Introduction and Background

CLINICAL TALKS ON Minor Surgery y JAMES G. MUMFORD, M.D. ASSISTANT VISITING SURGEON TO THE MASSACHUSETTS GenerAL Hospital, AND INSTRUCTOR IN SURGERY, Harvarp University Mepica ScHoou. BOSTON The OX Corner Bookstore INCORPORATED 27 AND 29 BROMFIELD STREET CopyricHT, 1903 By James G. Mumrorp, M.D. The Fort Hill Press SAMUEL USHER 176 To 184 HIGH STREET BOSTON, MASS. 10 Maurice Howe Ricuarpson, M.D. In recognition of eighteen years of instruction in good surgery, this little book is cordially inscribed by THe WRITER NOTE Tuis series of brief talks is the outcome of an inti- mate dealing as a teacher with medical students for some ten years, and a realization of certain of their needs. I have treated here of homely, commonplace subjects. Such subjects find little place in the text- books and lend themselves but feebly to brilliancy of demonstration. The cases described and the printed words are reproductions of actual experience. j.G.M. 29 Commonwealth Avenue, Boston, May, 1903. CONTENTS PAGS Lecture I. The Examination and Study of Cases 1 Lecture II. Incised Wounds Soy oe 8 a Lecture III. Simple Fractures 9. sss o27 Lecture IV. Lacerated Wounds . . . . 36 Lecture V. Compound Fractures see 4g Lecture VI. Granulating Wounds and Varicose Ulers . } ee ee Lecture VII. Felon, Whitlow, Paronychia, Palmar Abscess 5. eee . 67 Lecture VIII. Boils, Carbuncls . . . + 8 Lecture IX. Bunions, Ingrowing Nails, Corns, and ‘Warts Se ee QB LectureX. Massage - . + + ss 10g Clinical Talks on Minor Surgery LECTURE I THE EXAMINATION AND ‘STUDY OF CASES Gentlemen: About twelve years ago, some one coined the phrase ‘‘antiseptic conscience.” I think it was Dr. Kelly of Baltimore. That phrase and the thought it contains were once essential, because twelve years ago most of the men who were doing the surgery of the world belonged to the generation which in its youth knew the old sepsis. To them the principles and practice of antiseptic surgery came halt- ingly and often imperfectly. They had indeed need to cultivate the antiseptic conscience: but they had conscience for many other things, —great principles underlying good surgery, principles as important to-day as ever they were. One is impressed at times with the con- viction that many of those sound, ancient 1 2 CLINICAL TALKS principles latterly are being pushed back into a very subordinate position. To-day a majority of the surgeons in active practice have grown up with the antiseptic idea. In the course of their development, the antiseptic conscience has become part of their being. That intangible thing which we call surgical instinct includes and partakes of that same conscience. There is no danger of any man who has received his training in the past twenty years going far astray, with that con- science to prompt him. Every source of surgi- cal infection has been so thoroughly and univer- sally studied that, with one or two exceptions which I must speak of later, our technique is now perfect, or as near perfection as it is likely to become. But there are those other principles which were so important to the former generations. Are you students of to-day aware of them? Is it not a fact that you have come to look upon asepsis as the one thing needful, and to feel that, asepsis being accomplished, there is noth- ing more to be done? Are you to be as good clinicians as were your surgical forebears? That is a question which your teachers often ask themselves; over which they hesitate in the answer. If I name some of those general principles to which I refer they seem commonplace enough, ON MINOR SURGERY 3 and most of you will say, perhaps, that you have them always in mind; but such is not by any means the conclusion of observers who watch the detail of work in our great hospitals. The most important lesson which a surgeon has to learn is to estimate the patient’s general condition. I put that, as essentially above any question of therapeutics. That matter of the general condition is a very large part of diagnosis. You have various routine questions which you ask in a perfunctory fashion: the patient’s age, birthplace, residence, occupa- tion, family history and previous condition of health, and in some sort you learn the answers, — but those answers are not idle babble; they have a very real bearing on the matter in hand. Here, in this surgical clinic, you are altogether too prone to assume that every case you see is an operative one pure and simple, and you look no further. Gentlemen, I am forced to admit and I admit it with chagrin, that the fault lies largely with us, your surgical teachers; it is one of the deplorable results of specialism gone mad. In the old days, it was required of the surgeon that he have a good practical working knowledge of general