NAL LIBRARY OF MEDICINE NLM 0055M2flA D NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service NLM005542880 fr Syllabus of Lectures surgery. JAMES G. GILCHRIST, A.M., M.D., Professor of Surgery IN THE Ho.MCEOPATHIC MeOICAI, DEPARTMENT OF THE State ITniversity of jowa ■-;■■•>. M n*«>pic. ( Microscopic. Haemorrhage. Immediate effects of trauma-j Separation of parts. ' Disintegration more or less. r Elimination of foreign material. Later consequences. -j Exudation of reparative material. ' Organization of plasma. Surgical repair different from original organization—fills space, but only as a bond of union. [ Protoplasm—Contractility: irritability, fibrilization j Cell-body. Biological cell— Tetanus: (See NXXY. Nerves.) XV. TUMORS. A new tissue; local redundancy; cellular structure, only a caricature of normal tissue. Not hypertrophy; nor hyperplasia. Effects on near pans:—Absorption, displacement, inclusion, infiltration. ETIOLOGY: Exciting causes, traumatism of minor degrees; irrita- tion constant, but not intense; inflammation of low grade; in all a minor lesion, just sufficient to excite hypernutrition. Predisposing causes; Heredity, as furnishing a weak tissue. Sex, as related to profound and repeated crises; as, in women, menstruation, pregnancy, lactation,'etc., women giving more cases of tumor, men more varieties. Age, the critical periods of life: e. g , pub erty and adolescence, giv- ing heteralogous conditions; maturity, homologous; senility or menopause, teratoma. Occupation, as inducing habitual irritation; fatty tumors on shoul- ders; cysts on hip, etc. Mental conditions, isolation, grief, anxiety, mental depression, as in carcinoma. Tissues, as parts frequently irritated: e. g., breast due to lactation; other essential glands; stomach; border line between unlike tis- sues, as lips, etc. Blastodermic theory of Monod and Arthraud: True tumors, and inflammatory or trophic neoplasms. t 1. Teratoma—all layers of blastoderm. True tumors. \ 2. Mixed tumors, two layers of blastoderm. Pure tumors, one layer of blastoderm. Connective-tissue proliferation. rs. 2. t 3. / YLLABt S OF LECTURES ON SURGERY. STRAIN: Overstretching muscles or ligaments; possible rupture of some fibres. Occasional permanent atrophic changes. Not a ■"sprain" (see "Joints".. Rhus., Hula. rest. CONTRACTIONS: Tonic spasms of muscles, at first painful: dis- appear, or modified under anesthesia. Cause, some nerve lesion, near or distant; congenital shortening of muscles; from prolonged use of apparatus: traumatism, as loss of muscular tissue, or mis- placed tendon-insertion. Hysteria. Test: Put part on stretch, ■ •finger point" pressure painful. Phirnb., Strych., Sil.. Rhus., Ruta. Canst, Tenotomy, open—subcutaneous. CONTRACTURE: Old contractions that have ceased to be spas- modic or inflammatory. Atrophy of muscle—fibrous degenera- tion. Agglutination from exudations. Unchanged under anes- thesia, "finger point" pressure not painful. Forcible replace- ment, and immovable dressings. Massage—Galvanism—Tenoto- my (open ?). Nit. Ac, Sil., Led,. Canst. "TRIGGER-FINGER" (Dupuytren's finger contraction): Not mus- cular: contraction of fascia. Section, subcutaneous. TALIPES: (Clubfoot): Contractions (or contractures) of muscles of the leg, twisting the foot in various directions. Congenital, from pressure from coils of uubilical cord, or other intra-uterine accidents—defects in development. Acquired, from accidents, or morbid conditions, that cause false positions of the foot, often as compensation. Accidents to muscles, tendons, or ligaments about foot or ankle. Treatment, search for maintaining cause, to be removed. If contracture, tenotomy—forcible reposition and retention—massage. If contraction, tenotomy—remedies—never forcible replacement. If from deformity of parts from trauma- tism, special indications. Old talipes, past early life, bones dis- torted so that full recovery is doublful, and fascial shortening. Brucca Ant. Pes Equinus: Contraction of muscles of calf; or paralysis of flexors. Walks on toes. Pes Varus: Contraction of tibialis anticus, and other adductors, and flexors; or paralysis of opposing muscles. Walks on outer side of foot. Pes Calcaneo; Contraction of flexors, or paralysis of extensors- Walks on heel. Mixed-forms, as Equina varus, etc., combinations of above. XXIV. SURGERY OF BLOOD-VESSELS. N,KVUS (Birth-mark-Mother's mark): Tumor forms, Angieomata, erectile tumors. Local vascular hypertrophy; increase- in size (and number?) of blood- \ SURGERY OF BLOOD-VESSELS. 43 vessels. From large pendulous tumors, to small flat areas of dis- coloration. Capillary: Flat, non-pulsatile; bright color; irregular outline. Acetic acid. Secale, electrolysis with carbon points. Venous: Varyiug size; dark color; elevated in varying degrees; irregular outline; compressible? Excision, when small; electroly- sis: strangulation; astringent injections. Arterial: Tumor-like; pulsatile; higher temperature; bright cfdor; pulsation controlled by pressure on afferent vessels. Liga- ture of feeding vessels, and as above. 3. VARIX (Varicose veins): Increase in capacity and length of veins. giving tortuosity. Physiological (compensatory), from obstructed veins (as in pregnancy); no lesion at point of varix. Pathologi- cal changes in coats of veins—thinning—thickening—cribriform. In pendulous or unsupported veins. Slightly lowered tempera- ture; staining of part; thinning of integument. Treatment, re- move apparent cause; elastic pressure (or support), Ham V., Nu.r V., Sulph. Support by "reefing;" double ligature; excision of veins. 