COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX64054896 R D33 B76 1 909 700 surgical suggest RECAP URSIGAL SUGGESTIONS Vv'Ai.TER ML BRICKNER, M, D. i :LI MGSGHCOWITZ^i^M-fo^ HARpLD,:HAXS,:;M.-©. ''':'«!»«»5:«W»53S?«*i»«^ir5e«S*>?1^^ ^ ^OSEJJ B1131. QJA nocf College of l^ffpeiciane atib S>urgeons! ILibrarp yoo SURGICAL SUGGESTIONS yoo SURGICAL SUGGESTIONS PRACTICAL BREVITIES IN DIAGNOSIS AND TREATMENT WALTER M. BRICKNER, B.S., M.D. Assistant Adjunct Surgeon^ Mount Sinai Hospital ; Editor-in-Chief. American Journal of Surgery^ New York. ELI MOSCHCOWITZ, A.B., M.D. Assistant Physician, Mount Sinai Hospital Dispensary ; Associate Editor, American Journal of Surgery, New York, HAROLD M. HAYS, M.A., M.D. Associate Editor, American Journal of Surgery, New York. THIRD SERIES new york, u. s. a. Surgery Publishing Company 92 william strfet 1909 Copyright, 1909 BY Surgery Publishing Company 7?7>33 PREFACE The flattering reception accorded to the first issue of " Surgical Suggestions," published in 1 906, and the second series, " Five Hundred Surgical Suggestions," 1907, has encouraged us to meet the demand for this little book by the preparation of a larger series. To the "Suggestions" included in the earlier editions about two hundred have been added, many of these by Dr. Hays. Dr. Percy Fridenberg has contributed to this issue several of the Suggestions relating to atf ections of the eye and ear. These brevities are presented merely as random practical observations. W. M. B. December, 1908. HEAD. 700 SURGICAL SUGGESTIONS. Transverse scalp wounds require compara- Scalp, tively many sutures, longitudinal wounds but few. Placing the skin sutures in the scalp obliquely will often control hemorrhage from a wound as well as will ligating separate vessels. If a scalp wound extends through the peri- osteum it is safest to sew the periosteal wound at once and leave the scalp unsutured for twenty-four hours. Fracture should be ex- cluded, if possible, before closing the peri- osteum. Depilatories are useful in the preparation of the scalp for the treatment of abscesses or infected wounds, when the nature of the infection or the matted condition of the hair makes shaving difficult. A small, hard, irregularly nodular scalp tumor is very likely an endothelioma. A lit- MEAD. tie section should be removed under local anesthesia for miser oscopical examination. If the diagnosis is corroborated, radical removal is necessary. Lipomata of the scalp often undergo cystic degeneration. A tumor v^^hich grossly may look like a lipoma, may show under the microscope evidences of sarcoma. Fortu- nately these sarcomata of the scalp do not often form metastases. Lipoma of the scalp may also simulate a wen. Both grow gradually, are semi-fluctu- ating and are movable on the deeper parts. Aspiration for diagnostic purposes is not a wise procedure; for if the tumor be a cyst, the contents may readily flow out through a puncture hole, making it difficult to remove the cyst wall at operation. A small meningocele may resemble a seba- ceous cyst. The previous history is important in the diagnosis. A meningocele of this char- acter is present "as long as the patient can remember" and remains about the same size; a cyst begins as a small nodule later on in life and increases in size. MEAD. A severe neuralgia at the back of the head and neck in many instances can be reheved when all other means have failed, by sever- ance of the occipital nerves. A palliative remedy is the injection of cocain over the seat of the nerve. Strong antiseptic solutions should be avoid- ed in dressing scalp v/ounds. For "wet dress- ings" Thiersch's (boro-salicylic) or Burow's (aluminum acetate) solution is sufficiently antiseptic. An easy means of holding a small scalp dressing in place consists in tying over it strands of the patient's hair. If the patient is a brunette and a small scalp dressing is applied without a bandage as above described, the white gauze should be covered by a piece of black or brown cloth, unless the patient has enough hair to conceal a small dressing. Black bandages may be used to advantage in scalp dressings on dark-haired individuals. For the retention of an application or dress- ing on the scalp a gauze cap may be more quickly applied than a bandage and, for chil- HEAD. Cranium. dren especially, it will be more comfortable and less apt to be disarranged. A single thickness of gauze (cheese cloth) about a yard long and 28 inches wide (for an adult head) is folded on its length, in the manner shown in figure 1. The gauze is then laid Fig. 1 on the head, with the long fold next to the scalp and the folded end a little below the occiput, the free end of the long fold thus hanging over the face. The free edge of the short fold is brought to a convenient posi- tion, and its ends are tied snugly under the chin (figure 2). Then the long end is lifted back over the short end and tied snugly be- neath the occiput (figure 3). The cap thus adjusted consists of three thicknesses of gauze. In determining whether or not to operate after injuries to the head, a surgical judg- ment of the case is usually better than one based strictly on the application of neuro- logical rules. lO HEAD. There is no class of cases in which a prog- nosis is so often at variance with the extent of the injury as in cranial injuries. The prognosis in such cases should, therefore, al- ways be guarded. In cases of head traumata, bleeding from the mouth or nose does not necessarily mean that the case is one of fracture at the base. The hemorrhage may be entirely due to a localized injury. In fractures of the base of the skull with bleeding from the ear it is necessary to keep the auditory canal absolutely clean in order to prevent infection of the meninges. In cases of suspected fracture of the skull, percussion-auscultation will be found a valu- able diagnostic procedure: The forehead is repeatedly tapped sharply in the median line with the middle finger, the stethoscope being moved from one point to another from before backward. If a fracture be present, a cracked-pot sound is elicited just beyond it. The corresponding part of the head on the other side should be auscultated to eliminate possible error. II HE4D. **Egg shell crackle" elicited in palpating a tumor of the cranial bones is diagnostic of sarcoma originating in the diploe. &rain. Tumors of the brain frequently simulate, in their earlier stages, diseases of the stomach. Increasing deafness and blindness should suggest an intracranial tumor, especially if facial palsy be present. When an operation is performed for re- moval of a tumor at the base of the brain, one should be careful to retract upward (pressing on the hemispheres) instead of pressing downward (on the medulla), which may paralyze the vital centers. In exploring for tumors of the brain, the best guide for determining an isolated hard- ness is the finger; the use of a needle is very deceptive. In cases of brain tumor lumbar puncture may cause sudden death. Car. A furuncle deeply situated in the external auditory canal gives signs that may be mis- 12 MEAD. taken for mastoiditis. Great pain when the concha is moved about, will serve to differ- entiate it from the latter. Don't incise every furuncle of the audi- tory canal. Tampon with a wick of cot- ton or gauze saturated with liquor Burowii (acetate of aluminum), resorcin-alcohol, or balsam of Peru, and wait until pain has dis- appeared. Hot applications may be needed. A furuncle pointing and threatening to burst may be opened with a superficial cut. Avoid wiping the pus along the canal, as the result is almost inevitably a fresh crop of furuncles. Pain in the ear, increased on traction of the auricle, with slight diminution, if any, of hearing, suggests a furuncle in the meatus. Introduce the speculum with great care. The probe will often reveal a point of marked tenderness. One should not try to force his way into an auditory canal without first making sure that the patient has no disease of the external ear. The examination under such circum- stances will only aggravate the condition. 13 MEAD. Severe and repeated headaches may be due to the unsuspected presence of otitis media, with or without mastoiditis. Sudden one-sided diminution of hearing after bathing may indicate nothing more seri- ous than water in the ear, or a plug of wax which has swelled up and obstructed the canal. If no means of syringing is at hand, the instillation of ether and alcohol, equal parts, will dry up the plug and often cause it to disintegrate, with a corresponding im- provement in hearing. Swollen seeds, peas or beans in the external canal can be treated similarly. Don't pour hot oil into the ear to relieve pain. Heat can be applied much better in a hot mixture of glycerin, alcohol and water, which will not turn rancid or clog up the ear, and can be removed by syringing with water. A towel or large pad of gauze wrung out in boiling water and closely applied over the ear, covered with oiled silk or rubber tissue, is better than a hot water bag. A neuralgic pain in the region of the ear, should suggest a careful examination of the teeth for caries or alveolar inflammation. 14 MEAD. Three or four drops of peroxid of hydro- gen in the ear followed live minutes later by thorough syringing with a solution of boracic acid or bicarbonate of soda, will readily re- move impacted cerumen. In cases of unaccountable fever, especially in children, never fail to examine the ear. Tinnitus aurium, present only in the re- cumbent posture, is suggestive of aneurism of one of the posterior cerebral vessels. The history of a discharge from an car appearing a few days to a few weeks after the beginning of a slowly developing deafness in that ear, unaccompanied at any time by pain, is suspicious of tuberculous otitis media. Intermittent mucoid or mucopurulent dis- charge from the ear without pain or fever suggests nasopharyngeal disease; in children, adenoids. A bean-shaped pulsating swelling just be- low the mastoid apex, in cases of mastoiditis, may be only a lymphatic gland, but it may also be a thrombosed jugular vein. Its nature 15 HEAD. should therefore be determined before the operation is concluded. "Paracentesis" is a misnomer. The drum should be slit from below upwards and near the posterior margin, throughout its entire ex- tent. In withdrawing the knife it may be al- lowed to cut deeply into the upper canal wall near the drum (internal Wilde's incision). An old, narrow Graefe cataract knife is an ideal instrument for opening the drum membrane in otitis. Ethyl chlorid marcosis is the best for this brief operation. Irrigation of the ear with a warm boric acid solution (108° F.), is an excellent pro- cedure if there is a discharge of pus. But irrigation of the ear just after a paracentesis of the drum or when there is only a serous discharge, merely predisposes the mucous membrane and the mastoid to greater infec- tion. Pain and tenderness behind the ear is not always indicative of mastoid disease. One should not forget to look for pediculi in the scalp, for they often lead to an infection of the deep cellular tissues in this region. i6 HEAD. The cessation of a purulent discharge from the ear should not be taken as a sign of cure. The pus may have found its way into the mastoid cells. Persistent suppuration in a mastoid wound in most cases means dead bone at the bottom of the cavity. During mastoid operations always sever with scissors any fragment of tissue attached to a bit of bone loosened with the chisel or rongeur, before removing it. The tearing out of a fiber of the sterno-mastoid muscle, for example, will open a channel of infection in the neck. If the zygomatic cells are thoroughly laid open, one frequent cause of persistent sup- puration requiring secondary mastoid opera- tion, may be avoided. A persistent elevation of temperature after a radical operation for mastoiditis should lead one to suspect the possibility of a com- plicating brain abscess. If the fever shows wide fluctuations of temperature a sinus thrombosis is more probably the cause. 17 MEAD. Nitrate of silver may be attached in full strength to the end of a probe, as for appli- cation in the middle ear, by heating the tip of the instrument and pressing it into the stick of caustic; a little of the latter will melt and form a bead on the probe when it cools. Eye. Cystic swellings at the external angle of the eye are usually dermoids. In some cases they communicate by a small opening with an intracranial sac. An opaque growth on the eyeball in a child is likely to be a dermoid growth — that is, a growth of skin epithelium on the con- junctiva. A stye is often most easily treated by the removal of the hair in the infected follicle and the subsequent application of iced boracic acid compresses. Clipping the lashes close before ophthalmic operations renders the first dressing easy, as the lids are not glued together, there is no re- tention of secretion, and, accordingly there is less danger of secondary infection. i8 HEAD. A hyperdermatic injection of morphin, gr. 1/6, about a half hour before a major eye operation, such as cataract or iridectomy, will keep the patient quiet and make the extrac- tion calm, and free from pain. There is no danger of sudden motion of the head, and the tcchnic is more exact and rapid. A one-sided conjunctivitis or irritative con- dition, with tearing, photophobia, and lid- spasm should always suggest the presence of a foreign body on the cornea or behind the lid. In the latter case puffiness of the upper lid develops very rapidly and is a diagnostic aid. A dark body is best seen against the iris; a light one, against the pupil. The patient's eye should be turned accordingly. In looking for a foreign body on the sur- face of the eye, examine the tear-points with care. An incarcerated lash or cut end of hair may be the cause of the trouble. By pressing lightly with the flat end of a wooden toothpick in the region of a foreign body on the cornea, it will often come away. The conjunctiva should first be anesthetized with a solution of cocain. 19 HEAD. After the extraction of a foreign body from the cornea, a drop of castor oil be- tween the lids will ameliorate the pain. The sensation of a foreign body in the eye may be provoked by the presence of a small tarsal tumor. "Black eye," developing in an infant, without any history of injury, should always arouse suspicion of scurvy (Barlow's dis- ease). It is generally distinguished by lack of swelling, absence of bruise or redness of lids, and rapid gravitation of the blue dis- coloration to the lower lid and cheek. The orbital hemorrhage may take place on the other side, after a short interval. Recurrent attacks of inflamed lids, con- junctivitis, or corneal ulcer in one eye, suggest an infected lacrimal sac. Pressure over the inner canthus will generally cause muco-pus to present in the puncta. Small incised wounds over the eyelid are very prone to infection. Instead of sewing up the wound immediately, put on a wet dressing and wait twenty-four hours. 20 HEAD. Constant lacrimation with no other signs or symptoms may be due to a chronic dacryo- cystitis. Removal of the lacrimal sac will often efFect a cure. Frequent applications of tincture of iodin on a "tooth-pick" swab will often heal a corneal ulcer where other means fail. A periostitis at the margin of the orbit may resemble a cellulitis. It is often of syphilitic origin. When a patient complains of a pain in the eye with epiphora, don't always think it is due to conjunctivitis. The cause may be a beginning glaucoma. When there is a perforating wound of the cornea, necessitating enucleation of the eye, the wound should be closed so that the eye- ball does not collapse during the operation. The most stubborn and inflamed iris will yield and the pupil dilate if a leech be ap- plied just back of the lid-fissure, and a small crystal of atropin be placed in the conjunc- tival sac. Avoid systemic poisoning by pres- 21 HEAD. sure over the inner canthus with the tip of the finger, occluding the tear-ducts and pre- venting the atropin-laden tears from running down the nose and being swallowed. Marked exophthalmos with a purulent iritis may be an embolic condition (metastatic cho- roiditis) due to septic infection, e. g., of the uterus, as after an induced abortion. A difi^use swelling of the orbit, moderate exophthalmos, intense pain and tenderness and marked edema, mean an infection extend- ing deeply into the orbital planes. Unless early treatment is instituted, the eyesight may be lost, or the infection may extend along the course of the optic nerve resulting in menin- gitis or sinus thrombosis. Wherever there is fluctuation, early incision is necessary; and free drainage of the infected area is of para- mount importance. Wolfe grafts for the lids or for an artificial socket must be made very large to allow for shrinkage. Allow an extra half inch for each inch in length and width of the defect to be covered. 