Examining an Acromioid Tumor

acromion process over the middle of the deltoid muscle. It is about ON MINOR SURGERY 11 the size of a small orange; it is spherical and uniform in outline; its color does not differ from that of the surrounding skin; it is soft, rather gelatinous to the touch, but it does not distinctly fluctuate. It is subcutaneous, mov- able, not adherent to the skin, and the adjacent glands show no metastasis. Observe carefully the method of approach- ing your patient and handling the little mass. See that.he sits or stands at ease before you, with a good strong light upon him while your own back is turned to the window. Gain his confidence by assuring him that you do not expect to hurt him. He will then sit relaxed and will not shrink or grow tense at your touch, —an important desideratum. Now pass your extended palm gently over the tumor, once or twice. In that way you will gain a great deal of information, and if the parts are sensitive, you will give no pain. The tactus eruditus does not belong to the heavy-handed surgeon. I cannot too strongly urge upon you the great advantage and importance of gentle- ness. Your patient will recognize it at once. He knows when he is being handled by a man who knows his business. The reputation of being a rough or brutal surgeon helps no one. You will see the thoughtless, inexpert man plunge at a painful, sensitive region as though he were kneading dough. You can tell the 12 CLINICAL TALKS neophyte at once by his roughness. The gentle outspread palm and fingers of the examiner are extremely sensitive to tactile impressions and can be educated to a rare facility. It is seldom necessary to prod and poke with the finger tips. Passing my hand over this tumor I readily define its outline, its extent, its density, its mobility, and I note the absence of sensitive- ness. Now if I choose, I can pick it up in my finger-tips and determine, if necessary, its lack of fluctuation and the depth of its attachments. That is the whole story. You have the list of benign tumors in mind and, running over them, you see at once that this must be a fatty tumor or lipoma. After all, it makes little difference what you call it. The method of your examination concerns us at present, and if you have learned to take a broad view of your case, to approach it without rush or flurry, and to observe accurately those few important details of which I have spoken, the giving a name and the assigning treatment will natu- rally and readily follow. LECTURE II INCISED WOUNDS Gentlemen : Twenty years ago Mr. Sampson Gamgee published in London one of the very best books in English that is known to me, on the treatment of wounds and fractures. After describing in some detail the patho- logical conditions which are met with in these phenomena, he goes on to lay down the car- dinal principle of support for the injured part, and this he recognizes as the one essential in the therapeutics of traumatic surgery. I shall have much to say as to the meaning of that word “ support.” In the time of Mr. Gamgee’s writing, the word asepsis, in the modern sense, had hardly been invented; but it has now come not altogether justly to usurp the honors of surgical support; for in the consid- eration of all wounds, whether of the soft or hard parts, in which there has been any sort of disturbance of continuity, you should have constantly in mind that that severed continuity must promptly be restored; that those restored parts must be absolutely immobilized and sup- Es) 14 CLINICAL TALKS ported, and that this work must be done under aseptic conditions. I show you here a simple case in point. This man is a tinsmith, thirty years old, sound and vigorous. About two hours ago, while at his work, he cut through the skin and fascia of his palm, leaving as you see, a clean, straight wound, extending about three inches across the hand. Let us see how we may apply our two prin- ciples, support and asepsis. We must regard what we have to do as a surgical operation. The whole field of the wound — and in this case the field is the man’s hand — is sterilized, so far as may be in the manner with which you are familiar, — a thorough scrubbing with soap and water, followed by immersion in chlorin- ated soda and wiping with cotton sponges dipped in pure alcohol. The hand is then immersed for two minutes in an alcoholic so- lution of bichloride of mercury, 1 to 3,000. The hand and arm are then wrapped in a clean, steamed towel, and the patient sits before me with his arm outstretched, palm upward, upon the table. Meanwhile I have cleansed my own hands with soap, water and alcohol, and have put on rubber gloves, which have been steril- ized by boiling. I have gone into this matter in some detail with you, because details in asepsis are the sine qua non of successful sur- ON MINOR SURGERY 15 gery, and I do not expect to repeat again what T have just told you. Let us now examine the wound. We must be sure always that no foreign substance re- mains in its depths, and in this case we find none. As I hold the wound open, you see the extensive tear in the palmar fascia. Perhaps I am overscrupulous in closing this, but I believe that by so doing I shall hasten the restoration of function. I close it, as you see, with three interrupted catgut stitches, using the curved needle rather than the straight one. That leaves me the skin wound of the palm, which lies together without gaping. The severed edges are dusted with a simple drying powder, aristol; a bit of crépe lisse laid across and secured with collodion further supports them. I then apply a bit of absorbent cotton also held down with collodion about the edges, forming what we call the ‘‘cocoon dressing.” Now you will say that sufficient has been done to assure a prompt and sound healing by the first intention; but I ask you to observe that the second only of our cardinal principles has been applied up to this point. A reason- ably accurate asepsis has been provided; why is not that sufficient, and why do I go on to apply the first principle—support and im- mobilization? A very simple experiment on your own fingers will illustrate the reason. If 16 CLINICAL TALKS you prick your finger sharply, tie an elastic band around it and let it hang down for a few minutes, you will find that the whole finger shortly will throb painfully, and the pricked wound will smart and ache. Now remove the rubber band, place the hand upon the opposite shoulder, and hold it there steadily; you will quickly experience relief and a sense of com- fort. The series of phenomena which you have experienced are not dissimilar from what will occur in this man’s wounded palm. Were I to leave his hand unprotected, except for the cotton and collodion, he would naturally swing it at his side. Almost at once the process of repair will have begun —there will be the in- evitable increased blood supply in the wounded parts, a certain amount of exudation will go on, the venous circulation will be slightly im- peded, and all these conditions will be accent- uated by hypostasis, if his hand hangs down; in other words, the