3. ANEURYSM: A cystic tumor containing blood, communicating with an artery. False: An opening in an artery, and adventitious cyst (hema- toma). True: The walls formed of one or more coats of an artery. F'usiform (tubular); the typical form; sacculated; dissecting. / Aneurysmal varix. Anomalous forms: -j Varicose aneurysm. \ Cirsoid aneurysm. Traumatic (acute), single. .Symptomatic, multiple; aneurysmal diathesis. Etiology: Exciting, increased tension (as in stricture of urethra. or obstinate constipation). Traumatism, as lesion of one or two coats. Predisposing, diseases of coats of artery, atheroma, or fatty degeneration; habits, favoring preceding lesion, as alcohol- ism; occupation; general morbid conditions; sex; age; race. ■Semeiology: Differs in superficial and deep. Superficial, ap- pears suddenly; "stroke with a switeh;" rapid swelling; hot; pul- satile; "struggling under the hand;" proximal pressure diminishes pulsation and swelling; distal increases both; "bruit," blowing, whistling, purring, buzzing, depending upon size of opening, or distance from surface. Deep, obscure, bruit main reliance; in chest, "double heart sound," cough, and dyspiuea: both forms much pain. Diagnosis: Abscess—Hernia—Cystic tumors. Pathology: Traumatic, usually lesion in outer coat; -sacculated. A SYLLART'S OF LECTURES ON SURGERY. rapid progress, soft coaguluin. Symptomatic chronic; outer coat thickened, middle thinned, inner studded with deposits, coagit- lum laminated; commences tubular, becoming sacculated on side of least resistance. At points of division of arteries of first or second magnitude. Absorbs hard parts with which in contact. Prognosis: Natural termination rupture, hemorrhage, death. Occasionally spontaneous cure by organization of clot, and oblit- eration of vessel. Treatment: Object to cause coagulation, organization.of coagu- lum, and obliteration of vessel. Ligature, proximal—distal- double—secondory branch. Pressure digital—mechanical—Es- marchs. Galvanism, injections Secale, per-sulphate of iron; for- eign material as ueuclus for coagulation. Remedies, Lycop., Secale, Gallic Ac, five drop doses. XXV. SURGERY OF THE NERVES. NEURITIS: Inflammation of nerve. Traumatic—Symptomatic— Idiopathic—Acute—chronic. Ordinary signs of inflammation; pain constant, or remittent; sensi- tiveness of nerve to touch or pressure during remittance. (Neu- ralgia, intermittent, and not inflammatory). Pathology: Nerve swollen; infiltration into sheath and neuri- lemma; late stages leading to atrophy or sclerosis. Sometimes a secondary inflammation. Treatment: Allium Cepa. internally, or as poultice. Bell., Ars., Colocy.. Hyperic, Cham., Lycop., Stram.. Tgn., Rhus., Zinc, Sulph. Nerve-stretching, extent determined by condition of the nerve as to atrophy. Excretion. NEUROMA (Subcutaneous painful tubercle): Spuria, tumor of fibrous character, in connection with a nerve or its sheath. Vera. tumor developed from, or containing nerve tissue. Distinguished from "ganglion" by restricted mobility, and sensitiveness. Usu- ally an accompanying neuritis. Excision usually required, with suturing1 nerve with animal ligature. TETANUS (Lock-jaw): A state of tonic spasm, associated with intermittent clonic convulsions, commencing in voluntary muscles, and extending to involuntary. Traumatic, oftener from compound fractures. Idiopathic from sudden lowering of temperature, very often. Symptomatic, in connection with bodily crisis. Infancy. Etiology: Exceedingly obscure. Bacterial? Septic? Periphe- ral—Central. Semeiology: Prodromal, sudden pain, pressive, with nausea SURGERY OF THE HEAD. 45 under the sternum, almost like angina pectoris. Or stiffness and painful contraction of muscles about the jaw (Trismus). Explo- sive, tonic contraction of muscles of the trunk, often abdomen, with frightful clonic convulsions; contractions extend from mus- cle to muscle, until whole body may be distorted. Opisthotonos. body drawn backwards; pleurothotonos, to one side; empro- thotonos, curved forwards, profuse sweat, no fever; face dis- torted, fear, agony; inarticulate moaning; retained consciousness throughout; hypera>sthesia general, slightest unexpected touch. motion, sound, current of air, flash of light, or glistening object brings on convulsions. Contracted muscles like a board or iron- bar. Death comes from extension to involuntary muscles, as diaphram or heart. If recovery aged expression of face perma- nent. Muscles have been torn or bones broken. Hydrophobia in all but the history of a bite from a rabid animal. Pathology- : Negative as to anatomy. Somewhat constant fea- ture hypostatic spots in gray matter of cord. Prognosis: Better in traumatic cases. Better when acute, rapid. and after fifth day. Better if sleep with muscular relaxation. Diagnosis; Epilepsy—Hydrophobia—Strychnia poisoning. Treatment: Profound quiet; no violent restraint. Chloroform? Cwpr Acct., sub-sternal pain, Bell., trismus, Aeon., Cicu Vir., Stram,, Cham., Typical remedies, Nux ^Tom,, Strych. After recovery, Arnica for muscular lameness. XXVI. SURGERY OF THE HEAD. 1. CEREBRAL LOCALIZATION: Important for diagnostic purposes: chiefly in locating motor centres, in present state of knowledge: approximate localization from sutures. S'ujlit, occipital lobes of cerebrum. Hearing, temporal convolutions. Speech, lower third frontal convolutions. r Lower extremities. Motor Centres. -j Upper extremities. ( Face. f Tumor, slow, intermittent, remittent, non-inflammatory. Character of j Effusion rapid, continuous, non-traumatic. lesion. ■ Extravasation, rapid, continuous, abatement. ( Abscess, rapid, traumatic, inflammatory, continuous. 2. COMPRESSION OF BRAIN: Fracture (depressed); harxnorrhage: effusion; foreign bodies; tumors. Stpnptotns come on slowly, at maximum: Coma; cold face; eyes half open; clammy perspiration; "pumping" of larnyx: sterto- rous respiration; frothing at mouth; pupils irresponsive, contract- ed or dilated. 