Tina nnTOMw:! ISfiiHii MM NLM D055Mfill 1 Surgeon General's Office %, !5! $! Wfe ._ ">■ ;; /■■ /• / ' N"--tr=±/...... 'd &i 4T~ it,- c^-q NLM005548119 A PRACTICAL TKEATISE ON SURGICAL DIAGNOSIS Designed as a Manual for Practitioners and Students V AMBROSE L. RANNEY, A.M., M.D. Adjunct Professor op Anatomy and Lecturer on Minor Surgery in the Medical Department op the University op New York NEW YORK WILLIAM WOOD & COMPANY 27 Great Jokes Street 1879 Riesp 1870 Copyright 1879, By William Wood & Co. New York: J. J. Little & Co., Printers, 10 to 20 Astor Place. TO WILLIAM DARLING, M.D., F.R.C.S., Professor op Anatomy in the Medical Department op thb University op New York, AS A TRIBUTE TO HIS GENERAL SCHOLARSHIP AND HIS LIFE-LONG DEVOTION TO A SCIENCE IN WHICH HE HAS FEW EQUALS AND NO SUPERIORS, AND AS AN EXPEESSION OF THE WARMEST PERSONAL REGARD ENGENDERED BY YEARS OF PLEASANT INTERCOURSE, GDIris Mlavh. is Jnsttibt& BY HIS FRIEND, THE AUTHOR. INTRODUCTION. At the request of my private classes I publish this volume. As a text book for students it will, I trust, aid memory by pre- senting the symptoms of diseases in marked contrast; while to the practising pliysician it may prove a book of easy reference, when questions of diagnosis arise leading towards doubt or error. I am aware that many points of distinction given will admit of question, as authorities do not always agree. I have, however, se- lected from such authors as, in my opinion, best merit attention, and have avoided as far as possible all points on which argument is demanded, or from which serious error is liable to follow. I have endeavored to make, in most instances, selections for con- trast of such diseases as are most liable to be confounded, and, for perspicuity, have been forced to frequently duplicate the symptoms of many of them. In this volume all questions of etiology, pathology and treatment have been purposely omitted, as they have no direct bearing upon diagnosis, and therefore do not properly appertain to it. Each differentiation is, in most instances, so arranged as to allow the symptoms of each to be reviewed separately by reading from above, downwards; while by reading across the page the points of contrast become prominent. The " Common Symptoms" written below each differentiation explain, in general, the possible causes of error in diagnosis. At the close of this volume will be found enumerated under the head of bibliography those authors to whom I am indebted for many statements advanced and from whom occasional extracts have been given. I have adopted this method of acknowledgment since the arrangement of disease in a tabulated form precludes the frequent interpolation of authorities. Confusion would thus often result un- less explanatory paragraphs were also inserted and the object of marked contrast in symptoms would be thus thwarted. If I succeed in placing before students and the medical profession at large a work whose system and arrangement will probably be its chief recommendation, the object of this volume will have been ac- complished. 156 Madison Avenue, January, 1879. V CONTENTS. PART I. DISEASES OF THE BLOOD-VESSELS. General table of diseases of the blood-vessels, Aneurism, Classification of aneurism. Differential diagnoses of aneurism in general: Aneurism and tumor on an artery. Aneurism and erectile tumors, Aneurism and aortic pulsation, Aneurism and ab- scess over a vessel. Diagnoses of special types of Aneurism: Abdominal aneurism and abdominal tumors, Abdominal aneurism and painful diseases of abdomen, Ab- dominal aneurism and psoas abscess, Thoracic aneurism' and intra-thoracic tumors. Thoracic aneurism and pulmonary consolidation with a murmur in some large vessel, Aneurism of bone and cancer of bone, Cirsoid aneurism and pulsatile tumors of bone, Aneurism and encephaloid cancer, Aneurismal varix and aneurism, Cirsoid Aneurism and erectile tumors, Cirsoid aneurism and najvi, Aneurism of arch of aorta and aneurism of the innominate artery, Varicose aneurism and aneurismal varix, Varicose aneurism and varicose veins. Diseases of the arterial coats : Athero- matous degeneration, Fatty degeneration of vessels. Diseases of the veins: Adhe- sive phlebitis, Suppurative phlebitis. Abnormal conditions of vessels: Embolism, Thrombosis........................................................Pages 1-33 PART II. DISEASES OF THE JOINTS. General classification of Joint diseases. Differential diagnoses of. I. Diseases of the joints in general: Synovitis and rheumatic inflammation of joints, Scrofulous syno- vitis and hydrarthrosis, Acute arthritis and chronic rheumatic arthritis, Acute arthritis and syphilitic periostitis near a joint, Acute arthritis and suppuration ex- ternal to a joint, Bony anchylosis and fibrous anchylosis. II. Diseases of special joints : Morbus coxarius, its varieties, its common symptoms, its diagnosis. Dif- ferential diagnosis of morbus coxarius and congenital dislocation of the hip, Morbus coxarius and psoas abscess, Morbus coxarius and sacro-iliac disease, Morbus coxarius and trochanteric disease of the femur, Morbus coxarius and lateral curvature of the spine, Morbus coxarius and rheumatic deformity of the hip, Morbus coxarius and disease of the crest of the ilium, Morbus coxarius and inflammation of the psoas bursa, Morbus coxarius and infantile paralysis. Diagnostic points of tenderness in inflammation of the larger joints. III. Deformities of joints : General classifica- tion. Talipes, its varieties, Symptoms of talipes varus, Talipes valgus, Talipes equinus, Talipes equinus with paralysis of the extensor of the toes and flexors of the tarsus, Talipes valgus spurious, Calcaneo-valgus of moderate severity (Chinese foot), Flat foot, Diagnosis between spurious valgus and sprain of ankle joint. Pages 33-67 vii vm CONTENTS. PART III. DISEASES OF BONE. Classification of bone diseases. Differential diagnoses of bone diseases, Osteitis and osteo-myelitis, Caries and necrosis, Osteitis and periostitis, Periostitis near a joint and acute arthritis. Abscess of bone and arthritis, Rickets and malacosteon, Exos- toses and cysts of bone, Cancer of bone and pulsatile tumors of bone, Pulsatile tu- mors of bone and aneurismal tumors. Local types of bone diseases. Abscess of the antrum, Solid tumors of the antrum, Cystic tumors of the antrum, Malignant tumors of the antrum, Extra-cranial tumors, Intra-cranial tumors, Exostoses of the