22 HEAD. In prescribing eye-drops, order a dropper to be placed in the bottle in place of a cork, as a stopper. It will always be at hand and always clean, and the solution will not be contaminated. An old Beer's knife that has been ground so often that it is of no use for corneal in- cisions is excellent for opening styes or cha- lazia, and a small straight keratome, on ac- count of its double edge, is far better than any scalpel for splitting the lid margin in entropion and trichiasis operations. Avoid bichlorid of mercury solutions in eye work, as much as possible. After cocain has been used, they may cause a permanent opacity of the cornea. After using a cocain solution on the eye, be sure to keep it well irrigated, or protected by a bland ointment, or bandaged, to pre- vent drying and subsequent erosion. After iridectomy for glaucoma the pupil of the sound eye should be kept contracted by pilocarpin for at least a week, but not bandaged, for it should be open to frequent inspection. 23 HEAD. After using a mydriatic in an adult, instil pilocarpin I %, and keep the patient under observation until the pupil contracts. Test the vision carefully in every case of ocular injury, even if it is apparently noth- ing but a "black eye." When a grey or blue eye turns brown and loses sight, after an injury, one may be al- most sure of the presence in the globe of a chip of steel or iron that is slowly rusting (siderosis). A large pupil in an aged patient is a dan- ger signal, suggesting glaucoma with insidious onset. Nose. Severe pain in the orbit or even in the eye itself should make one think of frontal sinus infection, especially if there is, or re- cendy has been, a nasal discharge. Marked localized tenderness will soon confirm the suspicion, if the disease exist. A diagnosis of supraorbital neuralgia should not be made until frontal sinusitis has been carefully excluded. 24 MEAD, A persistent, chronic discharge from the nose should lead one to suspect chronic dis- ease of the frontal or other accessory sinus. Transillumination is a method of corrob- orative value only in the diagnosis of acces- sory nasal sinus disease. By itself it is of small diagnostic use. If a patient has had a nasal operation per- formed, especially if the accessory sinuses have been operated upon, severe frontal head- aches may mean thrombosis of the cavernous sinus, even if no fever be present. A large dose of antipyrin or quinin w^ill often clear up a frontal headache due to acute catarrh of an accessory sinus, by its astringent action on the mucous membrane and the consequent improvement of drainage. In every case of injury to the nose, with or without fracture, it is well to examine the septum for displacement. If displaced, it should be carefully restored, using a nasal plug, if necessary, to keep it in place. 25 MEAD. When paraffin is injected in the treatment of saddle-nose pressure should be made at the root of the nose and on both sides, to pre- vent possible embolism or the escape of the mass into surrounding tissues. Face. Non-malignant tumors of the parotid prac- tically never cause pressure effects on the fa- cial nerve. This may be of importance in differentiating them from malignant tumors. A swelling in the parotid region is not necessarily a part of the parotid gland. It may be an infection of the pre-auricular lym- phatic gland. Such an enlargement may be associated with herpes of the forehead, or it may be part of a chain of tuberculous lymph glands. The position of Steno's duct must be re- membered when operating upon the face. When paraffin is injected subcutaneously it is important to allow for increase of the size of the mass by the growth of connective tissue around it. 26 HEAD. In chronic osteomyelitis of the jaw it is better to wait months for a sequestrum to form than to operate a dozen times for the removal of necrosed bone. All swellings of the lower jaw accom- panied by a discharging fistula, and espe- cially if there be multiple fistulae, should be looked upon with the suspicion of actinomy- cosis until proven to be otherwise. A tumor in the soft parts of the cheek near a tooth cavity is often a dentigerous cyst. Syphilis may be the cause of a small tumor situated in the masseter muscle. A course of mixed treatment should always be resorted to before operation is decided upon. If a frightened or refractory child will not open its mouth, pass a probe between two teeth and back to the palate. Instantly the mouth will open and a gag may be slipped in. To determine how soon a patient's mucous membrane, e. g., of the mouth or urethra, becomes insensitive after the application of riouth and Pharynx. 27 cocain, or other anesthetic, the surgeon may employ the device of touching a little of the same solution to his own tongue, just after the application to the patient. The employment of adrenalin as an ap- plication with cocain to the mucous mem- brane of the cheek, e. g., for the excision of a leukoplakic ulcer, is not to be advised. There may be severe secondary hemorrhage. When there is bleeding from the tongue, post-operative or otherwise, and one feels reasonably sure that the hemorrhage is ar- terial, it can, as a rule, be easily arrested by passing the forefinger down to the epiglottis and hyoid bone and drawing the base of the tongue upward toward the chin. It is wrong to perform any radical opera- tion for an ulcer of the tongue without pre- liminary microscopical examination. Clinical symptoms, no matter how typical, are often misleading. A deep ulceration of the fauces or tonsils should not be diagnosed as specific without excluding acute lymphatic leukemia. 28 HEAD. The blood should be examined in all cases of gangrenous gingivitis for evidences of acute lymphatic leukemia. Before operating for pharyngeal adenoids or hypertrophied tonsils make sure that these are not merely an expression of status lym- phaticus. If they are, do not employ an anesthetic. Also determine whether the pa- tient is a hemophiliac. If he is, do not oper- ate at all. A retropharyngeal or peritonsillar swelling that is very edematous may disappear under the administration of large doses of salicy- lates. When opening a retropharyngeal or peri- tonsillar abscess in a small child, by the buccal route, have the head dependent and instruments at hand for tracheotomy. These instruments are needed but rarely, but then urgently. A feeling of discomfort in the mouth while eating may be the first sign of a calculus in one of the salivary ducts. 29 HEAD. Persistent hemorrhage after the extraction of a tooth is often relieved by the application of trichloracetic acid. If the hemorrhage does not cease after its application, tamponade of the cavity is the next best available means of stopping the flow of blood. Always examine a child suffering from chorea for the presence of adenoids. The removal of the growths in the pharynx may cure a mild case. NECK. In seeking a cause for torticollis, don't fail to examine the teeth. In all cases of torticollis, examine for caries of the spine. Perdiculosis capitis may be the indirect cause of acute torticollis by reason of a developing post-cervical adenitis. A submaxillary swelling should not be dis« missed as a lymphatic adenitis without study- ing Wharton's duct on the same side. Mas- sage of pus therefrom would demonstrate a salivary gland inflammation, probably due to the presence of a stone. 30 NECK. Examination into the nature and cause of discrete hard lympathic swellings on each side of the neck, along the sterno-mastoid, should include exploration of the pharynx and naso- pharynx for possible new growth. In all glandular affections of the neck it is quite as important to treat the source of in- fection, e. g., carious teeth, as to treat the inflamed glands. In "Ludwig's angina," the cardinal prin- ciple in the treatment is extensive incision. An incision that passes no matter how deep into the substance of the submaxillary gland proper, will prove of little avail unless the tissues within the wound have been broken up until they are practically pulpy. Have the tracheotomy instruments handy before operating upon a case of angina Ludovici. The greatest ultimate danger in cut-throat cases is the onset of a septic pneumonia. This may be obviated in a measure by closing up the pharyngeal wall, and by paying the strictest attention to asepsis. 31 NECK. In cut-throat wounds where the thyro-hyoid membrane has been severed, it is necessary, in order to restore perfect phonation and deglutition, to suture this membrane accu- rately. Avoid the use of peroxid of hydrogen in wounds of the neck. It is too apt to dissect up the loose cellular planes. The same warning applies in many cases of cellulitis of the hand or foot. In the presence of a hard, diffuse, chronic swelling in the neck having some of the ap- pearances of a malignant growth, the possi- bility that the tumor is a so-called "woody phlegmon of Reclus" must be considered. Hard subcutaneous tumors of the upper third of the neck, with signs of malignancy, are often epitheliomata arising from branchial clefts. An exquisitely tender swelling situated just above the sterno-clavicular articulation may be due to the perforation of the esophagus by a foreign body. If there are evidences 32 MECK. of acute laryngitis, with edema of the ary- tenoid cartilages, the cause may be a peri- chondritis of one of the tracheal rings or the cricoid cartilage. Any enlargement of the thyroid gland may cause paralysis of one of the vocal cords by pressure on the recurrent laryngeal nerve or may impede respiration by pressure on the trachea itself. But a laryngeal examin- ation should not be omitted, for the whole trouble may be caused by an enlarged acces- sory thyroid on one of the vocal cords. In performing operations on the neck» make the skin incision parallel to the muscu- lar plane. Do not empty a thyro-glossal cyst by as- piration before extirpating it. It is well to inject the cavity with a methylene blue solu- tion first, in order to make sure that all parts of the cyst wall will be extirpated. Another method is to first empty the cyst and then fill it with paraffin. In all operations in the left subclavian triangle of the neck, the location there of the thoracic duct must not be forgotten. 33 NECK. The best thing to do in such emergencies as air embolism is to apply compression im- mediately and pour large quantities of solu- tion, preferably salt solution, into the wound. Gradually increasing hoarseness in people past middle age, without definite cause, and with a history of pain radiating to the ear, is suggestive of malignancy. After an operation for extensive carbuncle of the neck, a comforting support may be supplied by placing under the bandage a piece of heavy manila cardboard (book-binders* board), wetted and shaped to the back of the head and neck. Tracheotomy. In urgent cases a high tracheotomy should l>e performed, not a low tracheotomy. The former can be done very rapidly; the latter requires considerable dissection. The best site for an urgent tracheotomy is through the crico-thyroid membrane. To hold the opening apart a couple of hairpins, bent at the end, may be used as retractors. 34 INECK. In the performance of high tracheotomy a great deal of room can be gained by dividing transversely the fascia that extends upward from the thyroid. After tracheotomy the air of the patient's room should be kept reasonably warm and moist. Draughts of cold air provoke much irritation. The greatest immediate danger after a tracheotomy is the possibility of a subsequent pneumonia. This can, in a large measure, be obviated by filtering the inspired air through a soft sponge saturated with warm one per cent, phenol solution. Repeated attacks of coughing after trache- otomy may mean irritation of the posterior wall of the trachea by the tube; change the length or shape of the canula. A "tumor" of the breast occasionally proves to be only a chronic abscess. It has happened that a breast amputated for carci- noma has been found to be the seat of old abscesses only. BREA5T. 35 BREA5T. In the treatment of a breast abscess the size of the incision is not as important as its location and direction. A small incision and the proper employ- ment of a Bier-Klapp breast cup will secure exceedingly gratifying results in many cases of mammary abscess. In the presence of a breast infection that fails to heal within a reasonable time after appropriate incision and dressings, it is well to think of local tuberculosis. The appearance of pus in the breast of a woman who is not, or has not recently been nursing, is suspicious of some unusual form of infection, e. g., tuberculosis. A tender, painful swelling just at or be- yond the upper, outer border of the breast, and near the edge of the pectoralis major, is usually an inflamed lymphatic gland. In its presence it is well to look for some skin infection about the waist line, e. g., furuncles, which are not rare at this site as a result of irritation by the corset. Per contra, with a 36 BREA5T. boil, abscess, dermatitis or other infection at or above the waist line, one may be on the lookout for glandular enlargement at the point referred to. In the performance of the radical oper- ation for breast carcinoma it is important to avoid injury to the periosteum of the ribs. Multiplicity of tumors of the breast usu- ally speaks against carcinoma. Breast tumors, especially in the early stages, seldom fail to present the classical signs by which their malignancy or non- malignancy may be determined clinically. In all cases where the diagnosis is doubtful, a specimen of the tumor should be removed for microscopic study, before undertaking a radi- cal operation. Involution growths in the breast are very often cystic, even though the mass appears to the feel to be solid throughout. Carcino- matous degeneration is sometimes found in the cyst wall of these originally benign growths. 37 THOKAA. In strapping the chest for fractured rib, two points should be particularly noted : 1 . The straps should pass well beyond the me- dian line. 2. They should be applied in full expiration. One or two straps passed over the shoulder help much to secure im- mobilization. Cold abscess and lipoma often simulate each other very closely, especially around the chest. If in doubt, aspirate. Do not be too hasty in making a diag- nosis of intercostal neuralgia. With the ex- ception of pulmonary and pleural conditions, ulcer of the stomach simulates intercostal neuralgia more frequently than any other lesion. It is remarkable how frequently a puru- lent pericarditis may exist without causing many or severe symtoms. Never neglect an examination of the cardiac area, therefore, in cases of suspected sepsis. When a patient complains of dysphagia, do not neglect to examine the pericardium for effusion. 38 THORAA. Care must be taken in resecting the last true rib not to open the pleural cavity; for not only does this produce a pneumothorax, but an extensive subcutaneous empyhysema may also result. A history of attacks with symptoms of esophageal stricture and intervening periods of well-being is suggestive of cardiospasm. A satisfactory method of x-ray study of esophageal diverticula and strictures con- sists in fluoroscopy of the thorax while the patient is swallowing an emulsion of bismuth subnitrate. A skiagraph may be made im- mediately afterwards as a supplementary record. Before operating for sarcoma examine the lungs carefully. Do not operate if the pa- tient has persistent cough and blood-stained sputum (not due to tuberculosis), even though no definite signs are found in the lungs — a metastasis has developed. A fluctuating swelling appearing between the ribs may, of course, be tuberculous or syphilitic in origin, but it may also be an 39 TliORAA. extension of an intrathoracic growth, e. g., dermoid cyst of the mediastinum. In all such cases, threefore, a careful examination, by auscultation and percussion, should be made. Clear fluid in the pleural cavity is not al- ways indicative of lung or pleural disease. It may be due to a new growth of the medi- astinum pressing upon the venae cavae. A mediastinal tumor may be present for some time without other symptoms than cough, expectoration, loss of flesh and slight fever — thus simulating pulmonary tubercu- losis. A skiagraph will determine the condi- tion; largynoscopy is also helpful for ad- ductor paralysis is frequently an early sign. A slender fish bone lodged in a bronchus will usually not cast a shadow on the x-ray plate. In such a case bronchoscopy and aus- cultation are more reliable diagnostic mea- sures. In addition to a variety of moist rales, one may hear, associated with the in- spiratory or expiratory murmur, or both, a musical or vibratory note, when a bone or pin lies in a bronchus. 