4(i A SYLLABUS of LECTURES ON SURGERY. Prognosis, better in traumatic cases; bad, when breathing becomes irregular, also when extension from one motor area to another. Treatment: Depressed fracture, trephine; or, if fragment is not impacted, Arnica. Effusion, Apis., Hell, Ars. Foreign, bod- ies, remove if accessible. Tumors, the same. Abscess evac- uate. 3. CONCUSSION OF BRAIN (Stunning): A severe jarring injury without fracture. Varies from complete insensibility, to momen- tary confusion of mind. Symptoms come on at once, in full intensity; resemble shock (q. v. ante). In two groups: Primary, Coma, usually answers when spoken to, but relapses again; eyes closed; pulse weak; sphincters and muscles relaxed; cold surface; pale face; respiration shallow slow; dilated pupils. Secondary reaction, returning warmth and consciousness, vomiting; fever and delirium; sometimes encepha- litis. Pathology', often negative; may be a mere molecular derangement, or fluidificatiou of whole or parts of brain. If not fatal, brain lesions may result in sclerosis. Prognosis, usually good, depending upon brain lesion; bad, when coma deepens. Good when vomiting. Remote consequences, vary- ing lesions of brain, as sclerosis, abscess, and irritation. Treatment, entirely medicinal. Am., Camph,, Veratr., or diffu- sible stimuli, by olfaction; Amyl Nitrate, Ammonia. No alcohol, unless subcutaneously (vide "Shock"). L IRRITATION OF THE BRAIN: Concussion, modified by bodily condition, and complicated by laceration of brain mass rather than fluidificatiou. Symptoms come on at once; curling and twisting about, but not convulsive as a rule; face frowning; eyes tightly closed; pupils contracted: incomplete coma, answers when spoken to, but peev- ish and irritable; pulse slow, feeble, skin cold: sometimes deli- rium, shouting, but answers correctly when spoken to. Treatment, as concussion. 5. INFLAMMATION OF BRAIN (Encephalitis): May succeed shock, or any brain lesion. High fever; delirium; holds head in hands; eyes blood-shot, open or shut; pupils contracted (or dilated?); com- plains of pain in head; vessels seen to beat strongly. Prodromal of suppuration. Treatment, Aeon., Bell.. Glon., Hyos., Strain. ii. HERNIA CEREBRI: Protrusion of brain material through open- ing in skull. Traumatic—Fungous mass pulsating synchronously with the heart; if pushed back causes giddiness; syncope. Distinguished from—fungous of dura mater—of cranium—sebaceous cysts. Treatmfnt, excision—pressure—close wound, or fit an obturator. SURGERY' OF THE SPINE AND CORD. 47 XXVir. SURGERY OF THE SPINE AND CORD. Normal curvatures of spine; normal flexions. Pathological curva- tures, exaggerations of normal curves (minor importances or curvatures in opposite or abnormal directions. Results in lesions of cord, chiefly atrophic; alterations in relation of viscera; hence wide range of functional abnormalities. Consequences, often rgidity, through anchylosis, and loss -of normal flexions. Some- times, apparently, continuously progressive. l. LATERAL CURVATURES (Scoliosis:) Most common, and serious: oftener in dorsal spine. Etiology: Muscular deficiencies; deficiency or disability in lower extremities; habitually faulty positions of body; occupation; sex: age. Diagnosis: Back uncovered, sitting, standing, and lying; promi- nence of breast and hip, on side of curvature. Impressions with sheet lead, as guide to progress of treatment. Treatment: Rarely apparatus of any kind, unless consolidation has commenced. Test, the ability to restore normal position. Mainly gymnastics; correct habits in lying, sitting, standing. Compensate for deficiencies. Fencing; suspension; massage. Promote deposition, and prevent absorption, Calc C, or the indi- cated remedy. 2. POSTERIOR CURAATURE (Kiphosis): An exaggerated dorsal curvature, or loss of lumbar (later becoming reversed). Difficult detection in early stages. Similar causes to above. Also treat- ment. 4. ANTERIOR CURVATURE (Lordosis): Exaggerated lumbar curv- ature, or loss of dorsal (later becoming reversed). Cause, oftener some disability in the hip-joint, or lower extremities. Treatment, as above, adding compensatory appliances when from tilting the pelvis from defects in lower extremities. :,. MODIFICATIONS AND COMPLICATIONS: Rotation of vertebra?, in connection with any of the preceding. particularly scoliosis. Gives additional abnormalities in spinal canal. Double Curvatures: As anterior lumbar, and posterior dorsal, or the reverse; lateral, in different directions in each region. Multiple Curvatures: Lateral in one region, and some other form in another, with rotation in one or all. Occasional conse- quence of paralytic affections from spinal lesions. A SYLLABUS OF LECTURES ON SURGERY. ANGULAR CURVATURE (Pott's disease. Spinal caries, or Tuber- culosis): Caries attacking the bodies of vertebrse, usually in middle or lower dorsal, or upper lumbar. Gradual angular de- formity. Etiology: As in caries in general, the exciting cause usually some traumatism. Semeiology: First stage, those of struma generally, with feeding of weakness and pain in the back. Characteristic gait, and man- ner of stooping. Second stage, projection of spinous process in- volved; gait—standing—stooping. Abscess, local pointing, or in groin, loins, or elsewhere. Health visibly impaired; progressive emaciation; urine loaded with bone-salts; sleepless. Third stage. deformity marked; locomotion impossible; often the last stage. Fourth stage, consolidation; anchylosis; permanent deformity, "hump-backed;" health poor, often permanently, from disturb- ances due to altered relations of viscera, and