cra- nium.............................................................Pages 67-84 PART IV. DISLOCATIONS. Definition, varieties, causes, and general symptoms of dislocation. Dislocations of special joints : I. Dislocations of the jaw : Differential diagnosis between the unilat- eral dislocation and bilateral dislocation, Unilateral dislocation and congenital dislo- cation, Dislocation of jaw and chronic rheumatic arthritis of the tempero-maxillary articulation. II. Dislocations of the shoulder : Classification of the varieties. Differ- ential diagnoses between, " Sub-glenoid " dislocation and fracture of neck of humerus, "Sub-clavicular" dislocation and " sub-spinous " dislocation, " Sub-spinous " dislo- cation and separation of the great tubercle of the humerus, '' Sub-coracoid " disloca- tion and " supra-coracoid " dislocation. Dislocations of the clavicle. Varieties and etiology. Subluxation of outer end of clavicle (dislocation of scapula). III. Dislo- cations at the elbow joint: Classification of, Differential diagnoses between both bones of forearm backwards and fracture of humerus above the condyles, Both bones of forearm backwards and radius forwards, and ulna backwards, Both bones of forearm backwards and both bones of forearm forwards, Both bones of forearm backwards and ulna alone backwards, Radius forwards and radius backwards, Ulna forwards and ulna backwards. IV. Dislocations at the wrist: Dislocations of the carpus, of the separate carpal bones, of the lower end of the ulna. Differential diagnoses between Dislocation of the carpus and Colles' fracture, Dislocation of the carpus and sprain of the wrist joint, Dislocation of the carpus and transverse fracture of both bones close to the wrist joint, Dislocation of the carpus and separation of the epiphyses of radius and ulna. Symptoms of dislocation of the lower end of the ulna forwards and backwards, and of dislocation of the os magnum. V. Dislocations at the hip joint. Varieties of dislocation of the upper end of the femur. Differential diagnosis be- tween "dorsum ilii" dislocation and " sciatic notch " dislocation, " Sciatic notch " dislocation and fracture of the femur with inversion of the foot, " Pubic " dislocation and "thyroid" dislocation, "Pubic" dislocation and fracture of the neck of the femur, Dislocation of the hip and contusion over the trochanter. Table of contrast of the symptoms of each dislocation of the hip. VI. Dislocations at the Jcnee joint. Varieties of dislocation of the tibia, and of the patella. Symptoms of dislocation of the tibia forwards, backwards, in rotary displacement, in lateral displacement. Symp- toms of dislocation of the patella inwards, outwards, upwards, and in rotary displace- ment. VII. Dislocations at the ankle joint. Varieties of dislocation of the astragalus. Symptoms of dislocation of the astragalus forwards, backwards, externally, inter- nally and upwards. Differential diagnosis between dislocation of the astragalus up- wards and fracture of both bones of the leg, Dislocation at ankle and a severe sprain, Dislocation at ankle and a previous deformity associated with injury___Pages 84-134 CONTENTS. IX PART V. FRACTURES. Definition, Varieties of fractures of long bones. Fractures of flat bones. General symptoms of fracture. Classification of special fractures. I. Fractures of the skull. Classification of varieties. Differential diagnoses of complete fracture of the skull and tract of outer tablet only, Fracture of outer and inner tables only, Fracture of inner table only and apoplexy with complicating injury, Fracture of the base of the skull and cerebral concussion, Cerebral compression and cerebral concussion. II. Fractures of the upper jaw. III. Fractures of the lower jaw. Differential diag- nosis from dislocation of lower jaw. IV. Fractures at the shoulder joint. Classifi- cation. Fractures of the scapula. Differential diagnoses between fracture of body and the spine of the scapula, Fracture of the neck of the scapula and fracture of the neck of the humerus, Fracture of the neck of the scapula and dislocation of the humerus. Fractures of the clavicle. Varieties of and their location. Differential diagnosis between fracture of clavicle inside of coracoid process and fracture out- side of the coracoid process. Fractures of the humerus near the shoulder joint. Varieties of and their location. Differential diagnoses between simple intra-capsular fracture and simple extra-capsular fracture, Impacted intra-capsular and impacted extra-capsular fractures, Fracture of the neck of the humerus and " sub-glenoid" dislocation, Fracture of the neck of the humerus and fracture of the neck of the scapula, Separation of the great tubercle of the humerus and ' • sub-spinous " disloca- tion. V. Fractures at the elbow joint. Varieties of and their location, Differential diagnoses between fracture of the condyles of humerus, fracture of coronoid and ole- cranon processes, fracture of the olecranon process and rupture of the triceps tendon, Fracture of the upper ends of radius and ulna, Transverse fracture of humerus and dislocation at elbow joint. VI. Fractures near the wrist joint. Varieties of and their location. Differential diagnoses between Colles' fracture and dislocation of the wrist, Fracture of both bones near wrist and dislocation of carpus, Separation of the epiphyses and dislocation of the carpus, Colles' fracture and transverse fracture of both bones near the wrist joint. VII. Fractures near the hip joint. Varieties of and their location. Differential diagnoses between simple intra-capsular fracture and simple extra-capsular fracture, Impacted intra-capsular and impacted extra-capsular fractures, Intra-capsular fracture of the femur and chronic rheumatic arthritis with contusion, Fracture of femur with inversion of the foot and '' sciatic notch " disloca- tion of the femur, Fracture of the neck of the femur and the " pubic " dislocation of the femur. VIII. Fractures at the knee. Varieties of and their location. Fractures of the patella. IX. Fractures at the ankle. Transverse fracture of both bones of the leg. Pott's fracture. Fractures of the malleoli. Compound fractures of ankle joint. X. Fractures of the trunk. Fractures of the sternum. Fractures of the vertebrae. Fractures of the ribs. Differential diagnoses between fracture of the ribs and the dry stage of pleurisy associated with contusion, Fracture of the ribs and pneumothorax