CHICAGO CLINICAL REVIEW. GIVEN AT WESLEY HOSPITAL, MARCH 31, '94., SURGICAL CLINIC, F. C. Schaefer, PROFESSOR OF CLINICAL, SURGERY, NORTH-WESTERN UNIVERSITY MEDICAL SCHOOL, PROFESSOR OF SURGERY TO WOMEN'S COLLEGE, SURGEON TO WESLEY HOSPITAL. Hypospadia - This little boy is two years old. His parents are strong and healthy. The child has a fine body, fully up to the average in stature; he is also healthy. His parents brought him here on account of a defect in his genitals, which they want remedied. He has the peculiar deformity, or vice of conformation, of the urethra known as hypospadia. This is characterized by fission or absence of the lower wall of the urethra so that the canal opens on the lower surface of the penis, at a variable point between the glans penis and the scrotum. The condition is due to an arrest of development and as the development may be arrested at any stage we can readily understand that the hypospadia varies somewhat in different individuals. Thus the penile orifice may be situated immediately under th*, glans ; sometimes it is located in a cleft of the scrotum and again cases have been recorded having the opening at different points on the under surface of the penis. In order to appreciate fully how this variable condition is brought about by the arrest of development it will be well to recall your knowledge of anatomy with reference to foetal develop- 2 SCHAEFER: SURGICAL CLINIC. ment. You doubtless remember that the balanic portion of the penis with the pendulous part are developed from the genital tubercle; the corresponding spongy portion of the urethra being formed by the genital furrow, while the anterior portion of the penis is thus developed from before backwards the urogenital sinus becomes elongated and forms the prostatic and membranous portion of the urethra, extending forwards, the scrotum being derived from the lips of the genital furrow. The penis therefore in the foStus consists of two different segments, an anterior, or external, portion and a posterior, or internal part the two sections developing towards each other. The glans appear about the third month, the prepuce and corpora cavernosa about the fourth month. During this month the prostate and scrotum are formed and the spongy portion of the urethra appears. For some unknown reason the process of development is interfered with so that the growth is arrested and the grade of the deformity is governed by the time of cessation of the development. Most authors describe three forms of hypospadia, all dependent upon the stage of growth. Thus we have: (а) Balanic or Glandular Hypospadia. In this variety the urethral opening exists in the lower surface of the glans. In some instances the glans is bifid on its lower surface. (б) Penile Hypospadia, in which the urethral orifice may be situated in any portion of the under surface of the penis, from the base of the glans to the peno-scrota] angle. (c) Scrotal Hypospadia. Here the development was checked early, the scrotum not yet having fully formed. This variety is'very puzzling and has led to embarrassing mistakes. In such cases the glans may consist of a mere tubercle and the bifid scrotum resembles the labia of the female rendering it difficult to distinguish the sex of the new born. I distinctly recall to mind the case of a young man who was supposed to be a girl until the age of puberty; he dressed as a girl and associated with girls. At the age of about 17 years his strong voice and rapidly growing neck attracted the attention of the curious and a medical examination sud- SCHAEFER: SURGICAL CLINIC. 3 denly converted the girl (?) into a boy, in so far as clothes were concerned. The surgeon's knife did the rest. The present case is a cross between the 2d and 3d varieties. The scrotum seems almost complete but the urethral orifice is located within its anterior border. This condition of the child is a source of great anxiety to the parents. Fortunately it is within our power to relieve their anxiety to a considerable extent. By surgical interference we can improve the organ not only in appearance, but make it functionally useful. The ancient surgeons are said to have endeavored to remedy this condition by burning a tunnel through the penile tissue with heated iron rods, a most barbarous and clumsy procedure. The most satisfactory method devised up to the present time, for operating for hypospadia, is that of M. Duplay, in three stages: First, to straighten and elongate the penis. Second, to form a new canal from the meatus to the- hypospadic opening. Third, to form a juncture of the two portions of the- canal. The first stage I carried out with this child two weeks ago. The penis was straightened and lengthened about one and a half inches. The incision was made directly under the glans, transversely across, obliquely downwards and backwards into the corpora cavernosa. The glans having- been drawn forwards with the free hand as the knife sank into the tissue. After the operation the penis presented the appearance of illustration 2. Since the operation was done the organ has naturally contracted a little. Formerly it had the appearance of illustration 1. Now it is one and a fourth inches longer. The urine trickled down the scrotum: at the present time it flows forward. He formerly cried with pain whenever the urine was voided ; now it does not distress him to pass it. The second and third stages of the operation will be done after the lapse of two or three months, when the