innervation. Pathology-: Gradual destruction of body of vertebra?; may ex- tend to neighboring ones; dislocation backwards, giving sharp angle to spine. In favorable cases, repair as in caries in general, with anchylosis, and gradual partial accommodation to new rela- tions. Prognosis; In early stages good, but anchylosis to be anticipated. Treatment: Before anchylosis, to take off pressure, and main- tain normality of spinal curves. Plaster-jacket with or without jury-mast: other forms of artificial support. Care in making ex- tension. After anchylosis—has commenced or is imminent, no extension, but support to prevent further deformity. In all stages, quiet, and recumbency (or its equivalent); evacuate abscesses as formed; takeoff pressure; and remedies as indicated. Calc C.. Calc ph., Sil., Merc V., Oleum As., Asaf. SPINAL CONCUSSION (Railroad spine): From extreme jarring injuries, as railroad accidents; falls; or continuous concussions from occupation. Symptoms: Prodromal, negative. Second stage, uncertain loco- motor co-ordination, particularly in the dark, or with eyes shut: diminished tendon-reflex. Third stage, progressive analgesia, until complete. At first hyperesthesia, later progressive anesthe- sia. Paralysis ascends. Pathology: Spinal sclerosis (posterior) usually in upper lumbar or lower dorsal, ascending, with atrophy below. Prognosis: Unfavorable in later stages. Treatment: Arg Nit., Pieac, Alum., Secale, Sil, SURGERY' OF THE THROAT AND NECK. 40 XXVIII. SURGERY OF THROAT AND NECK. 1. CUT-THROAT: Usually suicidal; homicidal more dangerous, from the direction of the wound. If fatal, so speedy that no treatment possible. Injuries to air passages, gives immediate danger of apncea from blood in lungs; later pneumonia; more remotely em- physema—distortion of cartilages. Treatment: Arrest haemorrhage; double ligature; suture each tissue separately; bandage to flex neck, and fix head. In suicidal cases tie hands, and constant watch. Swelling (oedema) imminent Aeon., Am., Calend,, Apis. 2. FOREIGN BODIES IN THROAT: Includes oesophagus and air- passages; latter usually protected. Gaseous, irritating vapors of various kinds; usually evanescent, but may induce inflammation. [ Hot—Scalds—oedema, and possible ulceration. y i Cold—Cough, temporary strangulation. 1 Chemicals. \Acl(l [Erosions, ulceration, and dan- ( Alkaline ) ger of adhesions, atresia. Treatment: Neutralize immediate effects by suitable antidotes (acids or alkalies); oedema, Apis., Rhus., Ars; erosions or ulcer- ations. Calend., Bougies to prevent stricture. Sil., for vicious cicatrization. Solid: All sorts of material, as coins, fish-bones, etc. f Size. Consequences depend upon j ' , „ , , , I Material. \ O0IUDie- [ ( Insoluble. Natural course to pass into stomach (or lungs?), ejected by vomiting or coughing. May be held by muscular spasm, or engagement of angles; ulceration and haemorrhage, with cicatricial stricture as final result. Treatment: Remove through mouth, entire or piecemeal. Inci- sion—tracheotomy—oesophogotomy. Push into stomach. Pre- vent vicious scarring by bougies, and Calend,, To correct the same, electrolysis, Sil. 3. 1JRONOHOCELE (Goitre): Enlargement of thyroid body, lobular or entire. Simple hypertrophy—fibrous degeneration—cystic de- generation—angiomatous—various tumor-forms. Etiology', of pure goitre, obscure; silico-fluoride of calcium; snow water; race; sex; age. Symptoms: Local, merely hypertrophy. General, more or less dyspnoea; cardiac irritability; pressure' effects; tension of nerves. Pathology: Local conditions as above; ex-ophthalmic ("Graves A SYLLABUS OF LECTURES ON SURGERY. disease") refers to Practice and Eye and Ear. Association with menstruation. Tumor-forms and malignancy, as general. Diagnosis: Moves up and down, with trachea. Prognosis: In simple goitre, no special danger, apart from pres- sure, and tension on nerves, Unfavorable in tumor-formations, in proportion to malignancy. "Graves disease," serious. Loss of gland, myxcedema. Treatment: Depends upon form: Simple trophic, S}>ong., Lapis Alb., Iod., Calc Iod., Baryta C, Cystic, tapping and Iod., or Bell., Pulsatile, ligature of arteries, and electrolysis. Tiunor- fonns. ligature of arteries—division of isthmus—enucleation, only partial on account of myxcedema. TOR ITCOLLIS (Wry-neck): Muscular contraction or contracture; mostly of sterno-mastoid, but other muscles and fascia added, occasionally. Bad effects on cervical spine. Congenital, often from rupture of muscle at birth. Acquired from various inflammatory, neurotic, or traumatic causes. Treatment: Careful tenotomy, and immediate reposition of head, as nearly as may be. TUMORS OF NEtJK: Trophic, of sub maxillary, parotid or other glands; congenital cyst (hydrocele of neck). Fibroma, lipoma, sarcoma, in order of frequency, or true carcinoma. XXIX. SURGERY OF THE CHEST. FOREIGN BODIES: Find entrance through air passages, or wound of thorax. Lodging in lungs, can only be removed by migration to trachea, in mucus, or suppuration. More or less motion gives rise to inflammation. When in trachea, tracheotomy. In lungs, accurately located, may be readied by incision and costal resec- tion. In rare cases, become encysted. If through a wound, and cannot be reached thereby, keep wound open, and discharge may bring it within reach. Want of continuity in wound an embarras- ment. Resulting inflammation. Aeon., Am. TUMORS OF BREAST: Of all varieties. Women, largest number; men, greatest variety. More tumors of breast than any other region, from functional activ- ity, and exposure to injury. For practical purposes, discriminate between, solid, cystic—inno- cent, malignant. Innocent Tumors: Solid, any period of life; rapid growth; pain- less; retains form of organ; usually becomes detached from tho- rax; if axillary glands implicated, not persistent, or painful. Cysts, smoothly globular, elastic or fluctuating. Perhaps more rapid growth. SURGERY OF THE ABDOMEN AND INTESTINAL TRACT. 