40 THOUAA. If a patient dates irregular or persistent cough from a time when he thinks he * 'swal- lowed" or inspired a foreign body, the fact that the physical signs elicited upon examina- tion of the chest are peculiar — different from those found in ordinary types of bronchitis — points strongly to the presence of a for- eign body. Bronchiectasis is not rarely complicated by brain abscess. The chief causative factors in peripleuritic abscesses are actinomycosis and typhoid osteo- myelitis. A careful history as to a previous typhoid and a thorough microscopic examin- ation of the pus should be secured. A peripleuritic abscess due to caries of a rib may give all the signs and symptoms of an encapsulated empyema. Aspiration of the chest usually withdraws clear fluid (an effu- sion due to the inflammatory process). A positive diagnosis can be made only by ex- ploration of the abscess cavity, when a necrosed rib may be found overlying a thick- walled abscess cavity. 41 THORAA. If the physical signs of pneumonia persist for an excessively long period, especially in children, it is wise to aspirate on the suspicion of empyema. In aspirating the chest, see to it that the syringe is in good condition before inserting the needle. Never apply the syringe to the needle after the latter has been inserted; a severe pneumothorax may result. If the syringe is found to be out of order while the aspiration is being done, withdraw the needle also and reinsert. There is one point that must always be thought of when pus has been aspirated after an exploratory puncture for either suspected empyema or liver abscess, — to make sure that the *'pus" does not come from a bron- chus. This can be determined, as a rule, by microscopical examination of the aspirated fluid. Very extensive and rapidly spreading sub- cutaneous infections may result after an aspi- ration of a foul-smelling empyema. It is therefore wise to always operate over the site of aspiration, and especially to see that the puncture wound is well drained. 42 THORAA. When operating for empyema thoracis it is a good rule to asiprate again when the pleura is exposed and before it is incised. This may save some embarrassment. The shock of evacuating an empyema tho- racis may be largely avoided by making but a small opening in the pleura (after resect- ing the rib) and applying at once several thickness of gauze. At the next dressing much or most of the pus will be found to have escaped into the gauze, and the pleural wound may then be enlarged without produc- ing shock. After operation for empyema, a cover of oiled silk or gutta-percha over the gauze dressing serves to prevent admission of air into the pleural cavity, while it will not in- terfere with the escape of air already in the chest. Indeed, a flap of rubber may be laid over the wound and fastened with a little chloroform above. This allows pus to escape from beneath it and excludes the admission of air. It is surprising how much information can be derived by abdominal palpation conduct- ed with the patient in a hot bath, the temper- ABDOriEN. 43 ABDOriEN. ature of the water being gradually raised to 105° F. It usually secures as much relaxa- tion as does the administration of an anes- thetic, sometimes even more. In addition to the avoidance of the dangers and the dis- agreeable features of narcosis, it has the im- portant advantage that the patient is able to call the examiner's attention to sensitive areas. In the presence of a tumor in the mid- line between umbilicus and pubes, the pos- sibility of a cyst of the urachus must be borne in mind. It may simulate an ovarian cyst or other tumor, or a distended bladder. Eczema of the umbilicus is sometimes merely the expression of an infected dermoid cyst at that site. A discharge from the umbilicus may be due to an infected dermoid cyst, to an ec- zema of the umbilicus, to a patent urachus (urine), to a cyst of the urachus (milky discharge) ; it may be of pus from an ab- scess within the abdomen or in the abdom- inal wall, or of feces (Meckel's diverticulum, perforated strangulated hernia, fecal abscess from tuberculosis). 44 ABDOriEIN Do not ligate tumors of the navel without making sure that the intestine is not included within the ligature. In performing paracentesis in the median line for abdominal fluid, be sure that the bladder is empty. When it is necessary to perform paracentesis in the lateral part of the abdomen, be careful to avoid the deep epi- gastric artery. Unless some other cause is evident don't fail to examine for signs of tabes when an adult complains of pains about the waist, in the back or in the lower extremities. Children who complain frequently of pain in the stomach should be examined for evi- dence of beginning Pott's disease. Such cases, treated before the development of cur- vature, usually yield very satisfactory results. In all cases of acute abdominal pain, never fail to examine the lungs and gums. The onset of pneumonia or pleurisy frequently closely simulates acute appendicitis; lead colic may simulate almost any painful ab- dominal condition. 45 ABDOMEN. Enlargement of the veins at the side of the abdomen is indicative of obstruction to the flow of blood in the inferior vena cava; dis- tention of veins about the umbiHcus sug- gests obstruction in the portal circulation. The former may be associated with varices of the lower extremities, the latter with hemorrhoids. In all cases of recurrent vomiting examine the midline of the abdomen for a small epi- gastric hernia. Catheterization sometimes makes the evi- dences of "appendicitis" or "abdominal tu- mor" vanish with the escape of the urine from a distended bladder. In cases of run-over by vehicles, if the wheels pass over the trunk from right to left the liver is the organ most commonly ruptured, whereas, if the wheels pass from left to right the spleen is more frequently injured. The hypodermatic injection of eserin (salicylate) gr. 1/30 — 1/40, during or just after an abdominal operation, will, in most 46 ABDOMEN cases, entirely or largely prevent the distress- ing tympanites that otherwise usually occurs. A pulsating swelling in the midline of the abdomen should not be too quickly accepted as an aneurism of the aorta. It may be a retroperitoneal tumor. In the presence of large masses of glands in the epigastrium, especially on the right side, examine the testicles for new growth. Large, slowly growing, slightly movable abdominal tumors near the median line, caus- ing few symptoms and not accompanied by signs of malignancy, are suggestive of mesen- teric cysts. A primary tumor of the lateral abdomi- nal region in infants and young children is usually a sarcoma of the kidney. In operating for perforating gun-shot wounds of the abdomen, find the source of any bleeding first, before attempting to suture any perforation. 47 ABDOriEN. In suturing the fascial layers of the ab- dominal wall do not take too large bites with the needle. Necrosis may occur, and sloughing of the fascia predisposes to the formation of hernia. If there is repeated vomiting and the pa- tient shows some evidences of collapse, after a laparotomy, especially after operation in the gastric region, examine for separation of the wound and prolapse of the abdominal contents. In children, in cases of peritonitis of un- known origin, examine for gonorrheal vulvo- vaginitis. A boggy, tender abdomen is often sugges- tive of a pneumococcus peritonitis. A care- ful inquiry as to a previous pneumonia or em- pyema is most important. The presence of an indefinite mass in the abdomen of a child running intermittent tem- peratures may mean a tuberculous peritonitis. A condition of euphoria is often seen in serious cases of peritonitis and should not be taken as a sign of beginning recovery. 48 ABDOriEIN A diagnosis between a tumor anterior to the rectus muscle and a tumor more deeply seated, can be made by grasping the tumor and then having the patient rise from the recumbent to the sitting posture. Tumors anterior to the rectus muscle do not escape from the grasp of the fingers during this maneuver, while tumors behind the muscle cannot be firmly held. Steady loss of weight without other de- monstrable cause should lead the physician to look for a possible malignant visceral neo- plasm. Persistent "indigestion" due to some condition not positively ascertained, should be submitted to surgical diagnosis. Excellent results may be obtained in liver abscess cases (solitary abscesses) , which drain for a long time, by applying a Bier cup over the superficial opening once a day for five minutes. One must be especially cautious in these cases not to increase the vacuum too rapidly as rupture of the vessels in the liver might easily ensue and cause seri- ous damage. Bile Tract. There is such a condition as idiopathic swelling of the liver — an acute hepatitis — 49 ABDOriEN. due to an unknown cause. The condition gradually subsides without treatment. Repeated attacks of "indigestion," not ob- viously due to some other condition, should awaken the suspicion of gall-stones. Most of the patients operated upon for cholelithiasis give a history of having been treated for a long time for "dyspepsia," and in many of these cases the correct diagnosis might ear- lier have been established. If pressure in the right hypogastrium gives rise to a referred pain in the shoulder region, the offending area is probably the gall- bladder and not the pylorus. In an attack of cholelithiasis the vomiting as a rule is not attended by relief of pain; the contrary is true in ulcer of the stomach. In differentiating between gastric ulcer and gall-stone pains, the assocation of a chill usu- ally points to cholelithiasis. If one suspects acute cholecystitis and on opening the abdomen does not find the gall- bladder enough diseased to warrant further 50 ABDOriEIN. procedure, it may be well to anchor the organ by suturing it to the abdominal wall. If further symptoms are manifested, the gall- bladder can then be opened without anes- thesia and a catheter inserted for drainage. Tenderness over the gall-bladder region, especially if accompanied by colicky pain, usually means a pathological condition of that organ. But an inflamed retrocecal appendix extending high up, hydronephrosis, acute pancreatitis, and an inflammatory condition at the pyloric end of the stomach are also to be kept in mind. Tuberculosis and cholelithiasis are only very rarely associated. Long pauses between attacks of gastric or abdominal pain speak in favor of chole- lithiasis. In the progress of a cholecystectomy, if a stone slips away after cutting through the cystic duct, and cannot be found, no great anxiety need be felt, for the stone usually comes away spontaneously in the subsequent discharge. 51 ABDOriEIN. Moderate bloody discharge after extirpa- tion of the gall-bladder, is most often due to oozing from the raw surface of the liver. Sudden, profuse, bloody discharge is more dangerous, for it means that the ligature has slipped from the cystic artery. Great pain following any operation upon the biliary tract should always lead one to suspect leakage of bile into Morrison's space. If such should be found to be the case insert a drainage tube. When operating for cholelithiasis, don't fail to examine the hepatic duct. When palpating the common bile duct for stone, make sure that a suspected calculus is not a gland. In catarrhal icterus the pulse is usually slow; in jaundice from cholelithiasis this is usually not the case. Gradually increasing jaundice without previous history of pain, or with a history of very slight pain, is very suggestive of malignant disease. 52 Before attributing enlargement of the liver to a surgical condition exclude chronic hep- atic congestion of cardiac disease. Examine the rectum in all cases of tumor of the liver. Likew^ise, before operating for cancer of the rectum examine the liver for metastasis. ABDOriEIN, Examination to determine the possible presence of cardiac disease or aneurism should always be made before passing a stomach tube. In the presence of such le- sions the tube should not be employed ex- cept as a life-saving measure in an emer- gency. stomach. A hasty diagnosis of ulcer of the stomach should not be made merely because the pa- tient has vomited suddenly large quantities of blood. If the bleeding occurs at regular intervals the possibility of vicarious menstru- ation must be considered. The occurrence after laparotomy of mark- ed distention of the upper abdominal zone, vomiting and collapse, points to acute dila- tation of the stomach. 53 ABDOriEN. It is well to remember that not all ulcers of the stomach are characterized by the classical symptoms of pain, vomiting and hemorrhage. Many patients presenting "dyspeptic" symptoms of only mild grade are afflicted with this disease, and such cases may easily be diagnosed as functional dis- orders until the persistence of the symptoms leads one to suspect the graver malady. The thirst following a hemorrhage from gastric ulcer is best relieved by small quan- tities of cocain in solution. If an undoubted case of ulcer of the stom- ach is associated with chills, in most cases it means that the ulcer is adherent to the spleen. A sudden desire for sharp, sour and spicy articles of food in a middle-aged or elderly person is often the first symptom of a be- ginning gastric carcinoma. In a case of gastric disease of doubtful diagnosis, progressive loss of weight is the most important sign in determining the prob- ability of carcinoma. 54 ABDOriEN The possibility of gastric cancer must be considered in cases of supposed pernicious anemia. In persons of middle age presenting gas- tric symptoms, the diagnosis of cancer should not be excluded because the symptoms have had a sudden onset. Such an onset occurs in a fair proportion of cases. Vomiting, secondary anemia and absence of free hydrochloric acid in the gastric juice a triad of symptoms at once suggestive of carcinoma ventriculi — may occur as a result of chronic nephritis. Especially if the urine contain no casts or albumin is the observer apt to be led astray. If a patient vomits coffee-ground material in which no lactic acid is present, one can almost always exclude carcinoma. A reasonable suspicion of the presence of a cancer in the stomach or intestine is suffi- cient indication for explorative operation. Before proceeding with a radical operation for carcinoma of the stomach, examine not only the liver but also the general abdominal 55 ABDOriEIN. cavity, especially the pelvis, and in females the ovaries, for any sign of metastasis. Do not be too sure that a mass in the re- gion of the pylorus is a carcinoma. In some cases the infiltration around a chronic ulcer is very extensive and may simulate the feel of a new growth. If a patient begins to vomit long after a radical operation for carcinoma of the stom- ach, do not jump to the conclusion that the cause is a local recurrence. It may be a metastasis in the brain. In a patient with spondylitis, symptoms simulating acute peritonitis may be due to acute dilatation of the stomach. The occurrence after laparotomy of marked distention of the upper abdominal zone, vom- iting and collapse points to acute dilatation of the stomach. It is a peculiar fact that post-operative prolapse through the epigastric wound occurs frequently in operations for malignant disease of the stomach. Such wound therefore should 56 ABDOriEN be closed with more than usual firmness and all possible precautions should be taken to guard against post-operative vomiting. In performing posterior gastro-enterostomy see that the opening in the transverse meso- colon is not so narrow that it may constrict the anastomosed segment of small intestine nor yet so large that it may permit of a possible hernia into the lesser sac. By in- serting a number of sutures between the meso- colon and the stomach wall about the anas- tomosis these possibilities may, in large part, be obviated. If within a week or two after the perfor- mance of gastrostomy the drainage tube should be expelled from the fistula, do not entrust its re-introduction to inexperienced hands. It has sometimes happened that the tube has been pushed into the peritoneal cavity, instead of into the stomach. In the presence of anemia or of faintness, without other apparent cause, inquire con- cerning the passage of black stools. The condition may result from hemorrhages due to an ulcer or neoplasm of the small intes- tine. Intestines. 