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pus, a dressing forceps will be slipped along the director, and when the abscess cavity has been reached its blades will be separated and the forceps gradually withdrawn with a rotary motion. This, which is known as Hilton's plan, is the best and safest method of opening deep abscesses, or those in the neighborhood of important structures.
Turning now to the examination of the limb, you will notice the general swelling of the knee which is characteristic of arthritis. You also see the discharge from the abscess in the popliteal space, which has been opened. There is also a distinct swelling of the thigh, which is very painful and hot. There is also redness, which, however, is not as marked as two days ago, for the part has been constantly poulticed since then. There are therefore redness, intense pain, swelling, and increased temperature, the four gardinal signs of inflammation. There is fluctuation when I press the part from side to side This is deceptive, for I find the same fluctuation on pressing the parts in a longitudinal directtion. Superficial oedema is also present, and this is another evidence of suppuration. The symptoms are therefore so insignificant of abscess, that I feel warranted in making an exploration. Of course, I do not think that evacuating the pus in this situation will have any effect on the disease of the knee-joint, but I think that it will afford enough relief from the pain and constitutional irritation to enable us in the course of a few weeks to operate on the knee-joint with more prospect of success than we could at present. The abscess may be simply beneath the muscles or it may be beneath the periosteum. The cause of the abscess is in all probability transmitted irritation from the knee.
I make an incision at the junction of the lower and middle third of the thigh, in such a direction as to avoid the femoral artery. I next carefully work the director through the tissues and at once pus is seen to swell up. The probe touches the bone. I pass in the dressing-forceps with the blades closed, open them in the wound, and gradually withdraw them. This lacerates the opening into the abscess and lessons the likelihood of immediate union. It is a good rule when it is desired to make pressure in the evacuation of an abscess, to make what pressure is considered desirable through interposed sponges, and not directly with the fingers. This produces less pain and lessens the risk of injury. Passing the director again, I find that the abscess extends across the front of the thigh and that the point of the probe can be felt a short distance beneath the skin on the outer side. I shall therefore make a counter-opening at that point, and pass a drainage tube across the cavity. The tube is secured by tying the two ends together. This tube should be allowed to
remain until the wound becomes covered with granulations; a week or ten days is usually long enough. It is not often desirable to allow it to remain a longer time.
I take advantage of the patient's being etherized to straighten the limb. I perceive no grating, and no effusion in the joint. There is, however, relaxation of the ligaments, and no doubt destruction of the cartilages.
One word about the significance of superficial oedema. It is some times a valuable point in distinguishing between a deep-seated abscess and some forms of malignant growth. The presence of this oedema affords a strong reason for thinking that the tumor is due to a collection of pus. [Temporary relief was given by opening the obscess in this case, but the joint-disease advanced very rapidly, and a week afterwards the knee was excised, the patient making a quick recovery.]
Hydrocele.-This patient presents the affection known as hydrocele, that is, a collection of fluid in the tunica vaginalis testis, giving rise to a tumor of pyriform shape with its long axis corresponding to that of the body. In this it differs from a sarcocele, which usually has its longer diameter in a transverse direction. A collection of blood in the tunica vaginalis would also present this pyriform shape, and under such circumstances other points would have to be relied upon in making the disgnosis, the most certain test being that with transmitted light. In the diagnosis of hydrocele from sarcocele, we have, besides the difference in shape, a difference in specific gravity. A hydrocele is light in proportion to its size, while a solid tumor gives a sense of greater weight when supported with the hand. The test with transmitted light, when it can be applied, is the most satisfactory. It has been tried in this instance and the tumor found to be translucent. It is performed by taking the patient into a dark room and holding a candle on one side of the scrotum while the observer looks from the opposite side, shading off the lateral rays with the hand. If the contents of the scrotum be serous the sac will be translucent. In some cases of hydrocele this test does not apply. The fluid may be dark-colored, or there may be an admixture of blood with it, as sometimes happens in acute hydrocele. In the colored race, the darkness of the skin prevents the light from being transmitted, and rendering this test inapplicable. Again, there may be such thickening of the tunica vaginalis that although its contents be clear, no light will be trans mitted. I remember a case occurring many years ago in one of the hos pitals of this city, where on account of the failure of the test with transmitted light and the great heaviness of the tumor, the surgeon diagnosed
sarcocele, and proceeded to remove the testicle.
An incision was made
and a large quantity of fluid escaped. A further examination showed that the tunica vaginalis was greatly thickened and lined with calcareous plates. It can therefore be seen that from the absence of the characteristic signs, the absence of hydrocele cannot be positively asserted. On the other hand there may be transmission of light in some cases of sarcocele. In cystic sarcocele, where there are usually numerous small cysts, there may be one or two large ones, and if the contents of these be clear, a certain amount of light will be transmitted. In order to reach a correct diagnosis, therefore, all the evidence must be carefully weighed.
There is one other point in the diagnosis, more particularly between hernia and hydrocele, and it is also applicable to sarcocele where the cord is not involved. The point to which I refer is that in hydrocele, if the tumor be grasped, it can readily be determined that the part above is not involved and that no portion of the tumor goes into the ring. If the ring be felt for, it will be found to be clear. There may, however, be in some cases hydrocele of the cord associated with the hydrocele of the tunica vaginalis. Another point in the same direction is that the history of hydrocele and hernia is different. It will be found that hydro. cele begins at the bottom and extends upwards, while the hernia begins at the top and passes downward. Examination of the abdominal ring is, however, more satisfactory than depending on the history.