51 /.Malignant Tumors: Oftener scirrhus; after fortieth year. Oc- cult stage, steady, slow growth; "square'' outline; nipple early retracted; painful; breast at first atrophies; adhesions to thorax: skin adherent; tortuous veins; dark color; stony hardness; Nod- ular; axillary and other glands implicated, persistent, hard, and painful; may be multiple, but usually single. Duration two to six years. Open stage. Nodules soften; ulcerate; small, deep. multiple ulcers; narrow areola; "crater" like; coalesce; extend in depth, superficially; indurated edges; irregular; painful; cachexia. Neuralgic concomitants; prodromal sciatica. Duration one to two years; from commencement six to eight years. Prognosis: Innocent growth may take on malignant characters: while innocent, prognosis good. Malignant tumors, before adhe- sion prognosis fair; after adhesion doubtful; after glandular ex- tension bad, hopeless. Occasional atrophy and elimination. Treatment: In all innocent tumors, and innocent stage of malig- nant, amputation of breast. If adhesions commencing, include integument, subjacent structures, and enucleation of all suspi- cious glands. Primary union not desirable. Remedies not to be used. Too much risk. 3. VISCERAL LESIONS: In general, great danger from haemorrhage and shock. Heart: Wounds of not necessarily fatal; depend upon kind, and location. Incised wounds, of auricles fatal; of ventricles some- what on direction, whether parallel or transverse as to muscular fibres. May be non-penetrating. Gun-shot'injuries, usually ex- tensive disorganization. Contusions of heart, serious impairment of function. Treatment of all heart lesions expectant. Lungs: Haemorrhage, coagulation. If solidifies, life may con- tinue. Suppuration, or other disorganization, destruction of lungs or life. Treatment expectant; enforced quietude. XXX. SURGERY OF THE ABDOMEN AND INTESTINAL TRACT. I. FOREIGN BODIES: In stomach or intestines; from mouth, or wound. If insoluble, spas- modic retention; ulceration; perforation; hemorrhage. Disposi- tion to pass through the canal, if not too large for pylorus, and ileo-ccecal valve. Otherwise to be removed by gastrotomy. 3. VISCERAL LESIONS: Contusions—lacerations—or various wounds. Contusions, nega- tive symptoms, usually only weight and some functional change. A SYLLABUS OF LECTURES ON SURGERY'. as icterus, in case of liver. Arnica, usually curative, and no sequelae; at times inflammation, adhesions, or suppuration. Lac- ceration (aggravated contusions), or Wounds, serious from haemorrhage (concealed), and possible peritonitis. Other indica- tions various. Stomach, vomiting of blood, and injesta in wound. Intestines, bloody stools, contents in wound, and tympanitis. Liver, Spleen, Pancreas, weight in region, sensitiveness; later functional changes, e. g. icterus, anaemia (?), fatty stools. Kid- neys and Bladder, bloody urine. Where bleeding suspected, laporotomy, and ligature, or haemostatics. Wounds of stomach, intestines, or bladder suture. After-treatment, as laporotoinies in general. HERNIA ABDOM1NALIS: Protrusion of viscera, through natural or accidental opening; ap- plies to any visceral cavity; without qualification, abdomen under- stood. r Congenital—Anatomical deficiencies, or ab- Time of appearance j normalities. ' Acquired—Traumatism. Duration \ Recent—No change in structure or relation. I Ancient—Changes in do do IEnterocele—Sound in reduction. Significance. Epiplocele—Sound in do Entero—epiplocele. . | Reducible—Spontaneous, or mechanically. 'llty'' Irreducible--! Strauglllated-acute- ( Incarcerated—chronic. Extent -I Pai*tial—Bubonocele. ( Complete—Scrotal—Pudendal. i Direct—Internal—Traumatic. Acquired. Inguinal. -j Oblique—External. Congenital. ' Straight—External. Old oblique. Location. \ Femoral—More in women. Congenital or acquired. Umbilical. Congenital, or acquired. Ischiatic—Traumatic. I Ventral. Traumatic. Etiology: Exciting causes, sudden diminution in capacity of ab- domen: wounds of abdominal parieties. Predisposimt causes, natural, congenital, or acquired. Natural—the existence of openings. f Preternatural elongation of the mesentery. ,, ., , j Patency of the vaginal process of the peritoneum. < ongenital J. Ar . , _ . j Muscular deficiencies. I Unusual size of openings. SURGERY OF THE ABDOMEN AND INTESTINAL TRACT. 5o i Intestinal or vesical obstructions; Occupation—Sex—Age. Wounds (scars) of parieties. Semeiology: Recent hernia, after some effort a tearing pain (aneurysm, blow with a switch; ruptured tendon, blow with a stick). Protrusion—sharp pain—tenesmus—puffing up of tumor —elastic—sensitive—soon becoming hot and inflamed. If not reduced becomes strangulated (q. v.). Ancient hernia, protrusion more when standing, and in morning; less when lying. "Cough impulse." Irreducible hernia, "incarcerated," constant protrusion, lessened when lying down. "Cough impulse." Strangulated, rapidly in- creasing inflammation and tenderness; fever; vomiting, later becoming stercoraceous; collapse: death. Or, plastic exudations. adhesions, and incarceration. Or, fcecal fistula, and artificial anus. Pathology: Recent hernia, possibly rupture of some fibres, or protective fascia; if reduced probable repair; if becomes ancient. gradually elongation of mesentery; thickening of sac; enlarge- ment of opening; atrophy of muscular fibres; agglutination of envelopes; alteration of relations. If strangulated, obstructed circulation; inflammation: exudation