tissues will have contracted to the maximum degree. Illustrations 3 and 4 show the methods to be pursued. To form a new canal the penis is held up (Fig. 3) a longitudinal incision several millimetres from the medium 4 SCHAEFER: SURGICAL CLINIC. line ab ab' is made extending from the base of the glans to withimone centimeter or less of the hypospadic opening. The internal lip of the incision is to be slightly raised so that the flap will slip on to the catheter, but not cover it entirely. The external lip to be dissected freely so that the skin of the lateral parts of the penis can be drawn towards the median line. This will turn the cutaneous surface of the inner flap towards the canal. The flaps are to be joined in the median line being held in position by means of quilled sutures (Fig- 4). After the flaps here joined and the canal is established the final step of the operation is completed, viz: to form the junction of the two portions of the canal. This is done by vivifying the edges and stitching over a catheter. SCHAEFER: SURGICAL CLINIC. 5 Excision of the Head of the Humerus. - Lady, aged 30 years. Nervous temperament. Mother of two chil- dren; oldest about 10 years of age. I excised the head of the right humerus three months ago, by Ollier's vertical incision. Some of you will remember having been present at the time The periosteum was lifted up from the greater and lesser tuberosities. The larger portion of both of these prominences, together with the head of the bone, were removed. This was a case of caries sicca resultant from syphilis. The patient had, it was supposed, inherited the disease, as she never presented primary lesions, and her physician claims that her husband has never had it. Six years ago she came accompanied by her husband, and her doctor, to consult me concerning an osteoma located above one of her ears upon the parietal bone. My diagnosis was a syphilitic neoplasm, and alterative treatment was recommended. Under the exhibition of mercury and iodide of potash the tumor disappeared; but at different times during three years other symptoms of the hydra-headed monster appeared. The last and most serious manifesta- tions led to the loss of the proximal end of the right humerus. This is about well. She uses her arm in her daily work about home, sweeps the floors, irons, washes, scrubs and makes bread. She can lift the humerus to an angle of 20° with the shoulder. Has no difficulty in flexing the forearm. Can touch the left shoulder with the right hand. Can place the right hand upon her head without bending the neck. Extension is not yet perfect. The faradic current should be applied frequently to the muscles of the shoulders and arm and she must practice various motions daily. Massage treatment will be of great service to her. In a few weeks her arm will be much stronger. Osteo-Myelitis with destruction of the greater-portion of the left tibia. Recovery with useful leg. Amputation through upper third of the right tibia. Patient 41 years of age. Sus- tained a compound fracture of both legs below the knee. While working in an iron mine in northern Michigan the roof gave away and hundreds of pounds of earth and ore fell onto his legs. The accident-occurred over two years ago. He was treated from spring until late in the summer of 1892, 6 SCHAEFER: SURGICAL CLINIC. at the hospital of the mines and was then sent to Chicago. Here he was treated successively in four hospitals. In the first hospital which he entered several operations were done on him. An effort was made, he states, to save both legs. After a few weeks sojourn there the right leg was amputated below the upper third. The left leg had also been broken just below the head of the tibia. Union took place here, but a diffuse osteo-myelitis extended through the length of the tibia. The entire anterior border of the bone, together with a great portion of the inner surface was destroyed by the inflammatory process. Three times bone chips wTere packed into the cavity of the tibia by two dif- ferent surgeons. . Each time the procedure proved a failure. At the second hospital he says the skin-what there was left of it-was nailed into the floor of the deep groove of the bone. This also failed. He was then advised to have the leg amputated. His friends took him to a third hospital and from thence he was brought to Wesley Hospital just before the holidays in 1892. At that time there was a diffuse osteo- myelitis extending from end to end through the tibia, ac- companied by a phlegmonous inflammation of the cellular tissue and integument from the knee to the ankle. There was gangrenous skin and a great deal of pus in the floor of the tibial gutter. The interior of the head of the tibia was suppurating. Knee was ankylosed. Altogether the case was a most unpromising one, and the temptation to ampu- tate above the knee was great. The patient wanted me to try to save the leg. I reluctantly consented after telling him that it meant months of wTork with the possibility of fail- ure in the end, and he replied that time was no object. His friends would stand by him if it took two years, and he wanted to take the chances. For three weeks the leg was subjected to continuous warm water irrigation night and day with now and then an hour's cessation. The parts were kept covered with boric acid gauze, the water soaked through and was guided away by a rubber trough placed be- low a hammock splint. In the meantime iron and quinine were given in moderate doses. After three weeks the inflam- mation subsided and I cleaned the bone out from end to end; scraped out the entire medullary groove and chiseled away SCHAEFER: SURGICAL CLINIC. 