offensive looking filiform warts which you see hanging from the lids and necks of your patients may be very simply treated. A snip of the scissors and a touch with the lunar caustic suffice for them. Then there are those venereal warts which are seen upon the genitals and are due to sexual contact. The patients are often much fright- ened and think the warts are indicative of seri- ous venereal disease; but you can assure them that such is not the case. The growths will disappear if washed persistently with a solu- tion of tannin in alcohol, one drachm to three ounces; the wart is then dried and dusted with salicylic acid. After all is said, however, these various forms of warts seldom make trouble and their treatment may be regarded as a very subordi- nate branch of cosmetic surgery. LECTURE X MASSAGE Gentlemen: We began this series of talks by describing the value and effect of immobili- zation. In this final exercise I propose saying some- thing of the value of motion in certain inju- ries, of motion in a limited sense only, — mas- sage. That is a subject about which there has long been much misconception among sur- geons, and even to-day this useful therapeutic measure is availed of less than it deserves. Massage is no new, fanciful, or untried thing. It is one of the oldest practices in medical his- tory, and is referred to not only by the earliest writers on surgery, but by poets who wrote long before medical literature began. If a boy bumps his shin he rubs it, if a dog bruises his foot he licks it. There you have nature prompting to a primitive massage, the uses of which have been elaborated into the skillful manipulations of our modern experts. The practice was in bad odor for long in this country because of the preposterous claims of 104 ON MINOR SURGERY 105 its ignorant exponents and the frequent danger they inflicted upon unsuitable cases. In the course of years all that was changed: educated men, many of them trained in Sweden and France, took up the practice; the operators, both men and women, came to see that their work was as assistants to surgeons and not as their rivals, until to-day we find a considerable number of such competent persons in every community. Lately there has developed a curious outcome of these conditions. A so- called "school " of medicine has grown up. Its followers apply to themselves the meaning- less term " Osteopathists " and they essay on their own responsibility various forms of mas- sage. It is needless to say that these ignorant persons make serious errors and do harm, and doubtless they will reach the limbo where thou- sands of preceding charlatans lie buried; but meantime they bring real distress upon our honest massage friends, whose business they are cutting into, as I am told. S,tudents often ask me how they can learn about the methods of massage and whom they shall employ, and I find there is much miscon- ception as to the limits of its usefulness. A common error also is to suppose that any nurse or orderly can learn to give it well after a short course of instruction. I believe, other things being equal, that the best masseuse may be io6 CLINICAL TALKS developed out of the trained nurse, but I must tell you earnestly that the best masseuse can remain the best only by constant practice. The tactile sense required is quickly lost if allowed to rust, and the strong, lithe muscles of the skilled workman become inexpert and feeble when long unused. Constant practice is as essential to the masseur or masseuse as to the pianist, the artist, or the football player. The professional model will pose immovable for an hour, if need be, before the "life class " in the studio; but I am told of the strong man Sandow being asked to pose in one of our art schools recently, and how, after enduring the strain for ten minutes, he was forced to drop his arm in exhaustion and chagrin. The aver- age nurse can give excellent rubbings and fric- tion when required, but when you want proper, expert massage, you must go to a specialist who does nothing else. I have no intention here of giving you a dis- sertation on massage, nor have I the time or requisite knowledge; but I do wish to point out to you and to illustrate some of the condi- tions in which massage is of value in surgery. One of the commonest of injuries — an injury for long a reproach to our art — is sprained ankle. It was the practice up to ten years ago — and the practice is still followed by the indifferent — to immobilize sprained joints. ON MINOR SURGERY 107 The result was that patients so treated were tied to crutches for weeks or months, the time depending on the severity of the sprain, — and after the splint and crutches were thrown aside they limped about as cripples for an indefinite period. It used to be a common saying that a man must expect to feel his sprain occasion- ally for the rest of his life, even if he be not left with a joint permanently stiff and painful. That such were the results sometimes seen, every surgeon of fifteen years' experience can tell you. A recent writer has said: "Suppos- ing a prize of ten thousand dollars were offered for the quickest way to make a well joint stiff, what more effectual means could be resorted to than first