or gangrene. Complications, often hydrocele, or varicocele. Prognosis: The existence of hernia alivays a menace to life, from danger of strangulation. Diagnosis: Aneurysm—Abscess—Hydrocele—Varicocele—Haema- tocele—Sarcocele—Labial (or other) cysts. Treatment: Depends upon conditions: Recent hernia, involves: f Taxis—Position—Anesthesia. Possible internal her nia; rupture. ! Compression, elastic. Rupture, or gangrene. Reduction, i „ , ,. i Congelation. | Aspiration—Possible fcecal fistula. I Inversion. Retention, by suitable truss, or equivalent. Strangulated hernia, only rational treatment herniotomj'. Divide fascial envelopes—open sac—incise constriction—suture canal. If gangrene, enterectomy, and unite intestines by primary or sec- ondary operation. Incarcerated hernia, as above, if adhesion can be broken up. If not, enlarge opening, to lessen danger of future strangulation, or enterectomy. Ancient hernia, truss if effectual, and Lycop., to shorten mesen- tery; if ineffectual, herniotomy. Essential features, obliterate sac—diminish opening—shorten mesentery (Lycop). a syllabi's of lectures on surgery. Intestinal Obstruction: Acute: Volvulus; twisting of pendulous portions, from rotation of body. Colon, or mesentery (?). Intussusception (invagination), telescoping one portion into another, from violent peristalsis. Probably common in minor degrees. Small intestine. Internal hernia, rent in mesentery: knuckle of intestine engaged therein. Traumatism. Small intestine. Symptoms: Violent pain, at first localized, then diffused; disten- sion of intestine commencing at point of obstruction; extending inwards, "sausage feeling,"on palpation; fever; anxiety; hiccough; gangrene; collapse. Sometimes sloughing of large masses, and recovery. Pathology-: Similar to hernia. Next to obstruction, inflamma- tion prominent, with exudation and adhesions; or gangrene and sloughing. Diagnosis: Impacted faeces; renal, or billiary calculus; perito- nitis. Prognosis: Grave, although apparently hopeless cases have recov- ered without functional loss. Chronic: Paralysis of intestines—pressure of tumors—malig- nant disease—cicatricial bands—strictures. Symptoms: Similar to acute, but less severe, and coming on slow- ly. Acute symptoms may intervene, sacculation above stricture, faecal accumulation, and volvulus or intussusception. Prognosis: Not good. Treatment: Malignant cases, expectant, or laporotomy and en- terectomy: Colotomy, and artificial arms. Non-malignant cases. laporotomy, and remove causes, or as above. HEMORRHOIDS (Piles): Originally varix of veins in anal region, later fibrous organization. (a) External. Acute:- Varying etiology: sedentary habits, standing occupation, prolonged constipation, habitual diarrhoea. Burning and itching in anus; soon smarting, tenesmus; painful stools, hard or soft; tense, more or less globular masses, about verge of arms, and within sphincter, painful to touch; forced beyond sphincter, held by spasm, and sufferings increased. Rup- ture, haemorrhage, and gradual subsidence. Remain often, as hypertrophied masses, easily inflaming. (b) External Chronic: From repetition of acute attacks. Masses like folds of thickened skin, flattened, or globular. May cause no symptoms; take on frequent inflammations: various reflexes. Treatment: Acute forms easily cured by proper remedy. Aloes, ^Escul,, Ham., Nux Vom., Petrol.. Sulph. Correct causative condition. If very painful, open with lancet, turn out clot, cold applications. SURGERY of urinary APPARATUS. no Chronic forms, if frequently inflamed, or causing reflexes, excision: care about scar. Remedies little value. -Sit. (c) Internal Piles: Between the sphincters, usually in rows. Arterial, or venous; villous (sessile), or pedunculated. Usually bleed freely; become inflamed, and symptoms violent. Reflexes numerous and important. Itching of anus and perineum; oozing of mucus: soreness of adjacent parts. Treatment: Mostly remedies as above. Nit Ac, Mur Ac. Merc, Graph,, Sil., Bell., Pids., Arsen. In bad cases, excision, or of whole pile-bearing tissues between the sphincters. Care about contracting scar. FISTULA IN ANO (Rectal fistula): A fistula opening in neighborhood of anus, caused by abscess, from traumatism, lodgment of foreign material, or tuberculous pro- cesses; opens on integument, or just within anal verge (in mucous folds), single or multiple. Communicating with bowel or not: blind external—blind internal—complete. Treatment: As fistula elsewhere. Destroy pyogenic lining; exci- sion—caustics—ligature (?). Paralyze sphincters. FISSURES OF ANUS: Rhugadcs in mucous membrane, extending to sphincter. Sympto- matic or traumatic; often (perhaps always) an ulcer. Intense pain, during and after stool; burning; agonizing. Reflexes num- erous and important. Treatment: Chiefly paralysis of sphincter. Bell., Graph., Nit ac, Paeonia, Ratanhia. XXXI. SURGERY OF URINARY APPA- RATUS. FOREIGN BODIES: In urethra from broken catheters, etc.; lodgment of calculi from bladder. Consequences, inflammation—ulceration—perforation— cicatrical stricture. Extract with forceps; urgency, incision. Bladder, renal or vesical calculi (q. v.): portions of instruments: bone-fragments: gun-shot missiles. Practically same as stone. Encrusted with urinary deposits; haemorrhage; cystitis. Female bladder easily reached through urethra. Male bladder, cystoto- • my, supra-pubic, or perineal. RUPTURE OF BLADDER: Contusion or concussion, when bladder is full. Consequences de- pend upon location, with reference to peritoneum, e. g., peritonitis. A SYLLABUS OF LECTURES ON SURGERY'. or pelvic abscess, and possible urinary fistula. Fruitless urging to urinate; catheterization, nothing, or only blood. Prognosis