Examination Paper: Surgery, by Walter Reed, [February 8, 1875] |
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Surgery I. Describe the operation for the relief of strangulated
femoral Hernia- give the anatomy of the parts
involved. I can best answer this question by first
giving the anatomy of femoral Hernia, & afterward
describe the operation. Examining the femoral
region, from without inward, we remove first the
integument, next [ 2nd] the superficial layer of the
superficial fascia, next [3rd] the deep layer of the
superficial fascia (between these 2 layers of fas-
cia we find the superficial femoral femoral branches
of femoral artery) 4 Fascia lata, consisting of
an antr& ext llayer, called the Iliac portion
& are intl & postr layer, called the pubic por-
tion. At the upper & inner pl. of the thigh, a
short distance below pourparts ligament
we find an oval opening, the saphenous ope-
ning, covered by a delicate fascia, the fas-
cia cribriform fascia, which serves to close the
opening. The saphenous opening presents
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externally a sharp, curved border, known as the
falciforme fascia [ligament] or ligament of Hey- which is
a part of the Iliac portion of fascia lata.
Removing the fascia lata, we expose a canal
about 1 inch in length, called the Crural canal.
This canal passes below pourparts ligament & ex-
tends from the abdominal cavity below above
(its upper opening being closed by the peritoneum)
to the Saphenous opening below. The boundaries
of this canal are in front, Iliac fascia of fascia lata,
behind, pubic pl. of fasc. lata-internally by Gim-
bernat's ligament & the fascia lata & externally, the
femoral vein, separated from canal by its shoath-
still more externally we find the fem. artery &
antr Crural Nerve. Gimbernat's ligt. is the inner
boundary of the upper opening of crural canal. It
is a triangular ligament, its base directed outwards
& apex inwards & is that pt. of pourparts lig. which
is attached to the pestineal line. & femoral Hernia
in its descent from above, first pushes before it
the parietal layer of the peritoneum [& a layer of areolar tissue] then enters
lying beneath the peritoneum
the crural canal, passes downward a short dist-
ance to the Saphenous opening, thence through the
opening, carrying cribriform fascia before it, &
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& then ce curves upward toward the abdomen.
The layers [coverings] of the Hernia from without inward are, 1. The
integument, 2. Superficial fascia, 3. Cribriform fascia,
4. Fascia lata. 5. Tranversalis fascia or fascia propia
(which closes upper pt. of the canal) 6. Peritoneum; and
these are accordingly the parts which are divided in the
operation for strangulated femoral Hernia.
In performing the operation a vertical incision
is made over the most prominent pl. of the to
swelling, extending from pourparts lig. & downward about
3 inches. The superficial fascia & fascia lata are
in succession divided on a grooved direction,
when the sac is exposed. This is then taken up with
forceps & a small incision made in it a groove
director is passed underneath it & the sac s
split up with a probe pointed bistoury. The
point of constriction is generally found at
Gimbernat's ligament. To divide this a probe
pointed bistoury is carefully passed up &
the constriction divided in a direction up-
ward & inward. The object in following
this line of incision is to avoid the intl
Epigastric Artery, which skirts the outer
& upper margin of the crural opening.
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Even in following this line of incision, the obtur
ator artery is sometimes wounded. This is due
to an abnormal distribution of the artery.
Normally it is a branch of the antr division of the
intl Iliac; but if sometimes arises from extl
Iliac in common with the intl Epigastric &
in passing to the obturator opening, skirts
the upper & inner margin of crural opening
& in this case can scarcely avoid being wounded.