to give it a wrench or sprain, and then do it up in a fixed dressing so that the resulting imflammation would have an oppor- tunity of producing adhesions of the parts? "^ The man whom I now show you slipped from the curbstone and * ' turned his ankle ' ' while running for a street car yesterday, and on rising found himself unable to stand or walk without agony. He was carried home and shortly after the removal of his boot found that his ankle was swollen, discolored, and very painful. This morning he came here on crutches for treatment. The one important lesion which we have to 1 "A Treatise on Massage," by Douglas Graham, M.D. io8 CLINICAL TALKS distinguish from simple sprain of the ankle is Pott's fracture — which you know to be a fracture of the fibula just above the malleolus, with eversion of the foot and rupture of the internal lateral ligament. Palpation in this case shows us no such fracture, and the x-ray plate which I have had taken demonstrates sound bones of the leg and tarsus. But what do you see and feel? The foot is swollen and boggy, especially over the internal malleolus, and the skin is stained a pale yellow from extravasated blood and serum. Doubt- less the man violently wrenched his foot, bruis- ing the synovia of the joint surfaces, stretch- ing and bruising the tendons and tendon sheaths, and tearing a few of the fibers of the lateral ligament. As a result there has been a certain amount of escape of blood from the damaged soft parts and a serous exudate, stimulated by the increased flow of blood to the part, in nature's primary attempt to repair damages. The exudate has infiltrated the tis- sues, with this resulting discoloration. As time goes on the exudate will settle out more and more towards the surface and the staining of the skin will become darker, until by the end of four or five days you shall see the skin over the dorsum deeply pigmented and the ecchy- mosis, following the tendons and muscle inter- spaces, appearing well up on the calf. ON MINOR SURGERY 109 Here then is our problem: Shall we leave all this exudate to remain quiet and to organize and cause adhesions of tendon and joint sur- faces, thus impeding the circulation and im- pairing the nutrition of the parts? or shall we endeavor to remove it and, by stimulating the circulation, promote repair and the reestablish- ment of function? I have told you of the results of the former practice. The masseur will now demonstrate the alternative. The patient's leg is bared to the hip, so that there shall be nothing to constrict or impede the circulation, as he lies upon the examining table. You see how the operator begins his manipulations gently and at a distance from the joint. I think it a pretty sight to watch the work of an expert. He kneads and rolls the muscles of the calf, urging always the return flow of lymph and venous blood away from the ankle. Shortly the circulation begins to im- prove. The puffy, indurated *feel" of the leg is less pronounced and the pain diminishes in the area worked upon as the exudate is forced along into the lymph spaces where the stimulated current is beginning to take it up and carry it on into the general circulation. Gradually the manipulations are carried into the region of the damaged joint; the toes, the sole and the dorsum of the foot receive their share of attention, until as you see, we are now actu- no CLINICAL TALKS ally rubbing and kneading upon the joint itself, where half an hour ago the pain and tenderness were so great that the patient could scarcely endure the weight of my examining hand. Having thus kneaded and stimulated the parts, and diminished the pressure so that the painful distention is no longer so apparent, the foot is put up in a carefully applied flannel bandage, from toes to knee, and the patient allowed to walk with the aid of his crutches. You see he finds that he can now bear some weight upon his lame foot. This treatment will be repeated daily for a week or ten days, by the end of which time I hope to be able to discharge him practically well. You must bear in mind that complications may be looked for in these injuries and may call for treatment. One of the commonest of them is acute articular rheumatism, in those persons who are given to that affliction; for you must remember that rheumatism, like tuberculosis, is wont to attack the parts weak- ened for resistance. I always bear this possi- bility of rheumatism in mind, and during the convalescence from sprains I forbid alcohol and look carefully to the patients' general con- dition, especially to his secretions. That ques- tion of tuberculosis is an important one also. We all know how frequently the development of a localized tuberculosis may be traced appar- ON MINOR SURGERY iii ently to some trauma, and I call your attention to the fact that a sprained joint, which remains unsound for long, especially when treated by the old-fashioned immobilization, gives us excellent conditions for the subsequent development of a chronic infection. You can well imagine how such a joint, illy nourished, anemic, with an impeded blood and lymph current, partially anchylosed and associated naturally with flabby, atrophied muscles, presents an admirable seat of