depends upon site of tear; lower parts, bad; upper, bet- ter, excepting as to peritonitis. Treatment, epicystotomy; flushing pelvis and peritoneum; careful suturing; retained catheter. Aeon-, Ars., Rhus. PERINEAL FISTULA: Urinary fistula opening on perineum; from abscess in pelvis, or impermeability of urethra. First indication, to restore urethra; next to close fistula, which is often spontaneous. URINARY LITHIASIS: Formation of calculi, in any portion of the urinary tract. May be renal—uretal—vesical—or urethral. (a) Renal Litiiiasis (Gravel). Calculi formed in kidney. Composition of urine 5% solids; incon- stant composition; manner of elimination, and significance of process. Increase in solids (s. g.) gives change in reaction, e. g. Acid ■? L 1"" *.111"10' acid. oxalate. Alkaline j Uric (lithic) I Calcic oxala f Calcic phosphate, i Amorphous. ( Crystalline. ] Triple phosphate (Am. Mag. Ph). \ Stellate- I ( Rhombic Rhombic. Essential to calculus, increase s. g.; lowered temperature; presence of a nucleus. Forms in tubules, gaining bulk by accretion. In- fluence of climate—race—water—food. Pass to bladder. Nephritic colic. Fate ■' 1 ' Retained in tubule. \ Hydro-nephrosis. ( Pvo-nephrosis. Semeiology': Nephralgia (nephritic colic): Sudden, intense pain, in loin, extending to groin, perineum, and meatus. Frequent, small urination, or ineffectual urging; later vomiting, sudden ces- sation of pain, and profuse urination, often bringing the stone with it. Duration, one hour, to several days. Habitual, no colic; quantities of inorganic sediment. Hydro-nephrosis, often no symptoms. Gradual fullness in renal region; deep fluctuation. At first diminished urine; later normal quantity. Aspiration only positive sign; when rapid, symptoms of uraemia; very obscure. Pyo-nephrosis, chill; fever: swelling and tenderness in renal region: usual signs of deep abscess; pus in urine; aspiration only posi- tive sign. Stone may pass out through vagina, rectum, pelvis, or loins. Treatment; For the diathesis, correct habits, diet, etc. Uric SURGERY' OF URINARY' APPARATUS. ■">' acid. Ars.,Lye, Cliam., Sep., Calcic oxalate. Nitro Mur Ac. In general, Berber., Calc C (or ph)., Phos Ac, Benz Ac. Pyo-nephrosis. Aspiration; nephrotomy; extraction of stone; or nephrectomy. Nephritic Colic. No opiates. Chin., Lycop. (b) Uretal Calculus: Usually lodgment of renal stone. May be stricture ureter, saccula- tion, decomposition of residual urine. Symptoms obscure. When of renal origin, imperfect termination of colic, and gradual hydro- nephrosis. May be reached through rectum or vagina. Treatment, expectant, as when discovered kidney usually much disorganized. (c) Vesical Calculus (Stone in the Bladder). Originate in bladder, from decomposition of residual urine; nucleus of blood, pus, mucus; foreign bodies. No lithiasis. Oxaluria. Renal origin, calculus not passing out of bladder. Soft nucleus gives acid body; hard nucleus, alkaline. Simple—Compound—Alternating—Free—Encysted. Single, usually vesical origin; possibly no morbid action. Multiple, renal origin; showing lithic diathesis. Distinguished between fracture of originally single stone and multiple stone. Characters may determine source, i. e., lithic disease, or accidental chemical action in bladder. Calculus. Number. Size. Weight. Shape. Color. Odor. Consistence Surface. Uric Acld . 1 to 1,000. Pea to pig-eon's egg. 5 gr. to 2 oz. or more. Ovoid, irreg-ular; smooth corners from attrition. Yellow, or pale brown. Urinous. Hard. Smooth. Calcic Oxalate . 1 to 3. Same. Heavier than above. Ovoid, regular. Brown or black. Seminal. Very hard. Tuberculated " Mulberry." Triple PnosnPATE. 1 or others from frag-ments. Pigeon's egg, to fist, or larger. Light, may float on water Irregularly spherical. White, or yellowish. Ammonia. Friable. Irregular. Calcic Phosphate . As above or like paste, or mortar. As above. As above. As above, or irregular form, mould-ed by bed. Grayish white. Foetid. Soft. Irregular, " worm-eaten." SURGERY' OF THE MALE GENITAL* 50 Semeiology: Sometimes no symptoms, as encysted. Again, sud- den symptoms, as thrown out of encystment. Distinguished from cystitis, or irritable bladder. national Signs, irritation at meatus; frequent urination: sudden stoppage of stream; weight in perineum; rolling in bladder: later, cystitis, mucus, pus, blood. Advanced stages, symptoms very urgent. Positive signs, touching stone with sound. But, / Mistake sacrum for stone. Sources of error. ■] Rings, or ornaments on watch-chain. ' Enlarged prostate. i Encysted stone. } Floating calculus. ( Soft consistency. Pathology: Bladder thickened; pouched; contracted; inflamed, particularly at neck, where ecchyrnosis or erosion from impact of stone. Treatment: To dissolve (disintegrate) stone by chemical agents: lithia water, Getteysburgh water, etc. Failing, then remove stone from bladder, and treat lithiasis, if exists. Crushing. | Lithotripsy, ( Litholopaxy. ( Median. Perineal. -j Lateral. T... , i IBi-lateral. Lithotomy. j j Supra-pubic (epicystotomy). Vaginal. [ Rectal. (d) Urethral Calculus: Lodgment in urethra, in passage from the bladder; or originates interior to stricture, as in uretal calculus. Diagnosis simple. Extraction by forceps, or section. XXXII. SURGERY OF THE MALE GENITALS. PHIMOSIS: Defect of prepuce, preventing retraction. Congenital, usually very long, with small opening; often adhesions. Acquired (acute), from some inflammatory affection (gonorrhaea), or traum- atism. Consequences, local, erosions, from smegma, and adhe- sions to glaus. General, various reflexes. Treatment: In old, acquired, or congenited, circumscision; split- ting; combination. Mucous membrane chief obstacle. Careful A SY'LLABUS OF LECTURES