7 a great portion of the posterior wall, excavating the tibial head until only a thin shell was left. In fact there remained only an open shell of the entire tibia. The anterior border, two thirds of the inner surface, and a considerable portion of the outer surface of the bone was gone. The entire wound was kept scrupulously clean. In a short time healthy gran- ulations sprang up from the whole denuded surface. After many months of patient waiting, persevering treatment and repeated operations we were rewarded with a complete cure. You notice there is only a little depression left in the head of the tibia, perhaps f of an inch by A inch wide, where there had been a cavity large enough to hold a small orange. The groove from the head of the bone to the ankle is almost completely filled. It is entirely covered with skin. The small depression at the upper end was lined by grafts after Thiersch's method. Last July the stump of the amputated limb distressed him with constant neuralgic pain night and day. It troubled him more than the right leg. A nerve was evidently entangled in the cicatrix. A reamputation one inch higher was done, the nerve found and cut short. This put an end to his sufferings. Passive motion has given sufficient suppleness to the knee-joint so that he can bend it readily to a right angle. He now has an artificial right leg and takes great pleasure in walking about with a cane. You will doubtless agree with him that the left leg is better than a wooden one. He feels abundantly rewarded for the time spent in saving it. We had the advantage of other institu- tions in keeping him a sufficient length of time to conduct the case to a successful issue. Scalp Restored by Skin Grafting. -It gives me pleasure to show you how an extensive wound, in fact an entire skull, was covered with a new integument by means of skin-grafting. This young lady was scalped by machinery, in a laundry nearly eight yeaas ago. The scalp was taken off from the eye lashes to a point two inches be- low the superior curved line of the occipital bone. The na sal bones were crushed and the zygomatic processes were broken off. One e&r was gone and the other hung by a small shred of skin below the external auditory meatus. The sterno-mastoid and trachelo mastoid muscles were exposed 8 SCHAEFER: SURGICAL CLINIC. for two inches from their insertion on the mastoid process while the trapezius muscle was uncovered almost to the shoulder blade as the neck flap of skin dropped away from it. The case was fully published in the Journal of the American Medical Ass'n, June 1893; also in the Transac- tions of the 9th International Medical Congress, 1887, Vol. 3. I simply take the opportunity now of showing the patient, six and a half years after the cure was effected. You see the scaJp is perfect to-day. The method of grafting pursued is my own. 4,500 grafts were placed upon her head The grafts included the derma-the entire thickness of the skin with the sweat glands. Her new scalp sweats. Another in- teresting feature in this case is the fact that there is quite a cushion of connective tissue beneath the scalp. You can "wrinkle " it up at any point and at the forehead you can pull the skin away from the bone nearly an inch. We have thus succeeded in giving the patient a scalp possessing two of the most important qualities for durability and comfort, viz: a loose skin that possesses the power of keeping itself moist. This is the largest area of skin, on record,that was ever produced by grafting upon the cranium. To form an idea of its size mark off an oval surface 18x14 inches in its greatest diameters. You will be surprised at its dimensions. Hydrocele.-The patient now presented before you is thirty-four years of age. Has never had any serious illness and gives a perfect family history. He is a carpenter by oc- cupation. Two years ago he noticed a slight swelling in the left half of the scrotum which he supposed was caused by a strain in jumping from scaffolding. This swelling enlarged from month to month until after a year it formed a tumor larger than two fists. About one year ago it was tapped by a Chicago physician; it disappeared entirely, but gradually returned and is now larger than ever. You notice the scro- tum is enormously enlarged, measuring 16 inches in circum- ference near its lower end, tapering slightly at it ascends but extending into the inguinal canal above. Its vertical circumference is 19 inches. Our patient claims that he has never had gonorrhoea nor syphilis. The tumor fluctuates; by striking one side with a finger a wave is clearly transmit- ted through to the opposite side, the impulse can be plainly SCHAEFER: SURGICAL CLINIC. 