57 ABDOriEIN. A gradually increasing anemia in an eld- erly person, without any other symptoms, is highly suggestive of a latent carcinoma, often in the intestine. In typhoid fever spontaneous rupture of the spleen may simulate intestinal perforation. The triad of symptoms — ^pain, vomiting and distention — ^without fever, points to in- testinal obstruction. Attacks of abdominal pain preceded by "rumbling" of the bowels is suggestive of some obstructive condition. The passage of a small amount of gas or even of feces, after an enema, does not gainsay the presence of intestinal obstruction. In an acute condition simulating intesti- nal obstruction, if a large mass can be felt in the abdomen think of omental torsion. In acute intestinal obstruction it is often preferable to relieve the immediate danger to life by tentative enterostomy or colostomy than to hunt for the cause of the obstruction. 58 ABDOriEN. Simple or multiple enterostomy, usually with prompt suture of the opening, is many times a life-saving operation in the presence of intestinal paresis, as from general periton- itis. Post-operative acute intestinal obstruction in rare instances has for its causation an in- terstitial hernia through the abdominal w^all. A mass composed of confined gut is usually present. An attack of acute intestinal obstruction, vvrith passage of blood, and in the presence of a cardiac lesion, is suggestive of throm- bosis of a mesenteric vessel. Every case of intestinal obstruction of ob- scure origin should be inquired into closely with reference to a previous history of chole- lithiasis. If a definite history of this is ob- tained, one may suspect obstruction by a gall-stone. When operating for volvulus of the large intestine, insert a rectal tube as high up as possible before attempting the reduction. The volvulus will quickly collapse and the neces- sity for evisceration will thus be avoided. 59 ABDOMEN. In infants sudden, severe colic associated with diarrhea or the passage of small quan- tities of blood, should lead one strongly to suspect an intussusception. When reducing an intussusception don't pull on the intussusceptum but push on the intussuscipiens. When a patient gives all the signs and symptoms of appendicitis, if the stools have been noticeably black, a duodenal ulcer should be kept in mind. A perforated intestinal ulcer, especially if low^ down, may simulate acute appendicitis. A very high leucocyte count with a high percentage of polynuclears, and the presence of a large amount of fluid in the peritoneal cavity, accompanied by general rigidity, may suggest the diagnosis. A palpable tumor in the umbilical region is often a malignant growth of the transverse colon. Benign growths of the mesentery are also found here. A mesenteric cyst may give the same signs as a small ovarian cyst. Mesenteric cysts, 60 ABDOMEPS. although movable, are usually attached to the ascending colon. When the colon is dilated a direct relation can be made out between the gut and the tumor. The presence of a tumor of the sigmoid flexure with symptoms of chronic obstruction does not always indicate a cancer. Such a condition may be due to a "diverticulitis." A fecal fistula may be made to heal more quickly by the application of the actual cautery. In the presence of a movable, sausage- shaped mass in the abdomen, with a his- tory of chronicity, it is well to think of the possibility of its being a case of hyperplastic tuberculosis of the intestine. This diagnosis will be rendered more likely if there are definite signs in the lungs. At the onset of an attack of acute appen- Appendix, dicitis the pain is usually referred to the gas- tric region. The cessation of severe pain during the course of acute appendicitis often means per- foration. 6r ABDOIiEIN. The twisting of the pedicle of an ovarian cyst may simulate both the symptoms and signs of attacks of appendicitis. A moderately hard, palpable mass in the right iliac region is often diagnosed as acute appendicitis with inflamed omentum around the appendix. But ileocecal tuberculosis with inflammatory exudate should be kept in mind. The tenderness in appendicitis may not be (probably usually is not) just at McBurney's point. The base of the appendix is, however, usually at, or near, that point. The site of greatest tenderness is often over the tip of the appendix. A line drawn between that site and McBurney's point will many times repre- ent the general direction in which the appen- dix is lying. In cases of chronic appendicitis, if an ex- amination be conducted with the patient in a hot bath ( 1 05 ° F. ) , the thickened appen- dix may often be felt to roll under the finger. The location of the Head zone will often decide whether a case is one of acute appen- dicitis with inflammation of the serosa or acute salpingitis. If the Head zone com- 62 ABDOriEN, mences at the level of the umbilicus, extends over to the right lumbar region and to just below Poupart's ligament, it is probably acute appendicitis. If the Head zone begins two or three inches below the umbilicus with a broad base on the abdomen and extends to a single point midway between the hip-joint and the knee, the case is probably one of acute salpingitis. In a case of appendicitis, there is great significance in the disappearance of a Head zone which had been present but a few hours before. It means that the tension on the serosa of the appendix has lessened. The natural conclusion to draw is that the appen- dix has ruptured. Sudden, marked rise of temperature a few days after an operation for appendicitis, espe- cially if attended by chills, may mean throm- bosis of the portal vein, multiple abscesses of the liver, or subphrenic abscess. If there is a sudden rise of temperature after appendicectomy, examine the rectum. A bulging of the wall of the rectum on the right side or anteriorly indicates the forma- tion of a pelvic abscess. 6-. ABDOriEN. A persistent sinus after an operation for appendicitis in the majority of cases means that a portion of the appendix has been left behind. It may also mean that an exudate has not broken down or that some foreign body has been left in the wound. One should give the sinus an opportunity to close by itself, but if it does not do so, a prolonged opera- tion is necessary. The walls of the sinus must be carefully excised, all rents in the serosa of the intestine sewed over and drain- age instituted, as there is often considerable oozing from raw surfaces. First and fore- most, the primary cause of the sinus must be found and corrected. HERNIA. It is a wise rule never to attempt taxis in cases of strangulated hernia. The only exception might possibly arise in a case seen within the first hour. All cases of hernia in which there is a history of frequent urination should lead one to the suspicion that the hernial sac contains part of the bladder. A properitoneal epigastric hernia may give no external signs. The patient merely com- plains of pain in the epigastrium. 64 HERNIA. An inguinal hernia giving signs of obstruc- tion and partially reducible, may empty into a properitoneal sac in Hesselbach's triangle, a loop of gut being compressed against the neck of the sac. In cases of strangulated hernia a simple enterostomy after cutting the neck of the sac will often save a life where a prolonged oper- ation would result in death. If a peculiar looking mass is found at the inner side of the ring in the course of an operation for inguinal hernia, do not incise or dissect it before convincing yourself that it is not the bladder. Probably the most important step in radi- cal inguinal hernioplasty is the total removal of the sac. It should be traced back to the loose peritoneum itself, exposing the deep epi- gastric vessels, the ligature or sutures to be applied at that level. To leave even a little projecting knuckle of peritoneum invites re- currence. Do not be too hasty in resecting a strangu- lated loop of intestine. It is remarkable how 65 HERNIA. frequently such loops become viable after long continued applications of hot saline so- lution. If the sutures in a hernioplasty are tied too tight or too near together, a distressing in- duration of the issues will often take place. This may be relieved by opening up the lower angle of the wound so as to let out the serum between the different layers of tissue. A glycerin dressing by its hygroscopic power will allow of speedy absorption. Examine the umbilicus and the inguinal and femoral canals in all cases of obscure intestinal obstruction. Small strangulated femoral hemiae often simulate very closely the feel and appearance of a gland, and in such cases one may be easily misled. In ligating the omentum, it is a good rule never to place a ligature around a piece larger than the width of a finger. Bloody stools after herniotomy in which omentum is amputated are usually due to thrombosis extending to the colon. 66 RECTUn. Hemorrhage from the bowel in children is not infrequently caused by a polypus in the rectum. Prolapse ani is a frequent accompaniment of bladder stone in children. Prolapse of the rectum in children usually yields to treatment by strapping the nates together with adhesive plaster, if carried out intelligently and persistently, for several weeks or months. The child should be obliged to defecate in the recumbent posture and while the strap is on. After defeca- tion the strap is removed, the parts cleansed and a fresh strap applied, all while the child is recumbent. A mass protruding from the rectum of an infant or child may be an intussusception and not a mere prolapse. Don't fail to make a digital rectal exami- nation in cases of appendicitis and in all ail- ments when the diagnosis is obscure. Nor should it ever be omitted before an opera- tion upon anal disorders. It may save the embarrassment of a subsequent discovery that 67 RECTUn. a patient's hemorrhoids, for example, were but an expression of a carcinoma higher up in the rectum. A radical operation for hemorrhoids should not be undertaken until the etiology of the piles has been determined. Some- times the cause is an obstruction in the por- tal circulation due to hepatic disease. Per contra, abscess of the liver may be due to in- fection from a hemorrhoid operation per- formed even some months before. In case of sudden pulmonary infarct, a patient should always be examined for hem- orrhoids. A thrombosis of one of the veins of the prostatic plexus may also be the cause. Bleeding from capillary hemorrhoids high in the rectum usually yields to injections of cold water, or a cold solution of tannic acid. In these cases, however, it is important to exclude the presence of an ulcer further up. If a thrombosing pile is opened before the clotting is complete, it is very apt to fill up again and may even become edematous and inflamed. 68 KCCTUn When removing hemorrhoids much atter- pain and edema may be obviated by making radiating nicks in the skin margin of the anus. To relieve the edema following a hemor- rhoid operation, apply a glycerin dressing covered with rubber protective. After an operation for hemorrhoids it is desirable to insert into the rectum a tampon canula, made by smearing with vaselin gauze layers wrapped about a piece of rubber tub- ing, about three inches long and transfixed at its distal extremity with a large safety pin. The tampon canula prevents oozing by its gentle pressure, allows any considerable hem- orrhage to show itself externally, makes the escape of flatus painless and the introduction of an oil enema easy. A moderate prolapse of the rectum with hemorrhoids may possibly be relieved by the treatment of the hemorrhoids with clamp and cautery. Blood lost at stool in the form of a jet is practically always from a hemorrhoid. 69 KECTUM. Although profound anesthesia is required to abolish the anal reflex, chloroform or ether is not always needed in order to divulse the sphincter ani. This may be accomplished painlessly, and often with fair satisfaction, under ethyl chlorid or nitrous oxid narcosis, especially if an opium suppository is intro- duced a half-hour beforehand, and a pledget of cotton wet in cocain solution is applied just before the operation. After operations upon the rectum, espe- cially after those involving divulsion of the sphincter ani, voluntary urination is apt to be inhibited for a day or more. This is espe- cially the case when stretching is done in a sagittal direction, i e., towards the urethra and the coccyx. It may save catheterization, therefore, if the stretching is done only later- ally, i. e., towards the tubera ischii. The only evidence of an acute intussuscep- tion may be the passage of a small amount of blood per rectum. One should always make a thorough rectal examination for an intussusception even high up in the small in- testine may sometimes be felt per rectum. 70 RECTUM. Stretching the anal sphincter alone will in many instances relieve an intense pruritus or a small prolapse of the anal mucus mem- brane. The insertion through the sphincters at night, for a few minutes at a time, of a coni- cal dilator (e. g., of hard rubber), of gradu- ally increasing size, is often a valuable ad- junct in the treatment of pruritus ani. When pruritus ani is caused by a local eczema it is well to remember that the latter may be seborrheal in origin. In such cases other areas of the disease, as on the chest and, especially, the scalp, should be sought for; they will require attention also, in order to effect a cure. What a patient describes as a diarrhea may be, instead, a fecal stained mucoid dis- charge due to the irritation from impacted feces in the rectum. A complaint of excessive moisture about the anal groove should not be dismissed with- out a careful examination for a fistula. RECTUn. Severe burning pain in the anus coming on during, or just after defecation, and lasting for but a short time, almost always points to the presence of a fissure or ulcer. It may be very small and thus elude all but a most thorough search. OENITO- UWNAKy TRACT, Kidney and Ureter. It is not sufficiently established that the character of the crystals found in the urine indicates the presence or identity of lithiasis in the urinary tract. When cystin crystals are constantly found in the sediment, how- ever, if symptoms of lithiasis are present, the stone is probably made up of cystin. An approximate determination of the or- igin of a hematuria may be obtained by not- ing the following points: If pure blood is followed by clear urine, the origin is in the urethra; if the patient first passes urine, then blood, the source of bleeding is probably in the bladder; if urine evenly mixed with blood is voided, the kidney is probably re- sponsible for the hemorrhage; if long, fine clots resembling worms are passed, these, usually, are from the ureter. 72 QENITO-URINAtty TRACT, A point worth remembering in the diag- nosis of nephrolithiasis is that red blood cells are almost always found in the centrifuga- lized sediment of the urine even in the inter- val between attacks of colic. In a very acid urine red blood cells may be disintegrated and appear under the micro- scope as an amorphous material. When it is important to determine the presence or ab- sence of blood in the urine it is sometimes necessary, therefore, to resort to a chemical test, e. g., that with guaiac resin. A radiographic shadow simulating that of a urinary calculus may be produced by an atheromatous plaque, as, for example, in the internal iliac artery, a phlebolith, a calcareous gland, or a calcified enterolith in the appen- dix. When skiagraphing for suspected renal cal- culus the entire urinary tract should be ex- posed, I. e., the kidney regions, ureters and bladder. Not infrequently a stone supposed to be in the kidney may be lodged in the lower end of the ureter, within reach from the bladder. 