ON SURGERY'. management of adhesions. Recent acquired, remedies as indica ted. Aeon., Bell., Rhus. PARAPHIMOSIS. Retraction of prepuce behind corona. Accidental. Inflammation rapidly induced, and increasing difficulty in replacement. Danger of strangulation and gangrene. Treatment: On principle of dislocation—first increase deformity; thumbs on glans, fingers behind constriction. Retraction, and division of constricting ring, with director and blunt-pointed knife. Aeon., Am., Bell., Rhus., after reduction. SARCOCELE: Tumor of scrotum, usually commencing in testicle; of any variety; chiefly fibroma, sarcoma, or malignant. Swelling begins at bot- tom of scrotum, slowly extending upwards; chronic; non-inflam- matory. Treatment: Excision in all cases. Suspension for temporary relief. HEMATOCELE: Blood-cyst (haematoma) of scrotum, usually within tunica vaginalis. Acute; traumatic: commences in bottom of scrotum; globular or pyriform shape; dark color; ecchymotic; opaque. Treatment: Avoid opening. Am., Coni.. Ham., and compres- sion. If degeneration occurs, open freely, wash out, and examine testicle for lesion. HYDROCELE: Dropsy of tunica vaginalis, or the cord. Chronic; usually non- traumatic. Tunica vaginalis, commences in bottom of scrotum; globular, or pyriform; light; translucent; painless. Of the Cord, may extend from the former; or commence higher up. Irregular form, resembling hernia, or varicocele. A frequent complication of other scrotal diseases. Treatment: Recent cases, Sil., Hell., Ranunc B., Apis. Aspi- ration, and Sil. "Long incision." Excision. VARICOCELE: Varix of veins of scrotum, or (labia); oftener on left side. Chronic; commences lower and back part of scrotum; irregular enlargement; feels like a mass of worms: somewhat smaller when lying; often some "coldness" and relaxation of scrotum; atrophy of testicle; various reflexes. Treatment: Recent cases, suspension, Ham., Nux V., Sulph,, Aloes. Chronic, "reefing" scrotum; ligature, single or double: ligature and division; ligature and excision. MALFORMATIONS AND ARRESTED DEVELOPMENT. bl 7. ORCHITIS (Hernia Humoralis; Epididymitis): Inflammation of epididymus, usually involving testicle. Acute; symptomatic, or traumatic; concomitant of gonorrhoea; hard swel- ling, ovoid or spherical; painful; sensitive; fever; slowly declin- ing; a permanent "button" at lower extremity of epididymus. Sometimes abscess. Trfatment: Support; hot fomentations. Aur Met., Am., Bell., Com., Phytol., Sil,, Cicuta V., Puis. XXXIII. MALFORMATIONS AND ARREST- ED DEVELOPMENT. 1. HARE-LIP: Congenital fissure of the upper lip. Arrested development. (a) Single, never in middle line; associated with some abnormality in jaw. (b) Double, fissure on each side of median line; the space of the intra-maxilary bone. (c) Complicated,, by fissure of hard palate; fissure of alveolus; pro- jection of intra-maxilary bone; extending into nares. Consti- tutes an imperfect cleft-palate: a disability in all forms, from sim- ple obstacle in suckling to deformity of jaw. Treatment: Operation as early as possible; at all events before dentition. Cases of post natal completion of development under Calc C. 2. CLEFT PALATE: Congenital fissure in palate, hard, soft, or both. Arrested develop- ment. Partial, in soft palate only, or extending to alveolus. Complete, extending through jaw, and hare-lip. Constitutes disability as to phonation, and deglutition; often, conse- quently, innutrition. Treatment; Operation (staphyloraphy), after second year or later. As to phonation, sometimes better results from obturator. If hare-lip, closure will often close palate, particularly with Cede C. 3. SPINA BIFIDA: Congenital deficiency in arches of one or more vertebrae, oftener in lumbar spine. Arrested development. An elastic tumor, increasing slowly in size; emptied by compression but quickly fills again; pressure sometimes causes convulsions. Oftener simple distension of meninges by cerebro-spinal fluid; again abnormalities' in spinal nerves, with arrested development of lower extremities. 62 A SYLLABUS OF LECTURES ON SURGERY'. Treatment: Elastic pressure, and Calc C. In old cases, or large tumors, aspiration, pressure, Calc C. Post-natal completion of development common. 4. EXTROPHY OF BLADDER: Deficiency in abdominal walls, and anterior wall of bladder. Ar- rested development. Often accompanied by abnormalities in genital apparatus, e. g. Hypospadius. Epispadius, etc. Treatment: Operation. No records of spontaneous cure. 5. WEB-FINGERS: Often hereditary defect. Of toes also. Frequently associated with supernumerary (rudimentary) members. Operative treatment. XXXIV. OUTLINES OF OPERATIVE SURGERY. Legal Questions: Competency of patient to consent; responsi- bility for departure from standard methods. Classification: Emergency—expediency. Major—minor. For- mal, informal (impromptu). Capital. Primary, secondary, inter- mediary. Objects: Save life, or function; remove blemish, or disability. Requirements: Knowledge of regional anatomy. Manual dex- terity. Mechanical knowledge. Boldness, with caution. 1. Preliminary; Establish necessity, to satisfaction of all con- cerned . Settle responsibility. Plan line of incisions. Estimate possible obstacles. 2. Preparatory: Commit to writing, articles provided by oper- ator, and by family or attendants. Secure sufficient and adequate assistance, in capital cases, particularly, for division of responsi- bility. Fix time, e. g. Season—weather—hour—room. 3. Operation: Punctuality. Compare list of wants. Test anes- thetic. Assistants to attend to appointed duties only. i. After treatment: If not conducted in person, put in writ- ing. Contributory negligence. c JUN7 i9fi0 Ui'iSi-^ U: m NLM005542880