of a traumatic origin, Fracture of the ribs and emphysema of tissues, Fracture in general in the vicinity of joints and dislocation of bone.. .Pages 134-201 PART VI. DISEASES OF THE MALE GENITALS. I. Diseases of the testicle. Inflammatory orchitis. Syphilitic orchitis. Tubercular orchitis. Malignant orchitis. Cysts of testis. Sarcoma of testis. Hasmatocele of testis. Lipoma of testis. Fibrous tumors of testis. Enchondroma of testis. Be- nign fungus of testis (hernia testis). Chronic induration of testis. Arrested devel- X CONTENTS. opment of testis. Congenital maKormations of testis. Neuralgia of testis. Atrophy of testis. Incomplete descent of testis. Calcareous deposit of testis. Differential diagnoses between Acute orchitis and neuralgia of the testis, Syphilitic orchitis and tubercular orchitis, Malignant orchitis and syphilitic orchitis, Cysts of testicle and hydrocele, Benign fungus of testis and cancer of testicle with fungus growth, Orchi- tis and epididymitis. Diagnostic table of the four principal enlargements of the tes- ticle. II. Diseases of the tunica vaginalis and the spermatic cord. Simple hydro- cele. Hydro-sarcocele. Congenital hydrocele. Encysted hydrocele of the testis. Diffuse hydrocele of the spermatic cord. Encysted hydrocele of the spermatic cord. Varicocele. Cirsocele. Table of causes of varicocele. Lipoma of the spermatic cord. Spasm of the cremaster muscle. Differential diagnoses between Hydrocele and scrotal hernia, Varicocele and scrotal hernia, Encysted hydrocele and cyst of the testicle, Hydrocele and congenital hernia, Hydrocele of the cord and inguinal hernia, Hydrocele and hsematocele. III. Diseases of the bladder. Malformations of, and its varieties : Deficiency of, Multiplicity of, Extroversion of. Inflammatory condi- tions : Acute cystitis, Chronic cystitis, Ulceration of the bladder, Suppuration of the vesical walls, Gangrene of the bladder. Hypertrophy. Tumors of the bladder. Bar at the neck of bladder. Hernia of the bladder. Inversion of the bladder. Rupture of the bladder. Calculi of bladder. Foreign bodies in bladder. Tuber- cle of bladder. Paralysis. Atony. Spasm. Neuralgia. Retention of urine. Incon- tinence of urine. Overflow of urine. Differential diagnoses between, Cancer of the bladder and vesical calculus, Rupture of the bladder and retention of urine, Retention of urine and suppression of urine, Retention and incontinence due to overflow, Acute cystitis and stone in bladder, Paralysis of bladder and atony of bladder, Chronic cystitis and chronic prostatitis. IV. Diseases of the prostate gland. Inflammatory conditions : Acute prostatitis, Chronic prostatitis, Prostatic abscess. Hypertrophy of the prostate, Atrophy. Cancer. Tubercle. Cystic disease. Prostatic calculi. Prostatic hemorrhage. Prostatic phlebolites. Wounds of the prostate. Differential diagnoses between Acute prostatitis and chronic prostatitis, Hypertrophy of the prostate and organic urethral stricture. V. Diseases of the urethra. Inflammatory conditions : Gonor- rhoea, Urethritis, Chancre and Chancroid of the urethra. Urethral stricture. Urethral dilatation. Urethral rupture. Urethral deformities. Urethral tumors. Urethral abscess. Urethral fistula). Urethral spasm. Congestive stricture. Ure- thral calculi. Foreign bodies in the urethra. Symptoms of urethral rupture within the triangular ligament, perineal abscess, rupture of the urethra in front of its membranous portion, rupture in front of the peno-scrotal junction, Fracture of the penis, Organic stricture, and Urethral tumors. VI. Diseases of the penis. Dis- eases of the glans penis : Balanitis, Posthitis, Herpes progenitalis, Vegetations, Venereal sores, Epithelioma. Diseases of the prepuce : Phimosis, Paraphimosis. Diseases of the corpora cavernosa : Inflammation, Calcification, Gummy tumors, Chronic circumscribed inflammation, Fracture of the penis, Anomalies of the penis. Differential diagnoses between Chancroid and chancre, Herpes and balanitic abrasion........................................................Pages 201-269 PART VII. DISEASES OF THE ABDOMINAL CAVITY. Injuries to the abdomen : Contusions, Wounds, Foreign bodies in the intestinal canal. Diseases of the intestine : Faacal abscess, Intestinal obstruction, Hemorrhoids, Pro- lapse of the rectum, Fistula) of the rectum, Fissure of the anus, Stricture of the rec- tum, Cancer of the rectum, Polypi of the rectum, Pruritus ani, Neuralgia of the rec- CONTENTS. xi tum. Hernia. Classifications of hernia. Nomenclature of hernia. Predisposing causes. Exciting causes. Table of diagnoses of inguinal hernia. Diagnoses of fe- moral hernia. Differential diagnoses between Typhlitis and perityphlitis, External hemorrhoids and internal hemorrhoids, External hemorrhoids and condylomata of anus, Internal hemorrhoids and rectal polypus, Rectal prolapse and rectal polypus, Cancer of rectum and stricture of rectum, Fissure of anus and fistula? of rectum, Direct and indirect inguinal hernia, Scrotal hernia and sarcocele, Scrotal hernia and hydrocele, Scrotal hernia and varicocele, Scrotal hernia and hasmatocele, Incomplete inguinal hernia and bubo, Bubonocele and undescended testicle, Inguinal hernia and impaction of fasces, Inguinal hernia and hydrocele of the cord, Femoral hernia and enlarged glands, Femoral hernia and psoas abscess, Femoral hernia and varix of the saphe- nous vein, Femoral hernia and inguinal hernia, Femoral hernia and lipoma of the femoral canal, Ventral hernia and umbilical hernia, Thyroid hernia and perineal hernia, Diaphragmatic hernia and mediastinal tumors, Congenital hernia and hydro- cele, Congenital hernia and infantile hernia........................Pages 269-311 PART VIII. DISEASES OF TISSUES. Inflammatory conditions of tissue : Tumefaction, Induration, Suppuration, Ulcera- tion. Gangrene of tissues. Erysipelas. Elephantiasis. Lupus. Differential diag- noses between Anthrax (carbuncle) and furuncle (boil), Abscess and circumscribed local oedema, Acute abscess and chronic abscess, Iliac abscess and abscess of the ab- dominal walls, Psoas abscess and femoral hernia, Abscess of the abdominal walls and enlargement of the spleen, Moist gangrene and dry gangrene, Cutaneous erysipe- las and phlegmonous erysipelas. Tumors. Classification of solid tumors. Classifi- cation of cystic tumors. Tumors classified on a basis of location. Tumors of the brain, of the scalp, of the orbit, of the antrum, of the