73 OENITO-URIINAKy TRACT. By a careful study of an x-ray plate it can usually be determined with fair accuracy whether a renal calculus is in the pelvis of the kidney or in the parenchyma, at the upper pole or the lower pole. In cases of renal colic do not make too positive a pre-operative diagnosis of calculus, no matter how typical the symptoms may be. It has happened very often at the time of operation that no stone is found. Fortu- nately, these cases are nearly always cured by the exploratory nephrotomy. Attacks of abdominal pain associated only with intestinal symptoms, may nevertheless be due to a renal or ureteral calculus, even though, in addition, a tender area may be palpated at a point more or less remote from the kidney regions. The perinephric space is a frequent site of metastatic inflammation after furunculosis or other septic infection. After nephrotomy, hemorrhage may usually be stopped by inserting deep mattress sutures into the kidney substance followed by super- ficial sutures of the same kind. 74 OCNITO-URINARy TRACT. If possible, always tie each component of a kidney pedicle separately, not en masse. If a stump ligature, e. g., of the renal pe- dicle, is slow to come away, the process may be hastened by fastening it taut to a piece of rubber tubing stretched across the wound. If pus persists in the urine after the extir- pation of a kidney for suppurative disease, it often means that the ureter is involved and will require subsequent extirpation. When operating upon the ureter for cal- culus or stricture, avoid undue manipulation; it is important to detach the ureter from its bed as little as possible. Hypernephroma is distinguished from the other malignant tumors of the kidney by the very early appearance of hematuria. Pyuria without symptoms is suspicious of an early tuberculosis of the urinary tract. The examination for tubercle bacilli in the urine by the ordinary method of staining, is not decisive by any means, even if the blad- der has been catheterized and differential 75 OENITO-URINARy TRACT. stains for smegma bacilli have been em- ployed. Numerous examinations with the aid of these procedures must be made, and even then the diagnosis is only a presumptive one. The only sure test is by injecting a large quantity of the sediment into a guinea- pig. 5lAdp aiwc may otherwise pass unsuspected. VJkVJAPIo. 85 reriALE generative oroais5. Don't be tempted to exclude gonorrhea because you see no bacterial or other evi- dence of vaginal or urethral infection. In women the presence of gonorrhea may not make itself known for six weeks or more, and salpingitis may be the first evidence. When the openings of the Bartholinian glands appear as two sharply defined red spots, an antedating inflammation may be diagnosed with certainty, and in a great ma- jority of instances a latent gonorrhea is pres- ent. Simple incision is not sufficient in the treat- ment of Bartholinian abscesses. They should be cauterized daily with iodin, and if they recur, excised. Furunculosis vulvae, even when it persists in spite of all other treatment, will often yield to daily scrubbing with green soap and the application of a dressing of sublimate solution. When cleansing the vagina and vulva in preparation for an operation, a soft cotton mop should be used for the vestibule; a stiff brush is too apt to bruise or lacerate the urethra and cause dysuria for some days thereafter. 86 PEMALE OENEKATIVE OR0AN5. The use of any considerable quantity of iodoformized gauze in the vagina involves the risk of a severe dermatitis of the vulva. In the case of a vesico-vaginal fistula, the vaginal opening can readily be discovered by the injection of methylene blue into the blad- der and noting its escape through the vagina. If, however, the opening communicates with the ureter, the blue colored fluid cannot be seen. In such a case, a catheter at times can be passed directly from the vaginal open- ing into the ureter. One should always examine the anterior vaginal wall carefully when there is any ure- thral discharge for it may be due to a peri- urethral abscess communicating with an in- fected vaginal cyst. Before performing curettage always make a final bimanual examination of the uterus in narcosis. The finding may determine some other form of treatment. Again, after curet- tage, before allowing the patient to get out of bed, carefully examine the pelvis for signs of a possible exudate. 87 rEMALE GENERATIVE OK0AIN5. As a final cleansing step after curettage of the uterus it is well to introduce, and at once withdraw, a packing of gauze. This brings out with it fragments of tissue not washed out by the irrigation. Sudden collapse after a curettage for sup- posed abortion may mean the rupture of an unsuspected ectopic gestation sac. A rise of temperature after a curettage may be due to a piece of gauze having been left in the uterus too long. A high temperature just after or during an abortion is evidence of intrauterine manip- ulation, especially if the discharge from the uterus is fetid. Bleeding after coitus is sometimes the earli- est sign of cancer of the cervix. Persistent bleeding or irregular prolonged menstruation is very suggestive of uterine fibroids. Uterine fibroids may be differentiated from disease of the tubes or ovaries by noting 88 reriALE generative organs. whether or not the cervix moves in the oppo- site direction when the tumor is pushed from side to side. An obstinate constipation may be due to an extreme retroflexion of the uterus, the or- gan lying in the hollow of the sacrum. Carcinoma of the cervix may remain hid- den in the lumen of the cervical canal, which is then eroded and forms an irregular ellipti- cal cavity. While the external os is closed suspicion of the serious condition present will be attracted by the foul or bloody discharge. No operation for sterility in the female should be performed without first excluding sterility on the husband's part. In case of hematocolpos and hematometra it is essential to precede all interference by a careful rectal examination in order to de- termine whether the tubes are distended or not. If hematosalpinx exists a laparotomy and salpingectomy must precede the vaginal operation, otherwise a severe peritonitis may be set up by a reflex discharge of infective secretion from the tubes. 89 TEMALE GENERATIVE OR0AN5. Mobile retroflexions that resist manual re- position are often easily and painlessly cor- rected by placing the patient in the knee-chest position and then depressing the perineum. The sudden inrush of air balloons out the vagina and this effects the desired results. In the early months of pregnancy exami- nations should be made to determine that there is no retroversion, or to treat it if it exists. A retroverted gravid uterus impacted in the curve of the sacrum always aborts. Ascites in the presence of a mass in the pelvis usually, but not necessarily, means malignancy. Avoid introducing a uterine sound in ex- aminations vv^hen pelvic inflammation is sus- pected. It may set up a parametritis. Impaction of feces in the sigmoid and rec- tum, with absorption symptoms, may simu- late pelvic peritonitis. In pulling on the round ligaments in the Alexander operation, use the fingers rather than instruments; a surer hold is given, one 90 PEfiALE OEINERATIVE OROA^5. can gauge the proper force to employ more readily, and there is less likelihood of the ligaments tearing. The sudden acute onset of abdominal pain with tenderness over the appendix region but with rigidity of the right rectus low down, is very suggestive of acute salpingitis. The diagnosis is further confirmed if there is high temperature and extremely high leucocyte count (20,000-40,000; polynuclears, 80- 90%), even though vaginal examination be negative. Twisting of the pedicle of an ovarian cyst often produces all the signs and symptoms of acute or recurrent appendicitis. An ovarian cyst with a long pedicle may be found in any part of the abdominal cav- ity. It rarely gives pain unless the pedicle becomes twisted. In such a case, a differ- ential diagnosis between it and a hydrone- phrosis is very difficult. One may suspect the true condition by the mobility of the tumor. The presence of a Head zone starting in the inguinal region and extending down the 91 reriALE GENERATIVE OROAN5. thigh in the form of a kite (tail downward) should make one examine the pelvic organs thoroughly, for the lesion very probably is in the adnexa. Do not exclude the diagnosis of extra- uterine pregnancy merely because vaginal ex- amination reveals no mass in the pelvis. The palpation of a pulsating vessel in the vaginal fornix of a woman who has skipped a menstrual period, will often give the clue to a possible ectopic gestation. In rupture of an ectopic gestation sac and hemorrhage, the patient may refer the pain chiefly to the region of the right hypochon- drium, and this may deceive the physician into the belief that he is dealing with a case of cholelithiasis. A careful history, vaginal ex- amination, and the evidences of internal hem- orrhage will differentiate the conditions. An abscess of the right ovary may give the same signs and symptoms as acute ful- minating appendicitis. If an incision for ap- pendicectomy is made, it should be of suffi- cient length and low enough down to allow of careful examination of the right adnexa. 92 reriALE generative organs. A large tumor supposedly a growth of the ovary may be a retroperitoneal mass, usually a sarcoma, having no connection with the sex- ual organs. In all cases of lumbago, especially of the BACK, chronic variety, examine the sacro-iliac joints for tenderness. Such cases may sometimes be almost instantaneously relieved by apply- ing broad strips of plaster from beyond one superior iliac spine to the other, across the back. The straps must be applied tightly and with the feet close together. A skin-lined sinus opening between the coccyx and the anus, when not very short, usually leads to a dermoid cyst situated close to the coccyx. Frequently loose hairs from the dermoid may be found in the sinus. A large abscess in the ischio-rectal region may communicate with an infected dermoid cyst at the base of the spine. Congenital paralysis of the lower limbs may arise from an internal sacral or coccy- geal spina bifida. In such cases rectal ex- 93 BACK. TIES. amination reveals the trouble and an opera- tion may afford marked improvement or even a brilliant cure. In a case of possible fracture or disloca- tion of the spine, give instructions that the patient be kept absolutely quiet in order to prevent an aggravation of the deformity. A tumor on either side of the vertebral column with a slight bulging in this region and scoliosis, is often a perinephric abscess. But if cord symptoms are present, a sarco- matous growth of the vertebrae should be kept in mind. Do not consider too lightly a history of "growing pains" in the extremities in chil- dren. These symptoms may be due to a grave osteomyelitis. Do not be in a hurry to perform primary amputations after severe traumata of the ex- tremities. First, combat the shock and pre- vent hemorrhage. Keep the wound as clean as possible; and only when the patient has quite recovered from his shock (at the end of a few days or more), perform the ampu- tation. 94 EATttEniTlE5. Pulsation in the course of an artery should not lead to the hasty conclusion that one is dealing with an aneurism. A tumor over- lying a large vessel, and also a vascular sar- coma of the bone, may simulate an aneu- rism very closely. Never incise a swelling in the course of a large artery without first making sure that it is not an aneurism. When clamping a vein in continuity se- cure the proximal end first; otherwise it will empty and may become lost to view. In acute (septic) osteomyelitis immediate operation is not too radical; in chronic os- teomyelitis patient waiting is often not too conservative — the final expulsion of a seques- trum may be all that is necessary to effect spontaneous cure. In acute, no less than in chronic osteomye- litis of the long bones, an x-ray picture is of immense service as a guide in the operation. It determines the exact locaton, extent and even character, of the disease focus, and thus it saves much unnecessary destruction of bone by the surgeon's chisel. 95 EATREMITIES. When performing amputation, arthrec- tomy, osteotomy or similar operation it is wiser to leave the constrictor in place until the dressing is partly, or entirely, applied, than to remove it after tying the large ves- sels, in an effort to secure the small ones. In the former case the snugly applied dress- ing will safely prevent hemorrhage; in the latter case, there may be an alarming loss of blood from the numerous small vessels in the very time the efforts are made to tie them all. Do not amputate an extremity for sar- coma without a previous careful examina- tion of the lungs and mediastinum for me- tastasis. Such symptoms as continued cough, a small hemoptysis or beginning dyspnea, should be regarded as highly suggestive of such a complication. After major amputations an elastic con- strictor should always be left at the head of the bed, so that the nurse can immediately apply it in case of secondary hemorrhage. A synovitis that persists despite careful treatment should arouse suspicion of tuber- culosis. 96 EATRErilTlE5. A chronic synovitis of apparently un- known origin and very rebellious to treat- ment is sometimes due to a small focus of osteomyelitis just beneath the cartilaginous surface. Suppurating arthritides do not always re- quire exposure of the joint or even large in- cisions, irrigation and drainage. Such treat- ment invites mixed infection and ankylosis. If the pus be very thin — even though of strep- tococcic origin — thorough aspiration (which may need to be repeated) and immobilization, may effect a rapid cure with perfect func- tion. Purulent arthritis and periarthritis as it occurs in small children as a complication of one of the exanthemata (often in connec- tion with trauma) is usually quite amenable to conservative, and even ambulant treatment: aspiration, or irrigation and drainage, and im- mobilization. Judgment is needed, of course, to determine what cases are amenable to this conservative surgery, and at what point in the treatment it must be abandoned in favor of more extensive intervention. A chronic cystic swelling in the neighbor- hood of a joint is in the majority of instances a distended bursa. 97 EATRErilTIE5, One should inquire carefully for the his- tory of the application of carbolic acid to a wound, especially of the finger or toe, when a gangrene with a distinct line of demarkation has developed. Resection of the head of the projecting phalanx so often yields an entirely satisfac- tory result that amputation should not be ad- vised for hammer-toe until the less mutilat- ing operation has been tried. An acute non-purulent tenosynovitis may ppcr ^^ satisfactorily treated by immobilization ' with plaster strips. The superficial location of the ulnar nerve must be borne in mind when incising an ab- scess about the inner aspect of the elbow. Persistent pain in an arm may be due to the presence of a "cervical rib." Do not apply an elastic ligature about the arm without first interposing a towel. This may obviate subsequent paralysis. 