medicine. Operations were a last resort; John Hunter and Liston told their classes that the knife was an opprobrium, and should be used only when all other means 4 CLINICAL TALKS failed. Of course that extreme view has long ceased to prevail; — modified, first, by the in- troduction of ansthetics and later by the development of asepsis. Indeed for long the pendulum was swinging the other way, when the knife was deemed the only reliable meas- ure. Now, again, thanks to increased knowl- edge, we are appreciating that there are other resources. Every one of those data which the clinical clerk takes down by rote may be of the greatest importance. Age may rule out many things, such as cancer, arteriosclerosis and the like; the place of birth and the race may suggest tuber- culosis or malaria, as may the residence. The other day I saw a case of anthrax of which the diagnosis was rendered probable by the patient’s surroundings ; there are numerous occupation diseases, — lead-poisoning and ‘‘housemaid's- knee” will at once occur to you. That matter of family history or hereditary tendency is im- portant, in spite of the new light we are con- stantly getting on the whole question of eti- ology ; and especially the patient’s previous condition of health is to be studied. Here is a patient who illustrates in his own person many of the points we are considering. You see he is a young man. His age is twenty- three. He is of American parentage and of vigorous stock. He was born, reared, and now ON MINOR SURGERY 5 works in a neighboring town, which has been notorious for its unwholesome location, — being low-lying, ill drained, and inadequately supplied with water. The young fellow is assistant to a sewer contractor, and spent most of last summer overseeing a gang of men engaged in laying drains. In September he became ill with typhoid fever, as appears from his physician’s statement and the story he him- self tells. Typhoid was epidemic in his town. Recovering, after an illness of some two months, he returned to work. After an interval of six months — that is to say, two or three days ago, — he was seized with acute pain in the region of the right shoulder. The pain increased, and is now very severe, —of a boring, throbbing, agonizing character. You see for yourselves that the patient looks like a sick man. He is flushed, with a coated tongue, the bowels are constipated, the urine is scanty and high col- ored. The man supports his arm in his hand; he favors it, as we say, and is evidently in great suffering. On examining him you find his pulse to be bounding and rapid, with a rate of 116, and a blood pressure recorded as 190 by the Riva-Rocci apparatus. When you come to handle the arm, you find some slight swelling and a sense of bogginess about the shoulder joint; but the joint itself is not especially tender on pressure and the 6 CLINICAL TALKS patient seems to refer his pain rather to the head of the humerus. Here is a very definite picture, gentlemen, On the history alone you should be able to make a correct diagnosis. The man is obviously the victim of an acute infectious process. He has been for long exposed to unsanitary conditions, and he has recently had typhoid fever. My assistant has just now found the leucocytosis in his case to be 40,000, and the temperature 104°F, What are we to conclude from this collection of signs and symptoms? There are but two processes which suggest themselves at once — an acute articular rheumatism and an acute osteomyelitis. To distinguish between these two conditions is of the utmost importance. In the two diseases the signs and symptoms are in very many respects identical; but we have two points as guides: the bone rather than the joint is the seat of pain, and the patient has recently had typhoid fever. We know that acute infectious diseases are frequent pre- cursors of osteomyelitis, and we are justified in concluding that we are dealing here with that process. A correct decision is urgent. Thé patient will be admitted to the hospital at once, the shaft of his humerus will be opened and drained, and he will doubtless recover with auseful arm, A few days’ or even hours’ delay ON MINOR SURGERY 7 might mean for him a systemic infection, sep- ticemia, and death. To take up the thread of our main topic again; there is that indefinable thing we call the patient’s General Condition. Believe me, you cannot too soon begin to bear that thought constantly in mind. Old Sir Benjamin Brodie used to say that he could often make a diag- nosis by the smell of a patient’s bedroom. It is unnecessary for us to know such shrewd tricks as that, but you must learn to put all your senses into action. You come here to this clinic, fresh from your laboratory studies. Hitherto you have learned only the uses