gums, of the lips, of the tongue, of the jaws, of the parotid gland, of the thyroid gland, of the lymphatics of the neck, of the integument of the neck, of the mammary gland, of the labia of the uterus, of the rectum, of the prostate, of the testicle. Tumors of special surgical regions. Tumors of the axilla. Tumors of the groin. Cancerous tumors. Differ- ential diagnoses between benign and malignant tumors, Scirrhus and encephaloid cancer, Epithelioma and scirrhus, Colloid cancer and scirrhus of viscera, Cancer of axillary glands and tubercular diseases of axillary glands, Cancer of the omentum and enlarged spleen. Tumors of the head : Classification of. Differential diagnoses be- tween sebaceous tumors of the scalp and fatty tumors of the scalp, Sebaceous tumors and exostoses of the cranium, Extra-cranial tumors and intra-cranial tumors, Ence- phalocele and dropsy of the brain, Encephalocele and cephalsematoma, Abscess of the antrum and solid tumors of the antrum, Epithelioma and lupus. Tumors of the Breast : Classification. Differential diagnoses between acute mammary abscess and chronic mammary abscess, Cysts of the breast and glandular tumors of the breast, Glandular tumor of the breast and hypertrophy of the mammas, Scirrhus of the breast and innocent tumors of the breast. Tumors of the Uterus : Classifica- tion. Differential diagnoses between congestive uterine hyperemia and the early stages of pregnancy, Fibroid tumor of the uterus and pregnancy, Retained menstrual blood and pregnancy, Uterine hydatids and pregnancy, Uterine fibroid and a solid ovarian tumor, Uterine fibro-cyst and ovarian cyst, Uterine polypus and uterine fibroid. Tumors of the ovary: Classification. Differential diagnoses between Ovarian dropsy and ascites, Fluid ovarian tumors and pelvic abscess. Unilocular ovarian cyst and venal cyst, Ovarian tumor and pregnancy. Tumors of the pelvis : Classifica- Xll CONTENTS. tion. Differential diagnoses between pelvic cellulitis and pelvic peritonitis, Pelvic hasmatocele and extra-uterine pregnancy, Vaginal polypus and inversion of the uterus, Pelvic hematocele and extra-uterine pregnancy. Tumors of the spine : Classifica- tion. Congenital tumors of the spine. Spina-bifida. Differential diagnosis be- tween spina-bifida and congenital fatty tumor of the spine connected with the me- ninges..........................................................Pages 311-375 DISEASES OF THE BLOOD-VESSELS. DISEASES OF THE BLOOD-VESSELS. The Diseases of the Arteries to which surgical attention is most frequently directed, are of two classes : A. Diseases of the Arterial Coats, under which will be con- sidered : 1. Atheroma. 2. Fatty Degeneration of the Arterial Coats. B. Diseases affecting the Calibre of Vessels, comprising: 1. Aneurism. 2. Occlusion of Arteries from Pressure. 3. " " " " Emboli. 4. . " " " " Thrombi. 5. " " " " Foreign Bodies. The Diseases of the Veins encountered in a surgical practice are: 1. Hypertrophy of the Venous Coats. 2. Atrophy " " 3. Degeneration " " " " 4. Adhesive Inflammation—"Adhesive Phlebitis." 5. Suppurative " —" Diffuse Phlebitis." 6. Varicose Tumors of Veins. 7. Obstruction to Veins from Emboli, Thrombi, and out- side pressure. 8. Parasites of Veins. Many of these diseases are with difficulty diagnosed during life by their rational symptoms, or physical signs. The pathological evidences are often the only means of positively deciding questions of doubt in diagnosis. It is, therefore, impossible to tabulate the symptoms of some with 4 SURGICAL DIAGNOSIS. sufficient positiveness of statement to allow of admission into a volume on diagnosis, without entering into the domain of pathology. Such as are so involved are therefore purposely omitted. I begin with the consideration of Aneurism. ANEURISM. By Aneurism is meant a tumor containing blood, and communicat- ing with the calibre of an artery. Aneurism may be classified from two distinct standpoints : 1st. On a pathological basis, having reference to the construction of the sac of the tumor. 2d. On a basis of the anatomical location at which the tumor is developed. On the first basis, Aneurism may be divided into two great varie- ties, dependent upon the condition of the arterial coats ; under each of which may be grouped those various types of Aneurism to which a special nomenclature has been applied. The following table will explain itself: Fusiform Aneurism, where all the arterial coats are equally dilated throughout the entire circumference of the vessel. True Aneurism, where all the arterial coats are dilated at one spot in the cir- cumference of the' vessel. N/Evus, where the capillary vessels are ab- normally dilated, and extensive anasto- mosis exists. Arterial Varix, where a single vessel is uniformly dilated for some distance along its course. Cirsoid Aneurism, where a collection of dilated and tortuous vessels exists. Hernial Aneurism, where a protrusion of the coats occurs through the external coat. Dissecting Aneurism, where a separation of the arterial coats by blood exists. Diffuse Aneurism, where an escape of blood from the artery into surrounding tissues occurs. Varicose Aneurism, where an indirect communication between an artery and a vein exists through an intervening sac. Aneurismal Varix, where a direct com- munication between an artery and a vein exists. False Aneurism, where one coat only of the artery remains as a sac for the tumor. Aneurism classi- fied on &, path- ological basis. 2 great types. A. Where all the coats of the vessel are intact. 5 varieties. B. Where one or more of the ar- terial coats is rup- tured. 6 varieties. DISEASES OF THE BLOOD-VESSELS. By most authors Aneurism has been differently classified, and separate divisions have been made by some to include distinctive anatomical types. Thus, the term "Encysted" or "Common Aneurism," includes in many classifications the following varieties : True Aneurism. False Diffuse Fusiform " Dissecting " Again, the term "Arterio-Venous Aneurism" is used by some authors to include both "Arterial Varix" and "Varicose Aneu- rism," while to the " Diffuse " type of Aneurism the term " Cgsto- genic " was applied by Broca, and is still frequently employed. Aneurism may be classified in the second place on the basis of its anatomical location, as follows : f Thoracic. " Internal " Aneurism. -I Abdominal. I Pelvic. Aneurism, classified on a basis of , location. " External " Aneurism. f Carotid. Subclavian. Axillary. Brachial. Radial. Ulnar. Femoral. Popliteal. Tibial. Peroneal. By this classification the surgeon is enabled to designate and de- scribe the aneurismal tumor before its exact pathological condition is determined, should such be capable of diagnosis during the life of the patient. The diagnosis of aneurism as a disease is often difficult, and a dis- crimination between its types is frequently impossible. A. It may be confounded as a disease with 1. A tumor lying upon some large vessel. G SURGICAL DIAGNOSIS. 