98 EATUEniTIE5. A sinus leading high up in the axilla and discharging a moderately clear fluid may communicate with the shoulder joint or pleura. A small, hard, tender nodule situated over Hand. the thenar or hypothenar eminences may be a broken-down dermoid cyst. If a patient presents himself with a pain- less cellulitis of the finger or hand, it is neces- sary to make a careful examination for the possible presence of syringomyelia. The injection into a ganglion of the wrist of phenol-camphor, two to ten minims, ac- cording to the size, and repeated once or twice if necessary, will cause its complete disappearance in most cases. No attempt at preliminary aspiration need be made. Before anesthetizing a patient to operate upon a wound (e. g., of the wrist), in which tendons are severed, attach forceps or liga- ments to any tendon ends that are visible. While struggling during primary narcosis the proximal ends of cut tendons are sometimes drawn up, and the above device will obviate 99 EATREniTIE^. slitting up the sheaths to secure them. Squeezing the extremity proximal to the wound will likewise prevent these retractions. Never divide the annular ligament of the wrist. The hand is much weaker after it is divided than before. Frequently referred to the surgeon because of the constant pain and marked tenderness, is to be noted a group of cases of what might be termed "occupation wrist pain." They dif- fer from the ordinary case of "writer's cramp," " piano-player's cramp," etc., in that, while these latter frequently have pain in, or about, the wrist, the cases here re- ferred to have no spasm, the pain is con- stant, and it is not of a neuralgic character. Sometimes it radiates along the thumb (as in mail-openers) ; sometimes it is localized to the inner border of the lower end of the ulna, which is very sensitive to pressure (as in shirt-ironers) . The fingers are free. There may be pain in the forearm muscles (flex- ors). For a single tenorrhaphy make the inci- sion quite a little to one side of the line of the tendon and perform no more dissection TOO EATREniTIE5. than is necessary. This is to avoid adhesions of the tendon to the skin. If a tendon has been divided by an in- cised or lacerated wound and the skin has united over it, it is better to wait a fortnight or more before performing tenorrhaphy. Otherwise organisms introduced with the traumatism may cause suppuration and sloughing of the tendon, not only defeating the operation, but making a later attempt at approximation difficult or impossible. When exploring for a needle or other for- eign body the finger tip is often far more use- ful than a probe. It must be remembered, too, that strands of fascia often impart to a probe "the feel" of a foreign body. Cut- ting and picking at these deceptive strands of tissue soon distort the field of operation and destroy important relations. It is ex- tremely desirable to conduct a systematic and cleanly dissection when seeking a foreign body. Stereoscopic radiographs best demonstrate the position and depth of a needle or piece of glass. lOI EATKEIilTIE^. The best drainage should be afforded for all punctured wounds of the palm; suppura- tions in this region are very disagreeable and are followed by severe consequences. The surgeon should not wait for redness before making a diagnosis of palmar abscess. Owing to the density of the fascial structures this sign is often lacking in the early stages. In dealing with infections of the hand bear in mind that under a simple bleb may lie an extensive phlegmon, threatening, or actually involving, a tendon or bone and urgently needing a generous but wisely placed inci- sion; while on the other hand, a tendon may be thrust from its protecting sheath into the area of destruction by a knife sweep more earnest than judicious. A crater-like opening in a sodden skin, though freely discharging pus, may need enlarging to protect the tissues underlying; while another opening, too long continued by unnecessary packing, may crip- ple a joint or tendon by undue cicatrization. In the treatment of hand and finger in- fections, it is very important to release from bandaging as much and as many of the fin- gers as possible, and as soon as possible. The I02 EATREMITIE5, habit of bandaging up immovably all the fingers, in the treatment of a lesion of some of them, saves the surgeon time but, except in short cases, it often cripples the hand by stiffening the fingers. Occasionally, contractures of the fingers follow^ing the treatment of a cellulitis of the hand and forearm may be due, not to the cellulitis itself nor to the incisions made to relieve it, but to fibrosis and shortening of the flexors in the forearm, the result of too tight bandaging or strapping. Such a con- dition — Volkmann's ischemic muscle contrac- ture — must, therefore, be distinguished from the stiff, flexed fingers produced by the cellu- litis. Passive motions and massage are help- ful in both conditions, but in the former bone shortening (radius and ulna) is necessary to accommodate the contractured muscles. Remember that chronic ulcers on the hands are found in brass workers, and that a discontinuance of this occupation is neces- sary to secure healing. Indolent sinuses, as of the fingers after deep infections, frequently heal by the daily use of prolonged immersions in hot water. 103 EATRErimE5. In dealing with infections or injuries of the fingers amputation should be a last re- sort. This is especially the case with a thumb, the most important of all the fingers. In a case of fresh traumatic amputation of a part of the finger, if the amputated part has not been too lacerated or crushed, try to restore the member by cleansing the parts carefully and suturing it to the stump. Once in a while the graft will "take." Amputation of a finger gangrenous as the result of carbolic acid application should not be performed until the line of demarkation is well established. The necrosis may be su- perficial and in such an instance the finger may be saved by means of skin graft. Lj^^^^ Persistent pains in the leg may be due to Extremity. "obliterating endarteritis." This occurs oc- casionally even in young men and often goes on to the production of gangrene. The pathology is a slowly progressive thrombo- angeitis. Flat-foot is another cause of pains in the leg or thigh. 104 EATREniTIC5 In cases of pain in the hip of doubtful origin, examination of the kidney regions may discover the cause. The presence of sciatica demands a care- ful exploration of the pelvis by rectal or vaginal examination. It should also be re- membered that Osier described sciatica as one of the early symptons of cancer of the breast. A large slowly healing superficial ulcer of the leg may be due to a thrombosis of one of the small vessels leading to that part. Of course, syphilitic etiology must be first ruled out. Instead of suturing the skin after amputa- tion of an extremity, it is sometimes better to bring the flaps together with broad strips of adhesive plaster, aspecially if the operation performed is for an arteriosclerotic condition. During the course of a pneumonia, severe pain in the leg is indicative of the deposit of a septic embolus in the lumen of one of the veins, which often results in an ascending thrombosis and phlebitis, necessitating ampu- tation. 105 EATRErilTIE5. Severe pain in the knee joint with redness and high pressure may mean an inflamma- tory condition of the joint or adjacent bone, but it also may be due to a phlebitis of the superficial veins of the leg. The following are some of the conditions in the presence of which an examination for tabes dorsalis should never be omitted : 1 . All primary swellings of the knee or ankle joint without apparent origin. 2. "Sciatica" and "lumbago." 3 A deep ulcer on the base of the great toe. 4. Repeated vomiting at various intervals, with periods of well- being intervening. 5. Abdominal pains without other evident cause. Pain in the leg after an abdominal opera- tion often means the development of a fe- moral vein thrombosis. This occurs usually on the left side. Lymph-edema of the lower extremity as- sociated with a swelling in the groin (fluct- uating or not) is significant of carcinoma of the inguinal glands. The primary lesion may be in the rectum, e. g., an epithelioma of the anus that is giving no symptoms. io6 EATREMITIE5. When removing a lipoma or other growth from the inner surface of the thigh, a httle care should be exercised in order to avoid cutting the long saphenous vein. Ligature of that vessel (especially in ambulant and in non-aseptic cases) may be followed by a dis- tressing phlebitis. Inflamed areas and abscesses about the knees of creeping infants should be exam- ined for foreign bodies. Punctured wounds about the knee should be treated with the greatest solicitude and attention to asepsis, in order to prevent in- fection of the joint. In operating for loose bodies within the knee joint, do not be satisfied with removing but one body; a careful examination should be made to determine the presence of more, for they are very frequently multiple. Do not operate for foreign body in the knee joint without first excluding dislocation of one of the semilunar cartilages. In amputations below the knee, insist on active and passive motion of the knee joint 107 EATREniTIE5. at an early date. If this is not done con- tracture ensues, which makes the application of an artificial limb difficult. Bilateral swelling of the knee joints without pain, in a child, is due either to syphilis or tuberculosis, more likely the latter. Nurses should be instructed not to massage the limbs of patients who complain of pain after operation or confinement, without the order of the attending surgeon. If phlebitis and thrombosis are present, the manipulation may loosen a clot and cause instant death. Acupuncture, followed by the application of the Bier cup is an excellent way of re- lieving dropsy of the legs. A hematoma may be produced in the calf muscles by direct or indirect violence that the patient may pay little attention to at the time or even fail to recall. Swelling of the leg, associated with febrile disturbances, may be produced by hematog- enous infection of a hematoma of the calf muscles. Such a condition may somewhat io8 EATREniTIES. simulate osteomyelitis or other serious con- dition. It may be differentiated, however, by the location of the greatest tenderness and swelling and by a careful inquiry into the history. If no distinct traumatism is recalled the condition of the patient's arteries may nevertheless suggest the possibility of the oc- currence of such a hematoma. Patients with varicose veins should be in- structed that in case hemorrhage takes place, the best method of stopping it temporarily is to merely compress the bleeding point with the finger. Never advise an elastic stocking in cases of varicose veins where recent phlebitis exists. The pressure may detach a part or whole of the thrombus, propelling it into the general circulation. Chronic leg ulcers very often heal quickly under the Unna zinc oxide-gelatin dressing, when all other efforts have failed. Tenderness in the heel, or pain and ten- Toot. derness in the sole of the foot is very often, indeed, of gonorrheal origin. It will not be 109 EATREniTIES. relieved in such cases until treated on that basis. The patient may deny that he ever had gonorrhea. Examine his urine; shreds tell their own story. Do not be too hasty in ascribing the cause of pain in the tendo Achilles, or Achilles bursa, to an ill-fitting shoe. First exclude gonorrheal infection. If the cause of pain in the feet is not other- wise clear, examine them in the dependent position. This may develop the presence of erythromelalgia. The determination of the presence of a fracture of one of the mid-tarsal bones is extremely difficult, and usually impossible, without x-ray examinations. Yet these ex- aminations have shown the occurrence of such fractures, alone, or associated with in- juries to other bones, as the result of injuries by slight or severe direct violence. For this reason, and because fractures of the meta- tarsals by indirect violence are by no means uncommon, it should be practically a routine to submit the foot to skilful skiagraphy in all cases where either form of violence may no EATREi^lTICS. have occurred. It will save many patients from weeks of suffering and disability. In this region, more than any other, the x-rays are a means of diagnosis that cannot be dis- pensed with. Many,at least, of the sprains of the ankle involve a fracture of the tip of the malleolus, and should be treated by immobilization in plaster-of-Paris. If a patient complains of sharp pain in the big toe, examine the urine for albumin or sugar in order to exclude a diabetic or neph- ritic condition. In old people, as in diabetics, corns, bun- ions and wounds of the feet demand the most careful attention. They are often the starting points of gangrene. A very simple method of curing a corn is to excise it. In ingrowing toenail, evulsion of the nail gives temporary relief, but it does not cure. When the nail grows out again the condition recurs, often in aggravated form. Ill EATRErilTIE5. It is doubtful whether the classical opera- tions for ingrowing toe-nail cure permanently in even a fair percentage of cases. Conser- vative treatment will usually accomplish as much, even in the presence of granulating masses. This treatment includes drawing the flesh away from the nail with a strip of ad- hesive plaster, insertion of a gauze packing under the nail edge and the application of an absorbent antiseptic dressing. Be very guarded in the prognosis of ul- cerations on the sole of the foot in diabetic or tabetic patients, no matter how small or trifling the ulceration may be. They persist for long periods and may even never heal. PR AC- Very often the unskilful treatment of a fracture is worse than no treatment at all. Serious deformities may result from the neg- lect of small details no less than from the violation of important principles. The important considerations in the treat- ment of fractures are, at first, relief of pain and reduction of swelling, and, subsequently, preservation of function of the muscles, the nerves and the neighboring joints. Hence TURE5. 112 rRACTURE5. the value of early and frequent massage and passive motion (and in suitable cases, of active motion) and the necessity of avoiding splints that unduly compress the muscles or deprive them of activity. In the treatment of fractures of the fore- arm no consideration is more important than the avoidance of contractures of the fingers, by the intelligent use of splints and by means of early, active and passive movements. Permanent contracture of the muscles, not- ably of the flexor group in the forearm, may develop within a very short time after the application of a splint that exercises undue compression. It is a wise rule to inspect all fracture dressings within twenty- four hours; and when this is not expedient special care should be exercised, when applying the dress- ing, to avoid compression. In very many cases it is not necessary to the diagnosis of fracture to elicit crepitus and abnormal mobility — often painful man- ipulations. In several forms of fracture there are other positive diagnostic evidences. Thus, with Colles' fracture the level of the styloid of the radius will almost always be found to 113 FRACTURES. have receded from beyond that of the styloid of the ulna. Moreover, x-ray examinations save much painful manipulation. After all, the localization of bone tender- ness is not only the most useful sign in de- termining the site of a fracture, but, even in the absence of other signs, it is often, in itself, diagnostic of the presence of a frac- ture. As instances may be cited greenstick fracture of the clavicle, and fracture of the metacarpal and metatarsal bones. In all examinations of children, and in the examination of adults for suspected fractures, leave the painful manipulations for the last. The x-rays have taught us that mathemati- cal reduction is rarely, and even linear re- duction is seldom, accomplished even in cases in which excellent functional results are secured. Radiographs have thus fre- quently been made the basis of blackmail- ing damage suits. Nevertheless, the x-rays are, of course, of immense value in the treat- ment of fractures — ^not only for reference before and after reduction, but during the reduction itself. 114 rRACTUKE5. A fracture produced by only slight vio- lence should at once raise the suspicion of a malignant growth. In such cases a uni- form dark shadow about the bone as seen in the fluoroscope is to be interpreted as a neoplasm rather than a callus, for recent callus is not opaque to the x-rays. That a bone appears normal by fluoro- scopic examination does not gainsay the pres- ence of a fracture. A fracture of the radius, for example, may occur without displacement of the fragments. An x-ray plate will dem- onstrate the line of fracture when the fluoro- scope fails to. Severe localized pain after traumatism, es- pecially in children, may be due to sub- periosteal fracture, e. g., near the head of the humerus or the femur. Extreme local- ized tenderness is the chief sign; abnormal mobility and deformity are absent, and crepi- tus may not be elicited. In cases of fracture where the end of the bone lies close beneath the skin do not place a pad or any pressure whatever over this point. 