9 felt by a finger in contact with it. Light is transmitted through the tumor showing that it is translucent. The scrotum is somewhat pear-shaped. What is your diagnosis'? Hydrocele. Yes. What is a hydrocele'? By this term is understood an accumulation of serous fluid within the vagi nal tunic lining the scrotum, or within the tunic of the sper- natic cord. Hydrocele being located in different portions of the serous membrane as it is related to the cord or testicle, it has become convenient to adopt this classification which is com- monly accepted by the profession: Common Inguinal Congenital Vaginal Of the Testicle Encysted Of the Epididymis Of the Tunica Albuginea Hydrocele Diffused Encysted Congenital Of the Spermatic Cord Besides these various conditions we find complications, as an inguinal hernia with any of these forms of hydrocele. Again we may have a vaginal hydrocele co-existing with an encysted hydrocele of the cord, etc. As to the etiology it is claimed that hydrocele is fre- quently secondary to syphilis of the testicle, gonorrhoeal orchitis and malignant disease. Traumatism and general dropsy are among the causes. In the present instance the diagnosis as to hydrocele is easy. Sometimes a hernia is mis- taken for hydrocele. The history here is so clear that we need not stand in fear of treating a rupture for hydrocele. As such accidents have occurred it will be wise for you to make it a rule, if you are in doubt, to review in your minds the different points of vaginal hydrocele and incarcerated hernia as follows: DTFFE RE NTT A L DI AGNOSTS. VAGINAL HYDROCELE. Largest below. Commences gradually. Commences at the bottom of the scrotum, grows up. Cord can be made out above the tumor. INCARCERATED HERNIA. Largest above. Comes on suddenly. Commences at the external ring and grows down. Cord cannot be distinguished. 10 SCHAEFER: SURGICAL CLINIC. Testicle can not always be found. Tumor is tense and fluctuating. Dullness on percussion. Size generally constant for a short period. Translucent. Testicle can usttally be separated from the tumor. Tumor is usually* doughy. Frequently resonant on percussion. Size varies at short intervals. Opaque. It is not encysted, it is therefore not limited to the epid- idymis, tunica albuginea or cord. For obvious reasons it can not be of the congenital variety. It is not an inguinal case for in this form of hydrocele the testicle has not complete- ly descended into the scrotum, and the fluid is confined to the inguinal canal, it may even extend into the abdomen. Here the testicle is low down in the scrotum. We have ex- cluded all but the diffuse variety of the cord. The essentia} difference between this and the vaginal hydrocele lies in the form of the tumor and location of the testicle. In the former the testicle is found below and may even come to the front. In the common vaginal form the tumor nearly al- ways comes to the front and the testicle can sometimes be felt back of it. It is therefore plain that our patient is af- flicted with a vaginal hydrocele, distending the entire vagi- nal sac enormously. The fluid accumulated in consequence of a low grade of inflammation of the serous membrane and as it is of long standing the tunic is in all probabilitv considerably thicken- ed and altered in its structure. The treatment pursued in these cases may be palliative or radical. By palliative treat- ment we mean simply to tap the scrotum and aspirate the fluid, following this with strapping of the scrotum. This is usually unsatisfactory in chronic cases. Acute cases are sometimes cured by it. There are different methods known under the terms radical treatment: 1st consists in withdraw- ing the fluid and injecting iodine into the tunica vaginalis. This, however, fails frequently. Two other methods are left us. One is that of Volk man. (2) It consists in opening the tunica vaginalis scroti from end to end. The incised edge of the scrotum is next stitched to the edge of tne tunica and the wound left open. I, however, prefer another (3) method which seems to my mind more scientific and less dangerous, SCHAEFER: SURGICAL CLINIC. 11 viz: to dissect out the lining of the sac under antiseptic pre- cautions. As our patient is so placed that he can not afford at the present time, to remain in the hospital two or three weeks for the most radical cure, we will simply tap the cyst and inject iodine into it. In forty-eight hours he can go to work. Should the tumor return he says he will come back to us for more radical treatment next August, when he expects to be unemployed. He is a mechanic and must support his family by his daily work. The position of our patient must necessarily govern our choice of methods for treatment in some cases. I now constrict the tumor at its upper portion with my left hand. (The hair was shaved off and the entire scrotum scrubbed with bi-chloride solution.) The trocar and canula are held so that the index finger lies on top, its end coming to within one and half inches of the front of the trocar to form a guard so that the instrument is not inadvertantly forced into the testicle. I now place the point against the front of the scrotum avoiding the veins, and thrust it directly into the vaginal sac. You see the clear straw colored fluid run out. There is nearly a quart of it. We must now be careful to retain the canula in position so that the tincture Of iodine which is injected will go directly into the sac and not into the cellular tissue around it. Having thrown 4 5 of the 50 pr. ct. iodine solution into the sac, I now manipulate the scrotum so as to bring the iodine in contact with the entire lining, only a few drops returning. The rugae in the scrotum completely close the opening,-still it will be a wise precaution towrap the scrotum in iodoform gauze and cotton, covering all with a firmly applied scrotal suspensory bandage. Our patient will go to bed and remain there 24 hours, until the reaction will have somewhat subsided. Occasionally this treatment will cause a high fever for 24 or 48 hours, I therefore prefer to have my patient rest at least a day after submitting to it.