2. Erectile tumors. 3. Pulsation of a relaxed aorta. 4. An abscess over some large vessel. 5. Abdominal tumors. 6. Some types of painful abdominal disease. 7. Solid obscure tumors. 8. Intra-thoracic tumors. 9. Tubercular consolidation at apex of lung, complicated with an arterial murmur. 10. Psoas abscess. 11. Cancer of bone. 12. Pulsatile tumors of bone. 13. Encephaloid cancer. B. The different types of aneurism may also be confounded with each other when diagnosis is possible during life, and finally, C. The seat of aneurismal tumors, especially those of the inter- nal type, is to be differentiated by variations in the Bational and Physical Signs pertaining to the various localities in which the tumor may be situated. DISEASES OF THE BLOOD-VESSELS. 7 ANEURISM. TUMOR LYINO UPON AN ARTERY. Condition of the Tumor. The tumor is soft, elastic and The tumor may be hard and in- compressible, elastic. Mobility. The tumor is usually fixed. The tumor is frequently movable. Effects of Pressure. The tumor is diminished in size The tumor is unaffected by pres- on direct pressure. sure. The tumor is diminished in size The tumor is unaffected by cut- by pressure on proximal side of ting off the arterial supply above". vessel. The tumor increases in size when The tumor is not affected by pres- pressure over the distal end of the sure made over the artery on the artery is made. distal side. Auscultatory Sounds. A bruit, or abnormal sound on A bruit may possibly be present, auscultation, exists over the tumor, but is very rare. This bruit is synchronous with This bruit, if present, is seldom the action of the heart, and in large constant, and seldom, if ever, vessels is often double. double. It is not affected by the position It can often be arrested by change of the tumor. in position of the tumor. Pulsation. The pulsation in the tumor is The pulsation, if present, is of a expansive. heaving character, and not expan- sive. SYMPTOMS IN COMMON. Both may pulsate and yield a bruit on auscultation. " " produce shooting pains along the course of nerves. " « " stiffness in muscles, and muscular weariness. " << " impaired motion in joints, if so situated. " « " absorption of bone, caries, or necrosis. 8 SURGICAL DIAGNOSIS. ANEURISM. ERECTILE TUMORS. Condition of the Tumor. The tumor is soft, elastic and The tumor is usually of a spongy compressible. consistence. Locality of Tumor. The tumor is always located over The tumor may be located where the direct course of a vessel. the arterial supply would be nor- mally disproportionate to the size of the tumor. Appearance of Integument. The skin is usually normal. The skin is frequently implicated. Effects of Pressure. The distal side of the artery is The distal side of the main artery usually decreased in volume. is often normal in volume. Pulsation. The pulsation is uniform through- The pulsation is often marked at out the tumor. circumscribed spots, or centres. The pulsation is markedly ex- The pulsation is often not expan- pansive. sive in character. Surface of Tumor. The tumor is smooth and regular The tumor is often irregular on in outline. its surface, and indistinct in its outline. Auscultatory Signs. A bruit ia well marked as a rule. A bruit is often absent. SYMPTOMS IN COMMON. Both are indicated by the presence of a tumor. " " associated with pulsation. DISEASES OF THE BLOOD-VESSELS. 9 ABDOMINAL ANEURISM. PULSATION OF A RELAXED AORTA. Palpation. A tumor is detected on palpation No tumor in the abdomen is de- of the abdomen. tected on palpation. Pain. A pain in the bach always exists, Pain in the back, if present, is constant and often severe. not constant or severe. Auscultatory Signs. A bruit is heard over the seat of No bruit or abnormal sound ex- the tumor. ists over the seat of pulsation. Pulsation. Expansive pulsation exists. The pulsation is usually of a heav- ing character. Percussion. An abnormal area of dulness ex- No abnormal area of dulness on ists over the seat of aneurism. percussion is present. Condition of Vessels. An atheromatous condition of No atheromatous changes are de- the superficial vessels is often de- tected in the vessels, nor is a trau- tected, or a previous traumatic his- matic history present as a source of tory exists. origin. OSdema. CEdema of the extremities not in- OEdema in lower extremities sel- frequent from pressure. dom present, save from other cause. Femoral Pulse. The femoral pulse is frequently The femoral pulse is usually nor- decreased in volume. mal in volume. SY3IPTOMS IN COMMON. Both yield an abnormal area of pulsation. " may be associated with pain in the bach. 10 SURGICAL DIAGNOSIS. ANEURISM. ABSCESS OVER A VESSEL. Outline of Tumor. The tumor presents a sharp and The tumor is indefinite and ob- well-defined outline. scure in outline. Size. The tumor is usually of moderate The tumor is often of immense dimensions. size. Consistence. The tumor is soft, elastic and The tumor is usually tense, or compressible. doughy from oedema. Effects of Pressure. The tumor is diminished in size The tumor is unaffected by pres- by direct pressure. sure. Pulsation. Expansive pulsation is present. The pulsation is heaving in char- acter. The pulsation is not affected by Pulsation is often arrested by at- attempts to displace the tumor. tempts at displacement. Appearance of Skin. The skin is usually normal in ap- Skin is usually red and oedema- pearance over tumor. tons. Fluctuation. Fluctuation is seldom present. Fluctuation distinct during the advanced stages. Temperature. The local and general tempera- The local and general tempera- ture is usually normal. ture is elevated. Constitutional Symptoms.' Chills and rigors are absent. Chills and rigors are frequent as pus forms. SYMPTOMS IN COMMON. Both are indicated by the existence of a tumor. " " often associated with pulsation. " " " " " pain. DISEASES OF THE BLOOD-VESSELS. 