reparative process will be interfered with. You know that hitherto we have been able to devise no means of disinfecting thoroughly the skin. The epidermis may be scrubbed and treated with chemicals until it is fairly free from micro-organisms, but the corium cannot be touched by such methods, and in the corium normally there are to be found patho- genic organisms, mostly the staphylococcus ON MINOR SURGERY 17 epidermidis albus. You must bear in mind, too, that in the aseptic operations of surgery we have three principal sources of infection to consider: First, the instruments; second, the dressings and suture materials; and, third, the skin, whether of patient or operator. At the present time we have advanced so far that we have eliminated the first two sources. Instru- ments properly boiled carry no organisms; dressings and suture materials properly steamed and prepared are sterile. So we come to the third source, the skin. Even that to a large ex- tent may be ruled out, for we now wear aseptic gloves,— surgeons and all assistants,— so that we are left with the patient himself as the one most important carrier of possible infection; and after the most scrupulous care in prepara- tion, the patient's skin must carry in its deep parts pathogenic organisms, as we have seen. One asks, Why do not these bacteria always produce sepsis? Because to do so they must be present in great numbers, or else they must fall upon suitable soil, or both. I need not review with you here the well- known fact ‘that in varying degrees patients carry in their own tissues disease-resisting ele- ments; suffice it: only to remind you that or- ganisms which will grow and multiply in and infect one man will fall harmless upon another; and here is your practical point, that in a great 18 CLINICAL TALKS many cases, by appropriate treatment you may help to bring nearer to immunity, you may fortify the resisting powers of your indi- vidual patient. There again, as I said at our last exercise, you see the importance of study- ing your patient’s general condition. So it is practically in the patient's own skin, and there chiefly, that we must look for a source of sepsis. What became of these organisms at the time this man received this cut? Some of them were undoubtedly carried into the deeper parts, some of them still remain on the cut edges, and others will be forced into the wound itself and into the general circulation during the early hours of repair. Now this man’s hand has been relieved of a large number of organisms by our antiseptics. We must strive to render the deep parts of the field infertile. No better medium exists for the growth of organisms than.a stagnant or sluggish blood supply, and that condition exists to perfection when we leave the man’s hand hanging at his side. I now place it high upon his chest and secure it in a sling. We have now provided for asepsis and eleva- tion. Is there anything further that may help to hasten his recovery? There is, and it is that surgical immobilization to which I have already called your attention. ON MINOR SURGERY 19 If I leave the hand unconfined except by the light, supporting sling, there will be nothing to prevent his withdrawing it from the sling, and there will be nothing to prevent his using the hand and fingers even if elevated. Here, again, you may ask, What harm can possibly result from such use? We have con- ceived of an exudation essential to the heal- ing process in the palm; we have conceived of an increased flow of blood to the part; we can further see how the support of the arm has improved the venous circulation, and it takes very little imagination to under- stand how the action of the muscles dragging, pulling and contracting may well keep up an irritation which, superadded to the other con- ditions, will stimulate a bacteriological activity and initiate a sepsis. These are involved conceptions, but are re- quired to illustrate a condition which, after all, is simple enough; again we come back to our point and say that the one thing left and needful for the repair of this man’s wound is immobilization. Perfect immobilization, in the surgical sense, is far from being the simple thing you might suppose. It is not readily attained; and with- out giving careful thought to the anatomy of the parts, it cannot be attained. Take the instance of this man’s wounded hand. What 20 CLINICAL TALKS are the important structures which go to make up the anatomy of the palm and adjacent parts? Obviously they are the skin and fascia, the underlying tendons and muscles, and the bones. We cannot keep the wound in a state of surgical rest unless we immobilize the adjacent struct- ures, and that means that we must tie up the muscles of the part. Those muscles are the extensors and flexors of the hand, and their origin is about the condyles of the humerus and in the forearm, a fact elementary and obvious enough, but surprisingly overlooked often. So we must carefully bandage and restrain the movements of the forearm. Ob- serve now a point which I must emphasize repeatedly. Never apply for immobilization a bandage close to the skin or over a thin inter- vening pad. Learn always to use elastic compression. You see that I now cover this patient’s hand and forearm with six or eight layers of sheet wadding,— an elastic, very slightly absorbent material, which will not be- come caked and matted with perspiration. Be- tween alternate layers of the wadding I place four strips of moistened mill board —two laid straight down the arm and two twisted spirally about it. These harden as they dry and lend an added stiffness and elasticity to the dressing. So far the application looks very cumbersome and unwieldy, but with this cotton roller I ON MINOR SURGERY ar now carefully and snugly bind the whole into place. I pull the bandage very tight, greatly diminishing the bulk of the dressing, so that when completed it appears to be of moderate proportions. If you handle the completed dressing you find that it is quite elastic to the touch, and that it exerts everywhere a perfectly equable compression. It controls absolutely the muscles; no movement can go on under- neath it, yet it is extremely comfortable. It is tight, but it does not constrict. By its firm contact everywhere with the underlying parts it moderates and controls the circulation, but it does not occlude it. Here you have illus- trated on a large scale the principles of com- pression which you apply when you seize and compress gently and bring comfort to your sore thumb, which throbs and aches with the beginning of a ‘‘run-round.”” So now you see employed the four remedies which you must learn to apply in the dressing of all wounds: asepsis, elevation, immobilization, and com- pression, and the last three imply support, — remedies which may be modified in degree often to suit special conditions, perhaps em- ployed with over-scrupulous care in this par- ticular case, but always important, always to be borne carefully in mind; to become as much a part of your instinct and training as that anti- septic conscience of which we have heard tell.