In regard to treatment, we recognize two modes, one palliative, the other curative or radical. The palliative treatment consists simply in the removal of the fluid with a trocar and canula. The radical treatment consists in adopting some measure to prevent the reaccumulation of the fluid. The plan which I have usually practiced, and found satisfactory, is, after evacuating the hydrocele, to inject from two to four drachms of pure tincture of iodine, according to the size of the hydrocele, and allow it to remain. This was first suggested by an East India surgeon, Sir Ronald Martin, and, on the whole, is perhaps the most satisfactory mode of treatment yet recommended. This method of using pure tincture of iodine was particularly insisted on by the late Prof. Syme, who asserted that a cure was thus invariably effected. I cannot bear out this statement, for I have once or twice known the injection to fail, and a repetition of the operation to be required. Many other substances have been used by injection, one of the most recent being carbolic acid. Among other methods of treatment which have been employed is incision of the scrotum and packing the tunic with lint, the introduction of a seton, and the excision of a portion or a whole of the tunica vaginalis. These are
all more severe and I think on the whole not so successful as the injection of iodine.
For the present this patient wishes only to have the fluid removed. The only precautions to be observed in tapping a hydrocele are to avoid certain large veins, which can readily be seen, and to be careful not to wound the testicle. Even if the testicle be wounded no particular harm will be done, and indeed irritation of the tunic covering the testicle is one of the methods which have been recommended for the radical cure of this affection. The sac is to be made tense and the trocar introduced perpendicularly to the plane of the scrotum, and as soon as the fluid is reached the point is to be directed upwards.
When the fluid which escapes is of a milky hue, the patient should be warned against exercise. The milky color shows that the affection is a variety of encysted hydrocele, really a spermatocele, a cyst connected with the testicle and the fluid containing spermatozoids. A cyst of this kind is more likely to take on inflammatory action than the sac of an ordinary hydrocele. Some years ago I tapped a large tumor of this kind and instructed the patient to keep quiet. He did so for a couple of days, and then went to market, carrying a heavy basket. As a result of this exertion he had a violent attack of inflammation of the testicle, keeping him in the house for a number of weeks.
Hydrocele with Inflammatory Thickening of the Testicle, Simulating Sarsocele. (Hydro Sarcocele.)-The next patient presents many of the symptoms of sarcocele. He has a scrotal tumor which has lasted for eighteen months. It presents some of the evidences of a solid tumor, but the tunica vaginalis evidently contains fluid also, rendering it difficult to decide in regard to the exact condition of the testicle. You see that the shape of this tumor is not pyriform as in the preceding case, but that it has its long diameter in a transverse direction.
I shall, in the first place, tap the tumor and remove the fluid, and then if disease of the testicle be found, excision of the organs will be performed. In this operation I prefer, after the testicle is separated, to surround the cord with an ecraseur and divide it with that instrument. The cord may be tied in two parts and cut between the ligatures; if it be simply cut across, the bleeding is profuse, and it is often difficult to secure the vessels. There is, I think, less shock when the ecraseur is used. When the cord is divided, even if the patient is deeply etherized, the pulse rate often suddenly fails.
There seems to be no involvement of the cord in the present instance. I now introduce the trocar and canula, and at once a large
quantity of fluid escapes.
The testicle can now be readily examined, and it is found to be hard and heavy, but there is no sufficient evidence
of disease to warrant so radical an operation as excision. I will introduce a seton, which can be removed in a few hours, if necessary, and will do nothing further to-day; but the case will be kept under my observation, in order that its subsequent course may be observed. [The seton was removed in twenty-four hours, and the patient left the hospital in a week, apparently well.]-Phila. Med. Bulletin.
ON BURIED SUTURES, WITH REMARKS ON THE IMPORTANCE OF SUTURING SEPARATELY.
By C. B. Keetley, F. R. C. S., Senior surgeon to the West London Hospital; Surgeon to the Surgical Aid Society.
Buried sutures, or "sunk sutures," as they have been also called, are such as are completely covered by the skin, and do not involve that structure at all. In the forms of sutures uniting the fragments of fractured bones, especially the olecranon and patella, they have long been employed, and also as sutures to unite divided nerves and tendons, as well as wounded veins, intestines and other hollow structures. But all the above mentioned forms of buried suture differ essentially in their objects from those to which I wish to call attention. The former have each a narrow and very limited, though, perhaps, extremely important aim. For instance, a patella is sutured with a view to getting secure bony union, a wounded intestine with a view to preventing extravasation of fæces into the abdominal cavity.
The sutures of which I now wish to speak, are employed with intent to influence the whole course and final result of wounds in general. For instance, let us suppose buried sutures of the first kind to have been used to unite the two ends of a divided nerve; the use of the other kind of buried sutures would now commence, and proceed as follows:
Whatever muscles or aponeuroses had been divided in cutting down upon the nerve would be restored to their original relationships, and kept there by aseptic animal sutures, such as carbolized gut; then the wound in the deep fascia would be separately sewn up. Finally, the wound in the skin would be closed by either catgut or silver, or whatever might be preferred. What good do we expect to get from this?
I. We need no drainage-tubes. No spaces and pockets are left wherein blood or serum can collect, and, therefore, it does not collect.