11 ABDOMINAL ANEURISM. ABDOMINAL TUMORS. Mobility of Tumor. The tumor is immovable as a rule. The tumors are movable as a rule. Locality of Tumor. The tumor is situated in the line Abdominal tumors are often not of the artery. in the line of the artery. Condition of Tumor. The tumor is soft, elastic and Abdominal tumors are frequently compressible. hard, and seldom elastic. Pulsation. Expansive pulsation exists. Pulsation is either absent, or heaving in character. Auscultatory Signs. A bruit (synchronous with the Abnormal auscultatory sounds are heart, and often double) is present, usually absent. Effects of Pressure. A diminution in the size of the No variation in the size of the tumor occurs from direct pressure. tumor is detected on pressure being applied. Pain. A constant pain in the back Pain is often absent, or localized exists (diagnostic). over the tumor. Femoral Pulse. The femoral pulse is often de- The femoral pulse is seldom af- creased in volume. fected, save when the tumor is very large. SYMPTOMS IN COMMON. Both are indicated by a tumor. " may be in the line of a vessel. " " associated with pulsation. " << li " pain. « « « " change in volume of femoral pulse. 12 SURGICAL DIAGNOSIS. ABDOMINAL ANEURISM. PAINFUL ABDOMINAL DISEASES. Neuralgia, Renal, Intest. and Bili- ary Colics, etc., etc. Palpation. A tumor is often detected by in- No tumor can be perceived either spection and palpation, which is on inspection or palpation. immovable. Pain. A pain exists in the lumbar re- The pain is paroxysmal, with in- gion, which has been long con- tervals of relief, and usually of short tinued, constant and distressing. duration. It is seldom if ever local, or lumbar in location, but is dif- fused in some particular direction. Pulsation. Expansive pulsation is detected. No pulsation is present. Auscultatory Signs. A bruit, often systolic and dias- No bruit, or abnormal ausculta- tolic, is heard over the seat of pain, tory sound, is heard. SYMPTOMS IN COMMON. Both are associated with pain. " may be apparently unassociated with a tumor. Pulsation and bruit may be undetected possibly in both. DISEASES OF THE BLOOD-VESSELS. 13 ANEURISM OF ABDOMEN. PSOAS ABSCESS. Tumor. The tumor is usually circum- The tumor is elongated in shape, scribed and of moderate dimen- as detected by palpation and per- sions. cussion. The tumor is situated in the track The tumor is located over the of the aorta, or of some large vessel track of the psoas muscle, at the of pelvis. outside of spine. No tumor is perceived below A tumor is perceived in the groin Poupart's ligament in the groin. below Poupart's ligament. Fluctuation. Fluctuation is absent as a rule, Fluctuation is often present in but if present, is felt over the site the thigh over the location of the of the tumor. tumor. Auscultatory Signs. A bruit is present on ausculta- No abnormal auscultatory sounds tion. are perceived. Femoral Pulse. Femoral pulse often decreased in Femoral pulse normal in volume. volume. History of Patient. No history of spinal disease exists. A history of spinal • disease is present, and often precedes the ap- pearance of the tumor. Pulsation. Pulsation of an expansive char- No pulsation is detected as a rule. acter exists. SYMPTOMS IN COMMON. Both are associated with pain in the bach. " " " " a tumor in abdomen. " may be associated with fluctuation. 14 SURGICAL DIAGNOSIS. THORACIC ANEURISM. INTRA-THORACIC TUMORS. Location of Tumor. The tumor is always located in The tumor may possibly be situ- the course of the aorta. ated away from the direct track of large vessels. Density of Tumor. Tumor is only moderately resis- The tumor is usually hard and tant to pressure. markedly resistant to pressure. Auscultatory Signs. A bruit is heard over the tumor, No bruit is present, unless the on auscultation. tumor is in close relation to some large vessel. Percussion. The area of dulness on percussion The arefr of dulness on percussion over the tumor is limited in extent, is often extensive. Pulsation. The pulsation perceived is expan- Pulsation is usually absent, but sive in character. when present is heaving in charac- ter, save in malignant disease, when expansive pulsation may exist. Condition of Face and Neck. Swelling and oedema of the face Swelling and oedema of the face and neck exist, but nary in their and neck, when present, are persis- severity and extent, because of tent and constant in their extent changes in the line of pressure from and severity. the tumor. SYMPTOMS IN COMMON. Both are associated with local dulness on percussion. " " " " swelling and oedema of face and neck. " " " " possible dyspnoea, cough, pain and impaired deglutition. DISEASES OF THE BLOOD-VESSELS. 15 THORACIC ANEURISM. CONSOLIDATION AT APEX OF LUNG. With a murmur in some vessel of Thorax. Inspection and Percussion of Chest. A tumor is usually detected with- No tumor is detected on palpa- in the thorax on inspection, palpa- tion, but an area of dulness at the tion, or percussion. apex is perceived. Pulsation. Pulsation is often perceptible over Pulsation is absent. the seat of tumor. Area of Dulness. Dulness on percussion often ex- The area of dulness on percussion tends beyond the median line of the is always confined to one side, un- thorax. less both apices are affected. The area of dulness is always cir- The area of dulness is extended cumscribed. laterally downwards into the axilla. Auscultatory Signs. The murmur heard is generally The murmur is heard only over diffused over an extended area. the direct course of the vessel, and is most distinct over the consoli- dated lung tissue. SYMPTOMS IN COMMON, Both are associated with localized dulness on percussion. " " " "a murmur on auscultation. 16 SURGICAL DIAGNOSIS. ANEURISM OF BONE. CANCER OF BONE. Locality of Tumor. The tumor occurs in the line of The disease affects the articular some vessel. heads of long bones, especially the lower end of the femur. Condition of Tumor. The tumor is irregular in shape, The tumor is hard, irregular, in- and painful. compressible and painless in its ear- liest stages. Consistence of Tumor. The tumor is of uniform consis- The tumor becomes elastic and tency. fluctuant in spots during the ad- vanced stages. Rapidity of the Growth. The tumor grows slowly. The tumor grows rapidly and of- ten attains immense size. Effects of Pressure. The tumor is modified in size and The tumor is not affected by pres- appearance by impeded circulation, sure, or by impeded vascular sup- through pressure on the supplying ply. vessel. Mobility. The tumor can often be partially The tumor is immovably at- separated from the bone. tached to the bone. Appearance of Veins. The superficial veins are normal The superficial veins are mark- in appearance. edly enlarged. DISEASES OF THE BLOOD-VESSELS. 