115 rRACTURC5. In compound fractures involving loss of continuity do not needlessly remove any piece of bone that has even the smallest attachment. It is surprising how often such pieces heal into the wound and thereby help to save loss of substance. When applying a plaster dressing to the leg always include the foot if the patient is to be confined to bed; otherwise "drop foot" will develop. In cases of fracture of a rib, it is neces- sary to watch the patient carefully for a couple of days to note the onset of a possible lung complication. Localized pneumonitis sometimes occurs. In severe falls or blows or fractures of the pelvis, catheterize the patient as soon after the injury as possible in order to dis- cover a possible rupture of the bladder. Fracture of the outer end of the clavicle may follow a fall upon the shoulder. Un- less one makes a careful examination such a fracture may escape observation or be mis- taken for a dislocation of the outer end of ii6 PRACTURE5, the clavicle, with which condition, indeed, it may be associated. Shortening of the shoulder, as measured from the sternal end of the clavicle to the acromion process, is significant of fracture of the clavicle. In the aged, pain and disability in the arm after traumatism demand especial care in examination of the shoulder. Fracture of the head of the humerus is often overlooked. In fractures of the anatomical neck of the humerus, examine carefully for injuries to the brachial plexus. The radiograph of the elbow of a child shows shadows of numerous epiphyses. One inexperienced with x-ray plates is very apt to mistake one or more of these for fractures. When examining the skiagraph of a child's elbow suspected of fracture or dislocation, it is, therefore, important to have the normal picture in mind, or better yet in hand, for comparison. Fractures of the head of the radius are probably more common than generally sup- 117 PKACTURE5. posed, being overlooked frequently because of the absence of the ordinary signs of frac- ture. A patient should not be considered neuras- thenic because he cannot walk after union of a fracture of the os calcis. There is often considerable pain due to adhesions and the incorporation of portions of the tendo Achilles in the callus. Pain is often present for months after a fracture of the leg, especially in elderly peo- ple. This is mainly due to the formation of the callus and needs no operative interference. Of course, a subacute osteomyelitis must be kept in mind. If a small child has been pulled by the arm and thereafter has disability in that member, attention should first be directed to the upper end of the radius. Here one is apt to find a subluxation of the head of the bone ("pulled arm") or an epiphyseal sepa- ration. Marked tenderness over the lower end of the radius, after traumatism, without deform- ity, is suspicious of fissure of the bone. Mo- bility or crepitus may be obtainable. ii8 rRACTUKE5. The silver-fork deformity is by no means necessary to the diagnosis of Colles' frac- ture. If a patient gives a history of "sprained wrist" that has remained feeble and pain- ful in spite of appropriate treatment for suffi- cient time, and if the wrist presents thick- ening and tenderness at its radial aspect, a diagnosis of fracture of the scaphoid should be entertained. Colles' fracture must be ex- cluded, by the relation of the two styloid pro- cesses and the location of the deformity. Fractures of the radius and scaphoid may, however, coexist. Fractures of the neck of the femur in old people sometimes cause no other symptoms than disability. The mildness of the trauma and the freedom from much pain should not deceive one. A padded triangular wooden or card- board splint — one leg of the triangle band- aged to the thigh, and another to the trunk — makes an excellent ambulatory apparatus in the treatment of fractures of the shaft of the femur in small children. It maintains reduction, leaves the leg free and does not interfere with keeping the child clean. 119 PRACTURE5. LyriPHAT- IC5. Cardboard splints can be best molded to an extremity by tearing, instead of cutting them. When operating upon a fractured patella it is very important to sew the torn lateral Hgaments of the joint. These aid largely in the support of the joint. It must be remembered that fractures of the metatarsal bones may be produced by slight injuries. Thus, the base of the fifth metatarsal may be fractured by a twist of the foot while walking or dancing. An accurate knowledge of the lymphatic drainage of the various regions of the body is absolutely necessary before one can deter- mine the origin of a glandular infection. This is especially important in cancer, when sometimes the glandular involvement offers the first clue to the primary focus. Do not advise extirpation of large glands in any particular region without making sure that they are not the early manifestations of leukemia or Hodgkin's disease. If a bubo shows no signs of disappearing under wet dressings, ice bags, etc., and evi- I20 LyriPHATIC5. dences of suppuration are developing, it is better to make a clean dissection and excise the gland without opening it than to incise and drain. Exposure to the x-rays causes atrophy of 5KIN. the sweat glands; radiotherapy is proving the most satisfactory treatment for hyperi- drosis. Pure nitric acid, applied on the narrow, blunt tip of a glass rod is successful in the complete destruction of verruccae, but only if it is forced down to their very roots. A diffuse blotchy condition of the skin should not be diagnosed as measles until a careful physical examination has been made. The condition may be the expression of a streptococcemia, as from an osteomyelitic focus. Persistent furunculosis and allied suppur- ating skin lesions appear to yield in a large percentage of cases to Wright's vaccine treat- ment. Stock vaccines are usually suitable to such cases. The internal administration of yeast, calcium sulphid, etc., affords only oc- casional help. 121 5KIN. It is worth while bearing in mind that sub- cutaneous swellings are sometimes gummata. Localized, indurated or softening skin in- fections ("boils") often disappear com- pletely or open painlessly under an applica- tion of emplastrum plumbi in which is in- corporated 10 per cent, of salicylic acid; or of 10 per cent, to 20 per cent, salicylated soap plaster. After the boil opens the tiny dressing should be changed every two or three hours. When shaving the hair in the neighbor- hood of a boil, draw the razor from the base to the apex so as not to drive microorganisms deeper into the tissues. Do not treat localized subcutaneous red and tender swellings as infections without first making sure that they are not evidences of gout. Stains of anilin dyes may be removed from the fingers with strong hydrochloric acid, stains of iodin with aqua ammonia, and stains by silver nitrate with potassium iodid solution. 122 WOUND5. If an incised wound in the soft part does not heal as readily as it should, examine the urine for sugar. In wounds made by coal on the exposed parts of the body, remove all the particles of coal dust; otherwise a disfiguring pig- mentation might follow. A broad clean ulcer on the soft parts may heal per primam if its surface is swabbed with iodin and its edges then brought to- gether with adhesive straps. An ulcer with indolent flabby granulations may be stimulated to renewed activity by a thorough scraping or by vigorously rubbing it with gauze. Catgut strands do not always make a good drain for wounds; they tend to swell and occlude. Fresh wounds about a joint should not be probed to see whether the joint has been penetrated or not. This is an excellent way of infecting it. 123 WOUND5. The appearance of emphysema in the tis- sues about an infected wound, accompanied by fever and escape of bubbles of gas from the wound, should be regarded as very omi- nous, and indicative of gas bacillus infec- tion. Such cases should be treated by ex- tensive incisions. Blank cartridge wounds must be laid wide open, all dirt and wad carefully removed, and the area swabbed out with tincture of iodin, or with pure carbolic acid followed by alcohol. Tetanus antitoxin should be ad- ministered. If the powder grains are not properly re- moved in gunshot wounds of the exposed part, unsightly discolorations result. The posible development of a duodenal ulcer in cases of extensive burns, must always be borne in mind. Too prolonged or too rapid and vigorous use of the pump in the Bier apparatus will frequently cause a rupture of the superficial bloodvessels, and in many cases severe sloughing of the superficial parts ensues, the 124 VOUIND5, result of the treatment being worse than the primary cause of the trouble. AppHcation of the Bier cup to an abscess for four to five minutes twice a day is more beneficial than a single ten-minute application. Soft tumors under the skin, disappearing in the recumbent posture, are usually lym- phangiomata. TUriOR5. If a swelling is "fluctuating" do not be too sure that it is not a solid growth. Lym- phangiomata fluctuate. A subcutaneous tumor with a history of a puncture or the presence of a minute scar in the overlying skin, usually means that one is dealing with an inclusion or so-called Ran- vier cyst. In hard swellings of doubtful nature marked tenderness is significant of actinomy- cosis, when acute inflammation may be ex- cluded. Do not give a good prognosis in cases of melanosarcoma of the fingers and toes, no matter how small the tumor may be, and no 125 TUnOR5. matter how high the amputation is performed. In the majority of cases, these patients suc- cumb to metastases. In the presence of a pulsating tumor, es- pecially of the bone, examine the kidneys. Secondary hypernephromata pulsate. A pulsating tumor of the os ilium (en- dothelioma, sarcoma) may easily be mistaken for a gluteal aneurism. The "egg shell crackle" of certain bone tumors is characteristic of multiple myeloma. Examine the urine for albumose. In cases of bone tumor these organs should never be overlooked in seeking a primary growth — the prostate or mammary glands, according to the sex, and the thyroid. An amputation for malignant ulceration should not be performed until the possibility of its being merely a broken-down gumma has been satisfactorily excluded. A metastatic growth in a superficial lym- phatic gland or a gland of the skin may sometimes deceptively simulate the appear- 126 TUnOR5. ance of a sebaceous cyst. In a patient suf- fering with a malignant neoplasm, therefore, the development of a "wen," especially if at an unusual situation, should be regarded with sufficient suspicion to prompt investiga- tion of its interior. Individuals with bluish sclerotics, and with dark lanugo over the upper part of the back, are usually of tuberculous diathesis; and these signs are not inconsequential in making a diagnosis. Surgical tuberculosis, no less than pul- monary tuberculosis, calls for the most care- ful general treatment, post-operative and otherwise. Out-of-door life is as important here as for phthisis. The temptation should not be yielded to to incise a psoas, hip or other "cold" ab- scess, except in isolated instances and then only under the most rigid asepsis. The pro- duction of a mixed infection means chronic sinus, chronic invalidism and, often, amy- loid disease. TUBER= CUL05I5. In operations upon the head and neck the anesthetist must see to it that no instrument ANES- THESIA. 127 ANE5THE5IA. is allowed to lie over the cornea, especially if it is exposed. Ulceration may be caused with ease ; it is often healed with difficulty. During narcosis, when stertorous breath- ing calls for extension of the jaw, it is well to hold it forward on one side, then on the other, alternating at short intervals. Long continued pressure at the angle or angles of the jaw produces much soreness. Often the jaw can be kept forward by catching the lower incisor teeth in front of the upper ones (if they are strong) ; a single finger on the chin is enough to maintain this position. In light narcosis the pupils may dilate reflexly from operative manipulations. This, of course, is not to be confused with the sudden extreme dilatation that occurs when the narcosis has been carried too far. During the conduct of a narcosis, more important than the activity of the conjuncti- val reflex or the actual size of the pupil in determining the depth of the anesthesia, are the changes in the reactibility of the lid and the alterations in the size of the pupil. They are reliable indices to fluctuations in the depth of the narcosis. Sometimes a patient is quite 128 A1NE5THE5IA. relaxed and anesthetic although a fair con- junctival reflex is present; and, again, it may occasionally happen that a patient reacts even when that reflex is abolished. Avoid touching the cornea during the ad- ministration of an anesthetic. The ocular reflex can be obtained just as well through the lids, and the pupils and motions of the globe offer the most definite indications of the degree of narcosis. In crying infants it is extremely difl^icult to determine the presence, and location, of ten- der areas. This may be readily accom- plished by the administration of chloroform to the extent of primary narcosis. The phy- sical examination then becomes very easy and when a tender spot is handled it will be announced at once by lively reflexes. During the performance of a hernia op- eration it is often helpful for the anesthetist to allow the patient to react sufficiently to strain into view a sac that has slipped back into the abdomen. A convenient way in which the anesthetist may carry, all sterilized and ready for in- 129 ANE5THE5IA. stant use, his hypodermatic solutions, is the following: Shallow, wide-mouthed, half- ounce bottles are sterilized, labeled and filled. Over the mouth of each bottle is then stretched, and hermetically fastened, a cover of sterilized rubber (dam). Before the narcosis is begun the anesthetist disinfects his syringe and sets these bottles in a dish of sublimate solution. This sterilizes the sur- face of the rubber. When a solution is wanted the needle of the hypodermatic syringe is simply thrust through the rubber and as much as is needed is drawn into the barrel. The puncture hole closes without leakage. The covers of the bottles need to be changed only occasionally. Whenever the arrangement of a patient upon the operating table requires an extrem- ity to occupy a constrained position, that po- sition should be shifted from time to time to avoid pressure paralysis. The anesthetist should never draw the arms alongside the head, nor permit the strap of a leg-holder to press, for more than a few minutes at a time, upon the brachial plexus in the neck. Nitrous oxid narcosis can, in most cases, be continued "smoothly," with no cyanosis 130 ANE5TME5IA. and with fair degree of relaxation, even for an hour. A laparotomy may thus be per- formed, if ether and chloform are contrain- dicted. To secure such a narcosis it is best to use an apparatus that permits exhalation into the gas bag, and which has a valve for the admission of air. The bag should not be distended fully. After brief air and gas administrations, air is turned off and the pa- tient breathes N^O and his own CO2. At short intervals, and whenever there is any cyanosis, a single breath of pure air is al- lowed. Ten grains of trional (or veronal) the night preceding the operation, and a quarter of a grain of morphin one hour before operation, will make an anesthesia easier and more com- plete and it will not be followed by the usual after-effects of a complete narcosis. Local anesthetics cannot be injected pain- lessly into tense, inflamed areas unless the in- jection is begun at a point in the skin well beyond the seat of inflammation. The admixture of adrenalin to cocain so- lution counteracts much of the depressant efFect of the anesthetic and enhances the 131 A1NE5TME51A. local vaso-constriction. When the mixture is used on the surface of a mucous mem- brane, however, as in excising an ulcer in the mouth, one must be prepared for a marked reactionary bleeding. INFUSIONS. ^^^ ^ single intravenous infusion, as to combat the shock of hemorrhage, it is not essential that the solution contain any of the blood salts but the most abundant one — sodium chlorid. For repeated infusions, how- ever, as sometimes used in treating various toxemias, it is better to employ also the other salts, the solution being made of sodium chlorid 0.9, potassium chlorid 0.03, calcium chlorid 0.02, water 100. Intravenous saline infusions in too large volume are harmful by the production of con- gestion of the internal viscera. One to one and a half pints is enough for an adult of average weight In performing subcutaneous infusion do not allow too much fluid to accumulate at one area, otherwise necrosis may occur. Shift the needle to various parts not by swinging it from side to side, but by partly withdraw- ing it and reinserting it to another area. 132 POST-OPERATIVE The pain in the lower part of the back that is so frequently complained of after op- eration, can be best relieved by placing a small pillow in the hollow of the spine. In determining the cause of a post-opera- tive fever never fail to look at the throat. If, after a period of post-operative cathe- terization, the patient finds herself able to pass urine spontaneously, apply hot towels to the vulva. Gastric lavage is the best post-operative anti-emetic. Vomiting may frequently be controlled by one-drop doses of tincture of iodin in water at half-hourly intervals. The distressing thirst after abdominal op- erations, where fluid by mouth produces vom- iting, is best relieved by subcutaneous infu- sions of normal salt solutions or by the in- sertion of a tube into the rectum connected with a bag of saline solution placed just above the level of the patient's hips, allowing the injection of water drop by drop and so slowly 133 P05T-0PEKATIVE. that no irritation of the rectum is set up. The patient may in this manner receive small quan- tities of water for hours. Excessive purgation and too frequent enemata before operation may be productive of a great deal of post-operative distention. The tension on the sutures after an opera- tion for epigastric hernia may be relieved by placing a pillow under the knees and propping the patient up in bed. A post-operative distention that is not re- lieved by a high enema can often be reduced by washing out the stomach. After operating on diseased bone, the wound should not be dressed too often. The fine granulations which form are very liable to be pulled off with the removal of the packing. Before putting an unconscious patient to bed, the hot water bags should be removed or sufFiciently covered to prevent the occur- rence of a burn. 134 P05T-0PERATIVE. The occurrence of post-operative phlebitis is often encouraged by keeping the patient too long in bed. Old people should be allowed to sit up or get out of bed as soon after operation as possible in order to avoid post-operative lung complications. Do not allow patients to lie on the back immediately after an operation involving the vertebrae or the sacrum; a disagreeable ne- crosis of the skin flaps may rapidly take place. In differentiating shock and concealed liCriOR= hemorrhage progressiveness of the symptoms RJiAOC AND is very significant of continued bleeding. SHOCK Restlessness, increasing pallor, increasing air-hunger, increasing weakness of the pulse, falling temperature (subnormal), and the ephemeral effect of stimulation, all point to hemorrhage rather than shock. In addition, there is often some local sign or symptom. In post-operative collapse if, after study- ing the symptoms, there be any doubt whether 135 MEnORRHAOE AND 5MOCK. the condition be due to shock or to concealed hemorrhage, the wound should be opened and bleeding sought for. In dealing with secondary hemorrhage from the rectum (whether bleeding vessels are tied or not) , it is better to tampon with gauze wrapped about a piece of stout rubber tub- ing, than with gauze alone. The application of elastic bandages to the limbs to cut off their blood supply, will in- crease the amount of blood going to the vital centers and, therefore, is very beneficial to patients who have been operated upon in a condition of shock. Raising the foot of the bed twelve inches may combat shock more quickly than the re- peated administration of stimulants and, by the way, is far less harmful to the patient. One should remember not to use this means in abdominal cases where pus has been found in the peritoneal cavity. In many cases of shock, a venous infusion will more often save life than dallying with stimulants which merely, in the end, serve to tire out the heart. 