lodgment for tubercle bacilli. The organ- isms, as you know, begin their destructive proc- ess first in the epiphyses of the bones, and from there proceed to involve the joint surfaces; so here again we find further reason in the case of fresh sprains for expediating a healing. Another lesion which furnishes us with an opportunity for brilliant results from massage is dislocation. I have told you in a former talk of the value of massage in fractures, but in dislocation its use is even more satisfactory. Here is a typical case for us — a man with a subcoracoid dislocation of the humerus. He is a stout man and the diagnosis is not imme- diately apparent. You do not readily make out the flattening of the deltoid and outward trend of the humerus away from the side, but if you will practise bimanual palpation of the axilla on both shoulders you cannot fail to establish the diagnovsis. On the sound side, with one 112 CLINICAL TALKS finger below the coracoid process and the other high in the axilla, you can almost make the fingers touch through the pect oralis major, which alone intervenes. Try the same on the affected side and you will be surprised to find that, push as hard as you will, a great interval still separates your fingers. That interval is occupied by the head of the humerus, dislo- cated under the coracoid. The patient will be etherized at once and the dislocation reduced. To-morrow he will return for massage. F^r the first week this will be given for twenty minutes daily while the arm is supported motionless in a sling. The same method in general that we have seen employed on the ankle will be followed. Pain will quickly be relieved and the nutrition of the parts improved. After a week, gentle passive and active move- ments will be begun, and by the end of three weeks of such practice we hope to have estab- lished a cure. That matter of combining movements with massage in these cases is an important one. You shall find, for instance, in old shoulder dislocations which have been reduced and sub- sequently immobilized for a long time, accord- ing to the_ancient practice, wasting, weakness, and stiffness resulting. If then you attempt by massage to restore the parts you will succeed very likely in rendering the joint supple, but ON MINOR SURGERY 113 you will not increase materially the size and power of the muscles. Faradism will then help, by causing muscular contractions, but you can accomplish the same thing by active and passive movements. So remember that in all these joint injuries your massage must be supplemented by movements, in order prop- erly to restore normal function. There are numerous other conditions in which massage is of the greatest value, especially in contractures and deformities left by old injuries or inflammatory processes which have subsided. In those cases patience and faith are often required for a long time, but the final results usually justify the treatment. As to the use of general massage after major opera- tions and prostrating surgical affections, there is no time to speak except to say that I have employed it commonly in such conditions, and with the most gratifying results, for the secre- tions are thereby increased, the circulation improved, the appetite, sleep, and mental state stimulated, and the convalescence, after the patient's getting out of bed, materially and happily abridged. Naturally you will ask me. In what condi- tions is massage contraindicated? That is a question which it is difficult to answer in gen- eral terms, but I may safely say this — that wherever an active tissue-destroying process 114 CLINICAL TALKS is established, such as cancer or tuberculo- sis, there local massage is very likely to do harm. I am. perfectly well aware, after what I have said, that you may take to prescribing massage freely for lesions of all sorts and conditions, and that you are likely to be grievously disap- pointed at times. Nothing but experience will remedy such trials, for you must learn to select your cases and beyond all else you must know that proper massage is not to be had for the asking. Bad massage is worse than no massage at all. Good massage is not always easy to find. This community of ours is crowded with the spurious article. Make sure always that you have secured the best, and you will have provided yourselves with one of the most valuable of therapeutic meas- ures. In concluding this little series of talks, gentlemen, let me remind you that good sur- gery, like good literature, has certain old, salient, well-established characteristics and that it is at the same time a progressive science. We in our generation have contributed asepsis to the art of surgery, and thereby we have made possible an enormous widening of the safety zone of the operative field. But, after all, sound judgment, the skill of a handicraftsman, accurate knowledge of anatomy, appreciation ON MINOR SURGERY 115 of the nature of physiological processes, and a constant regard for the comfort of the patient are essential if you are to succeed in this most difficult, nerve-racking, exhausting, and fasci- nating branch of our profession. Date Due « / ■! -, ' / -l "^ ' • ^ RD31 M912 COLU.BiAUNWERS.VLlBRARlES(hs,.stx) "2002109387 r?,MMM:.