17 ANEURISM OF BONE CANCER OF BONE (continued). (continued). Pain. Pain is slight, and is rather an Pain is deep, lancinating and con- uneasy feeling than severe. stant: occurs often early in the dis- ease. Pulsation. Pulsation is detected early. Pulsation is detected late in the disease, and is often absent. Fungoid. No tendency to fungoid growth " Fungoid excrescences " are fre- exists, quent. Cachexia. No cachexia is apparent. A marked cachexia exists. The neighboring glands are nor- The neighboring glands are often mal. involved. SYMPTOMS IN COMMON Both are common in young people. " pulsate. " are indicated by a tumor. " may produce pain, 2 18 SURGICAL DIAGNOSIS. CIRSOID ANEURISM. PULSATILE TUMORS OF BONE. Mobility of Tumor. The tumor is unconnected with The tumor is firmly attached to the adjacent bone. the adjacent bone. Outline of Tumor. The edges of the tumor are in- The edges of the tumor are dense distinct. It seems to arise by dis- and hard. tinct cords beneath the integument. Pulsation. Pulsation is marked, and is ex- Pulsation is indistinct, and is not pansive in character. markedly expansive in character. Palpation. The walls of the tumor are ir- The walls of the tumor are ir- regular and knotted, but are soft to regular in their outline, but contain the touch. spots of ossification. Effects of Pressure. The tumor is altered in its size The tumor is only slightly modi- and appearance by direct pressure, fied by pressure either upon itself or by pressure over its supplying or its nutrient vessel. vessel. SYMPTOMS IN COMMON. Both are associated with the pressure of a tumor. " " " " pulsation. DISEASES OF THE BLOOD-VESSELS. 19 ANEURISM. ENCEPHALOID CANCER. Rapidity of Growth. The tumor grows slowly. The tumor is of rapid growth. Consistence. The tumor is of uniform con- The tumor is of unequal consis- sistence and seldom fluctuates. tence. being soft and fluctuant often in spots. Multiplicity. The tumor is seldom multiple. The tumor is frequently multi- ple. Glands. The neighboring glands are un- The neighboring glands are usu- affected. ally involved. Condition of Veins. The veins are normal in their ap- The superficial veins are promi- pearance. nent and tortuous. Pulsation. The pulsation is expansive in The pulsation within the tumor character, and exists from the com- appears only in the advanced stages, mencement. and is heaving in character. Pain. Pain is often absent, and, if pres- Pain is an early and active symp- ent, is frequently referred to dis- tom. Is severe and lancinating in tant localities. character. Effects of Pressure. Marked alteration in the size and The effects of pressure, either appearance of tumor follows im- upon the tumor or its supplying peded circulation within it, or di- vessel, are unimportant. rect pressure upon it. SYMPTOMS IN COMMON. Both are associated with the pressure of a tumor. " " pulsation. " " pain. (( et 20 SURGICAL DIAGNOSIS. ANEURISM. ANEURISMAL VARIX. Condition of Skin. The tumor is covered by normal The tumor, if near the surface, integument. is usually blue or purple in color. Rapidity of Growth. The tumor is sometimes rapid in The tumor grows slowly as a rule. its growth. Condition of the Veins. The veins are normal in the vi- cinity of the tumor, both as to their direction and apparent structure. The arterial volume and force of the pulse are either normal or de- creased. A bruit of a blowing character is usually present. This bruit is not continuous. No venous pulsation exists. The vein implicated becomes en- larged, tortuous, and sacculated. The venous coats also become thick- ened, so as to resemble those of an artery. The force of the arterial pulse is usually preternaturally increased. A "pathognomonic fremitus" is heard over the tumor, resembling the " buzzing of an insect," " the purring of a cat," etc. A " continuous souffle " is heard in the vein. A " venous pulsation " is present, which is synchronous with the heart's action, and which is in- creased by pressure on the proximal side of the vein. Force of Pulse. Auscultatory Signs. DISEASES OF THE BLOOD-VESSELS. 21 ANEURISM ANEURISMAL VARIX (continued). (continued). Effects to Patient. The patient is unconscious of The patient is conscious of the any abnormal sound or sensation peculiar fremitus, which affects the within the tumor. sleep, and leads also to a belief that an insect is imprisoned. Venous Return. The venous return is usually un- The venous return is usually in- impaired, terfered with, resulting often in oedema, coldness, pain, atrophy, etc., etc. SYMPTOMS IN COMMON. Both are indicated by the existence of a tumor. " " " " " " " pulsation. " " " " " " " abnormal sounds. " il affected by pressure over tumor and its supplying vessel. 00 SURGICAL DIAGNOSIS. CIRSOID ANEURISM. ERECTILE TUMORS. Appearance of Tumor. The tumor is always irregular in The tumor is often uniform in shape, and distinct pouches are its general contour. often present. The tumor frequently reveals dis- No distinct arterial convolutions tinct arterial convolutions. are detected, as a rule. The tumor apparently arises from The tumor is usually very in- distinct cords underneath the in- distinct in its outline. tegument. Fluctuation. Fluctuation is infrequent, but Fluctuation is usually detected may exist when the vessels are within the tumor. very large. Pulsation. Pulsation is strongly marked Distinct points of pulsation are throughout the entire tumor. usually detected. Location of Tumor. This type of aneurism is most No particular anatomical loca- frequently confined to the tem- tion is especially prone to become poral, occipital and posterior au- affected. ricular arteries. SYMPTOMS IN COMMON. Both are indicated by a tumor. " " associated with pulsation. b may be " " fluctuation. DISEASES OF THE BLOOD-VESSELS. 