136 5EP5I5. Bone tenderness, especially of the sternum and tibiae, is frequently significant of sepsis. In seeking the source of an obscure sepsis, do not overlook an examination of the is- chiorectal region. Small petechiae on the skin may indicate a sepsis of obscure origin. Aluminum instruments should not be boiled in soda solution like other instru- ments. They are to be sterilized by boiling in plain water or by passing them through an alcohol or Bunsen flame. irS5TRU» riENT5. Woven catheters may be sterilized by boiling in saturated ammonium sulphate solu- tion. Catheters and bougies may be kept aseptic if they are wrapped in gauze wet with the soap-spirits of the German pharma- copeia. Warming a laryngeal mirror prevents con- densation of the breath upon it for only a short time. The mirror will remain bright, however, throughout a prolonged examina- tion if, instead of warming it, its surface is smeared with an invisible film of soap. 137 IN5TRUrimNT5. Dipping a throat mirror in alcohol will as effectively keep off a film of moisture as heat- ing it. An "invalid table," the shelf of which projects over the patient's body, will be found a great convenience during operations as a receptacle for instruments in immediate use. It saves time and temper, and avoids accumulation of instruments on the patient's body. When scissors become "catchy" their edges can often be surprisingly smoothed by carrying each blade repeatedly from lock to tip between the firmly pressing thumb and forefinger. Each kind and size of scissors has its own capacity, and should be used only for what it is intended. Ophthalmic in- struments are not intended for ordinary dis- sections, tissue scissors should not be used for cutting bandages, nor bandage scissors for plaster-of-Paris. Bandage knives cut best when they have a "saw edge," which is easily secured by sharpening them on a window sill or other rough stone. 138 IN5TKUriEINT5. A scroll-saw, with an assortment of a dozen saws, can be purchased at the hard- ware store for twenty-five cents; it is ideal for resection of the small bones of the hand and foot, for amputation of the digits, etc. Well tempered carpenter's chisels and gouges, and a carpenter's wooden mallet answer the purpose admirably for bone work. A useful bone drill can also be selected from the stock of the hardware dealer. A gardener's pruning knife and a car- penter's miter saw are the best tools for the removal of plaster dressings. A cheap potato knife, rough sharpened on a stone, is excellent for cutting through starch bandages. Crochet needles are most useful for lifting buried stitches out of a sinus. Knitting needles find another purpose as a means of rupturing the membranes when this is needed in obstetrical work. 139 IN5TRUriENT5. Sharp and blunt retractors may be fash- ioned, in an emergency, by bending the tines of a fork and the handle of a spoon, respec- tively. A teaspoon is also useful as an elevator of the eye, when resection of the superior max- illa is performed. An inverted tea-strainer is useful in the dressing after colostomy, to prevent pressure of the gauze upon the gut. A spoon-shaped potato cutter may be used, in an emergency, as a wound curette. The multiple surgical uses of the hairpin are also well-known. Of stouter material, if necessary, a small self-retaining retractor can be quickly made from steel wire; it often ob- viates the need of an assistant when search- ing the hand or foot for a foreign body. Similarly, applicators, probes and de- pressors may be improvised by twisting stout copper wire. 140 HN5TRUriElNT5. A wedge of hard wood makes a gag quite useful, often, when administering anes- thesia. A discarded thermometer case (or a hard rubber douche point) is a serviceable handle in which to mount, with paraffin or adhesive plaster, a stick of silver nitrate. A bright and altogether satisfactory light for throat examinations can be had cheaply by covering a 1 6-candle-power Edison elec- tric bulb with a smooth layer of plaster-of- Paris, about three-eighths of an inch thick, leaving on one side an aperture the size of a silver half-dollar, or larger. The white inner surface of the plaster brilliantly re- flects the light. The outer surface may be painted black. Cheap powder blowers, such as are used for insecticides, may be employed as insuf- flators in surgical work, and pepper boxes are useful for dusting powders. Steel spring tape-measures are better than the wires generally sold for the purpose, for conducting to an x-ray tube the current from the coil or static machine; easily kept taut. 141 IN5TRUriENT5. and quickly adjusted, they are safest for the patient and most convenient for the operator; that they are not insulated is inconsequential — the coverings on the regular wires do not insulate the induced current. Wooden skewers are serviceable nail- cleaners. Rolling pins and kitchen towel racks are very convenient for adhesive plaster, rubber tissue, etc., especially for hospital dressings. A probe that has become bent and twisted is readily straightened out by rolling under the foot on an even floor. The weight scale is the most important of all instruments in determining the presence of a latent carcinoma. Hot bricks or stones retain their heat much longer than hot water bags. A barrel cut in two on its long axis, makes an excellent holder for bed-clothes in acute affections of the lower extremities. Not only does it avoid the heavy pressure of the cover- ings but it diminishes the chances of discom- fort caused by jarring of the bed. 142 5UTURE5. The threading of catgut or kangaroo ten- don through a needle-eye not very roomy may be made easy by cutting the suture end obliquely and flattening it between the han- dles of the scissors. Silk must not be cut obliquely, however, for this makes it apt to ravel while it is being threaded. Silkworm-gut is easily dyed, and inciden- tally impregnated with an antiseptic, by im- mersing it for twenty- four hours in one per cent, solution of methyl violet, before the boiling. When suturing a wound of the scrotum, if the tissue (dartos) is contracted, apply a warm compress for a moment to cause re- laxation. In removing a skin suture, pull up on one side and cut it as close to the skin as possible. This is in order to avoid drawing any of the exposed part of the suture through the wound and thus possibly infecting it. Woven silver wire for suture material in a recurrent hernia will often succeed when all other means fail. 143 5UTUKE5. One is wise in making assurance doubly sure by tying each fascial suture with three knots instead of two. EAAMIN" ATIOIN5. Everything is to be gained and nothing to be lost by having patients remove enough of their clothing to allow of a completely satis- factory examination in all cases. Instances can be called to mind, by any physician, of erroneous judgments arrived at before ex- posure of other parts of the body showed con- ditions altering one's opinion. Especially is it important to compare the corresponding members of the body on the sound and the affected side, in all doubtful cases. When a skiagraph shows a condition not recognizable at once as a definite lesion, it is important to make an x-ray picture of the corresponding part of the body on the other side. It may show that the condition is merely a symmetrical peculiarity, and not a pathological one. Free ammonia in the urine of a diabetic is a prognostic sign and its presence is a con- traindication to operation in diabetic gan- grene, for it shows the presence of beta-oxy- butyric acid in the blood. 144 EAArilNATION5. Before excluding glycosuria examine both morning and evening specimens of the urine. If a patient persists in running evening temperatures which cannot be accounted for after a thorough physical examination and blood examination, one should place the pa- tient on increasing doses of the iodids, for the fever may be due to an old syphilitic infection. When performing an office operation, too great care cannot be taken to sufficiently roll back or remove such articles of clothing as might become soiled. The patient may not say much if he is obliged to draw up a gar- ment wet with blood — but he'll probably think a few things. Tar-paper is a smooth, fairly waterproof material to tack on the floor when preparing a room for operation. Grocers' paper bags are well-adapted re- DRE55IIN05. ceptacles for soiled dressings. In the Bier treatment, the cup will stay in place without other assistance if zinc oxid 145 DRE55IN05. salve or vaselin is applied to the skin. Even better than this is a piece of smooth rubber tissue which protects the skin from irritation by the pus. By addling a one- fourth per cent, or stronger, solution of boracic acid to Burow's solution (aluminum acetate), the latter clears at once, if cloudy, and remains permanently free from turbidity or precipitation. Yellow salve soon turns brown on expo- sure to light, if made with lard as a base. Cold cream or lanolin makes a good base. Keep in a procelain jar with a screw top. When a "wet dressing" fails to properly drain a septic wound try a glycerin dressing — gauze wrung out in pure glycerin and cov- ered with waterproof material. When wet dressings are needed on hairy areas it should not be forgotten that they predispose the hair follicles to infection. Wet dressings, especially the very useful Burow's solution of aluminum acetate, when applied to the hand or foot, usually cause 146 DRE55IN05. maceration and whitening of the skin, which is apt to alarm the patient. The addition to the solution of one-fourth its bulk of glycerin or alcohol, will obviate this unsightly macera- tion. A bichlorid of mercury dressing should never be applied on an area of skin on which tincture of iodin has been recently painted. An iodid of mercury is formed, which is highly irritating. Ichthyol, if used in ointment sufficiently strong (25% to 50%), is perhaps the most useful single medicament in aborting early superficial infections. The addition of a little oil of citronella to an ichthyol ointment robs it of its dis- agreeable odor. 2% ointment of fuchsin in vaselin or zinc oxid frequently yields gratifying results in stimulating the epidermization of indolent ulcers and granulating wounds. Subiodid of bismuth dusted on an oozing granulating wound promptly stops the bleed- ing. It is also an excellent stimulant to the growth of epithelium. 147 DRE55I1N05. An ointment of beta-naphthol, 10; sul- phur, 45 ; lard, 24 ; and green soap, enough to make 1 00 parts, is useful in removing gun-powder not too deeply situated in the skin. It must be employed cautiously, how- ever, to avoid a destructive dermatitis. Gauze is preferable to cotton for padding the axilla or breasts in dressings that are not frequently renewed. Cotton easily becomes matted with sour-smelling secretions and thus sets up dermatitis. The skin over the tendo Achilles and about the heel cannot be too carefully padded when applying Buck's ex- tension apparatus. Collodion, commonly used to seal a punc- ture wound, as after aspiration, will not ad- here if the spot is wet or bleeding. To ob- viate this, pinch up the skin, wipe it dry, ap- ply the collodin and continue the compres- sion a minute or so until the collodion has begun to contract. When rubber tissue is not at hand to make a "cigarette drain," rubber tubing may be used in its place. Split a piece of tubing of appropriate length, and lay the wick of gauze 148 DRE55HN05. in the trough thus made, or draw the gauze through the tube with a probe. Fenestras may be cut as desired. Swabbing out with glycerin a sinus filled with exuberant granulations will dehydrate them, making them fresh and healthy. A urethral endoscope will be found a great help as a means of introducing a rub- ber drainage tube into a narrow, tortuous sinus. The painfulness of withdrawing packings that have dried in a wound may be avoided by soaking them with peroxid of hydrogen. The pain of a severe burn may be much relieved by covering the part with flat pieces of gauze soaked in liquor Burowii and pro- tected by rubber tissue, or by the application of a 10% ichthyol ointment on flat pieces of gauze. The change of dressings of burns may be made painless, and the growth of epithelium encouraged, by employing next to the wound 149 DRE55IN05. sterile strips of gutta-percha in the same man- ner as for skin-grafts. Subiodid of bismuth lightly dusted on the granulating surface stimulates epithelial growth. Patients will appreciate the use of black bandages for the scalp — where they are com- paratively inconspicuous, and for the hands — where they do not soil. Mastoid and scalp dressing may be re- duced in bulk, and the uncomfortable neck turns of the bandage avoided, by the use of starch bandages, which hold neatly and firmly. Bandages may be fastened in place more neatly and more securely with strips of ad- hesive plaster, than with safety pins. When bandaging a finger or toe, turns about the hand or foot will be unnecessary if the dress- ing is fastened down with a narrow strip of plaster run over the top from base to base, and another strip circularly about the dress- ing at the base of the digit. When using black bandages, employ black adhesive plaster. ISO INDEX. Abdomen Anesthesia Appendix Back - Bile Tract Bladder Brain Breast Cranium Dressings 43 127 61 93 49 76 12 35 10 145 Ear --._--. 12 Examinations ----- 144 Extremities - - - - 94 Bye ------- 18 Face ------- 26 Foot ------- 109 Fractures ---_.. 112 Generative Organs, Female Genito-Urinary Tract Glands, Lymphatic 85 72 120 ii INDEX. — Continued. PAGE Hand ------ 99 Head ------ 7 Hemorrhage ----- 135 Hernia ------ 64 Infusions - _ . . - 132 Instruments ----- 137 Intestines ----- 57 Kidney ------ 72 Lower Extremities 104 Lymphatics ----- 120 Mouth ------ 27 Neck ------ 30 Nose ------ 24 Penis ..---- 80 Pharynx ----- 27 Post-Operative . - - - - 133 Prostate ----- 79 Rectum ------ 67 Scalp ------ 7 Scrotum ------ 83 Sepsis ------ 137 Shock ------ 135 Skin ------ 121 Stomach ------ 53 Sutures ----- 143 INDEX. — Continued. Hi PAGE Testicle 83 Thorax --..-. ^g Tracheotomy ------ 34 Tuberculosis - - . . . 127 Tumors 125 Upper Extremities - - . _ ^ Urethra 80 Ureter - - . . . ^2 Urinary Tract ----- ^2 Wounds 123 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE 1 C28(1 140)MI00 RD33 Briokner B76 1909 COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 33 B76 1909 C.1 2002108690