Mr Evichseu has recommended that the edge of
bistoury be dulled so as to push the artery
before it. The obturator sometimes passes
along the outer & lower margin of the canal [opening] ,
but in this case would run no risk of being
wounded. The point of constriction is sometimes
found at the falciform ligament, a division of
which releases the gut. II. Describe the symptoms, and give the causes
prognosis, diagnosis and treatment of Pyaemia. Pyaemia The development of Pyaemia is character-
ized by a well-pronounced chill, which is
subsequently reapeated frequently & at irregular
intervals. During the chill, examination with
the thermometer shows an elevation of the tempera-
ture to 102°, 103°, & even 105° or more (according to Billroth
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as high as 107°). The pulse is accelerated ranging from
100 to 140-quick & compressible. The countenance is
flushed & eyes somewhat infected. The chills are
followed by sweating, which is sometimes profuse & ex-
hausting. The tongue is covered with a white coating
& moist - later on it becomes dark, dry & fissured.
There is thirst as the disease advances we observe
often that patient coughs & expectorates rusty colored sputa
which shows supervention of pneumonia, either labai or lab-
ular. The breath is said to have a hay-like odor.The
conjunctiva & surface of body becomes jaundiced, probably
due to metastatic abscesses in the liver. Diarrhoea is a
frequent symptom. Anorexia is present & sometimes vom-
iting. Delirium supervenes & is of a low, muttering kind.
The patient seems listless & stupid. Sometimes great pain
in joints due to formation of metestatic abscesses. The pulse
becomes more rapid & feeble, coma supervenes & the pa-
tient dies. The predisposing causes of pyemia are, over-
crowding of wounded patient in wards, a laid state of health
etc. The exciting cause is a wound generally held that wounds
of bone where vessels remain patulous are most often
followed by pyemia. Prognosis is very unfavorable - generally
causes death. Diagnosis, from Intermittent & Remittant fever
by the irregular course of the Chills from typhoid by greater
thermometrical range & temperature does not follow the regular
course which is seen in typhoid. From Hectic by greater range
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of temperature by the greater gravity of the affection does not pre-
sent the regular evening exacerbation as seen in Hectic.
Sometimes confounded with Rheumatism, when the Joints are involved.
In pyaemia the joint affection generally passes to suppervation
in Rheumatism it does not - also notice the greater gravity
of affection, the irregular chills, diarrhoea etc. Treatment divided into [1st] preventive- avoid crowding of
wounded together give free drainage & suppurating wounds
keep the wounds clean also sponges & bandages in a
clean condition. 2nd when the disease is developed, the treat-
ment is not of much avail & varies - the general indication
are to sustain patients strength by nourishing broths a stimu-
lants. Check diarrhoea if profuse give sulph. Quiniae
Gr. Tr-V every 3 hours, combined with opium-Carbolic
acid is sometimes given internally. I saw a patient recov-
er, who took 1 minium carbol. acid every 3 hours for
more than one week. The Sulphites have been rec-
ommended. But in spite of all treatment the patient
generally dies. III. Give the causes, symptoms and treatment of
sympathetic Ophthalmia. Causes. Any severe inflammation of one eye may
give rise to sympathetic ophthalmia in the other.
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Gonorrhoeal ophthalmia has been supposed to give rise
& a sympathetic inflammation in the other eye. The opera-
tion for Cataract [of one eye] sometimes gives rise to sympa-
thetic op [h] thalmia in the other. Malignant tumors of
one eye are sometimes followed by the same
symptoms. A severe wound of the eye, especially
if the foreign body is not removed, is apt to cause
sympathetic trouble in the other eye & even after
removal of the body, the injury which destroys
one eye may be lead to smypathetic ophth-
almia & destroy the other. The symptoms are pain [in] eye, conjunctional & sub-
conjunctional infection, photo bia [phobia] , intra-occular tension
increased, & unless trouble is arrested going on to
destruction of eye. The treatments is to subdue inflammation of
the eye giving rise to trouble, by counterirritation
around orbit - installation of atropia, keep
bowels open, etc. In case of morbid growths
in eye, or severe inflammation of [deep pts of] eye from
wound by foreign body. Enucliation of affected
eye will alone arresty the trouble. Respectfully submitted
Walter Reed. |