of the sense of sight, now you must cultivate your hearing, touch, and even smell, like old Sir Benjamin; and you must come gradually to appreciate that nebulous aura of physical condi- tion which every man, sick or well, carries with him. When to these things you add those instruments of precision, the uses of which you are learning, there will be an accuracy and finality to your decisions which were impossible for the ancient men. You will conclude from what I have said that a competent surgeon must be a very thor- oughly-equipped all-round man. Exactly that is my meaning. You must study your general medicine as well as your surgery, and you must follow carefully both sets of clinics. There was 8 CLINICAL TALKS a time, fifty years ago and less, when all sur- geons were general practitioners. Then with the development of specialties came a natural and proper narrowing of the surgeon’s field. For years we devised new operations, we at- tacked organs previously regarded as inaccessi- ble, we learned and perfected a new practice and a new technique. It has come about with this development of our branch of the art of medicine, that many diseases as well as organs have become the surgeon’s own, his own in part at least, — diseases and organs with which he never thought to tamper a few years ago. So again it is becoming apparent that he must be familiar with a great variety of processes which, a few years ago, concerned him little if at all. In that second stage of the surgeon’s develop- ment, he was often little more than a thorough anatomist and a clever handicraftsman. We have outgrown that stage. We now realize that the surgeon must know and be ready to apply the principles of physiology, chemistry, pathology, and bacteriology as well as those of anatomy and physics. He deals with almost every known disease and with every organ of the body. He must be familiar with the struc- ture and function of those organs, the nature of their disease processes and the appropriate methods of treatment, if he is to put to their best and proper uses the therapeutic measures ON MINOR SURGERY 9 with which he is especially equipped. He must not stand idly by until his medical con- frére says ‘‘cut.”” He must cut when the time comes of course, but must use his now matured judgment to sustain the advice of his colleague. Before now, following the old blind method, the chest has been opened for empyema, when no pus was there; the appendix has been re- moved when typhoid fever was the cause of the symptoms, and the gall bladder has been opened for the cure of lumbricoid worms. I have even known a colleague to scoff at a surgeon who used a stethoscope, and to look upon a micro- scope as an instrument outside of his ken. In all this, do not misunderstand me. A surgeon's duty is the treatment of disease by proper and recognized surgical measures; but he should have a sound knowledge of all disease as well, recognizing his own limitations; and while his medical colleague is at work with his proper investigations and remedies, the surgeon should stand by, waiting to be called upon for the employment of his own peculiar skill. Given then the particular case, such as that of the man with osteomyelitis: You have looked the ground over, have ascertained the gravity of the general condition, and now turn your attention to the special lesion under con- sideration. That lesion is in the arm near the shoulder joint; and without further doubt you 10 CLINICAL TALKS make your diagnosis and recommend appropri- ate treatment. But take this other patient whom I show you as a foil to his fellow. He, too, is a young man, — not more than thirty- five; his previous condition of health is unim- portant, and he, too, has a disease near the shoul- der joint. It is in the nature of a swelling or tumor, and he has had it for some fifteen years. It is a chronic process, therefore. When you see a swelling there are two ques- tions which should suggest themselves to you at once: Is this an inflammatory process or is it a neoplasm? For the purposes of practical exclusion you run over rapidly in your minds the old formula which applies to acute inflam- mations —Is there pain, heat, redness, swell- ing, and impairment of function? In this case all of these are absent save swelling; moreover, this is a chronic process. Then you call up your other familiar formula which applies to a swelling — What is its exact location, size, shape, color, consistency? You must have these two formule always in mind; always on your tongue’s tip, and be ready with your answers. This swelling has none of the characteristics of inflammation and the patient’s general condi- tion is excellent. Therefore it is probably a neoplasm and of a benign type. You say it is situated just below the