23 CIRSOID ANEURISM. N^EVI. Origin of Tumor. The tumor is seldom congenital. The tumor is usually congenital, but may develop even after puberty. Location of Tumor. The tumor is seldom sub-mu- The tumor may be either sub- cous in situation. • mucous, or sub-cutaneous in char- acter. The tumor is most frequent upon The tumor is most frequent upon the scalp. the face. Appearance of Tumor. The tumor is knotty and irregu- The tumor may be markedly ele- lar in shape. vated or flattened, but is uniform in appearance. Auscultatory Sounds. A "bruit" is detected, but has A peculiar "cooing noise" is simply a blowing quality. often detected in auscultation. Pulsation. Pulsation is usually detected on Palpation often perceives a pecu- palpation. liar <' vibratory thrill." SYMPTOMS IN COMMON. Both are associated with a tumor. pulsation. bruit. altered color of skin. elasticity and soft consistence. alteration in the appearance of tumor on im- peding venous return. 24 SURGICAL DIAGNOSIS. ANEURISM OF ARCH OF ANEURISM OF INNOMINATE. AORTA. Condition of Face and Extremities. The entire face, neck and both The right side only is affected, upper extremities are frequently with obstructed venous return, as livid, swollen and cedematous from a rule. pressure on the vena cava. Appearance of Thorax. The bulging of the chest wall The bulging of the chest wall, if over the tumor is often located on present, is confined to the right side the left side, Avhen present. of the thorax. Location of Tumor. The tumor is seldom, if ever, felt The tumor is often felt above the in the neck. thorax, in the neck. Pulsation. Pulsation may often be detected Pulsation is usually detected by by pushing the fingers down be- direct palpation over the right hind the sternum, if direct palpa- sterno-clavicular articulation. tion fails to perceive it;—or, by placing one hand on the sternum and one hand on the back, pul- sation, if indistinct, may be per- ceived. Effects of Pressure. Pressure on the right carotid, or Pressure upon the carotid, or right subclavian artery fails to di- subclavian artery of the right side minish the pulsation. causes either a marked decrease in, or a total arrest of the pulsation within the tumor. SYMPTOMS IN COMMON. Both are associated with an altered appearance of the face. " " " " frequent bulging of the thorax. " " " " pulsation and a bruit. DISEASES OF THE BLOOD-VESSELS. 23 VARICOSE ANEURISM. ANEURISMAL VARIX. Anatomical Condition. The artery and the vein are in The artery and the vein have a communication, indirectly, through direct communication. No inter- an intervening sac or tumor. vening sac or tumor exists. Condition of Venous Coats. The venous coats are not marked- The venous coats are greatly ly altered. thickened, and resemble those of an artery. Auscultatory Sounds. The "bruit" is harsh in charac- The pathognomonic "buzzing ter, and is heard most distinctly fremitus" exists, and is widely dif- over the intervening sac. fused. It is seldom carried into the vein. It is equally detected in both vein and artery. SYMPTOMS IN COMMON. Both yield a "vibratory thrill" on palpation. " " " venous pulsation. " are associated with change in the color of adjacent skin. " " " " defective venous return (often). " " " " alterations in size and appearance, on pressure upon, or obstructed circulation within the artery. 26 SURGICAL DIAGNOSIS. VARICOSE ANEURISM. VARICOSE VEINS. Pulsation. Venous pulsation is present. No pulsation in the vein is per- ceived. Bruit. A bruit can be heard over the No bruit is heard over the tumor. tumor, which is harsh in character. Volume and Force of Pulse. The force of the arterial pulse is The volume and force of the often affected, and the volume fre- arterial pulse below tumor corre- quently diminished. spond with that of opposite side. Effects of Pressure. The tumor shows marked altera- The tumor is unaffected by pres- tion in its size and appearance by sure upon the arterial vessel below pressure on the artery. or above the tumor. Condition of Superficial Veins. The superficial veins may be nor- The veins are seen to be tortuous mal. The deep veins are usually and dilated on the surface. engorged from defective vis-a-tergo. SYMPTOMS IN COMMON. Both are associated with a tumor. " " " " discoloration of the integument. " " " often with pain over seat of tumor. " " " " " impaired usefulness of limb. " " " " " " venous return. DISEASES OF THE BLOOD- VESSELS. 27 ATHEROMA OF VESSELS. FATTY DEGENERATION OF VESSELS. Origin. Atheroma may result from age, chronic alcoholism, gout, rheuma- tism, syphilis, exposure, or trau- matism ; all of which tend to pro- duce a condition of chronic endar- teritis. It is most frequent in the male. It may affect veins when exposed to irritation, as in Aneurismal Varix. It may be primary, when occur- ring in the old from general im- pairment of activity, and is in this case usually accompanied by similar changes in other parts ; or, It may be secondary to increased nutritive activity of the affected parts, as occurs in atheroma. Condition of Vessels. Rings of ossification are usually detected as the finger is moved along the affected vessel. The affected vessels become liable to rupture from slight accidents, as a result either of ulceration of their walls, or a rigid and brittle condition of their coats. When ligation is demanded, the loss of contractile power in the ves- sel and frequent breaking of the ar- tery betray the disease. Spots of ossification are absent, if uncomplicated by atheroma; but a condition of defective con- tractility exists, as shown by the effects of cold, stimulation, etc. The affected vessels show no de- cided tendency to easy rupture, un- less an atheromatous condition co- exists. The ligation of fatty vessels is not associated with frequent break- ing of the vessel, nor is its con- tractile power so seriously impaired. SYMPTOMS IN COMMON. Both frequently are associated with diminished arterial volume. " " " " " dilatation of vessel at the affected portion. a (t n tt 't tortuosity of the vessel. a a t( a a impaired nutrition to tissues when excessive arterial supply is de- manded, as in inflammation. 28 SURGICAL DIAGNOSIS. EMBOLISM. THROMBOSIS. Definition. Is an obstruction to a vessel, Is an obstruction to a vessel, usually arterial, by a previously usually of the venous system, by a moving body. coagulum of blood formed at the seat of obstruction. Origin. The embolus may arise from The thrombus may be the result fibrinous vegetations on the heart of injury, inflammation, pressure valves, resulting from a previous from tumors or ligature, enfeebled endocarditis, from small blood co- or obstructed heart's action, or an agula floating in the current, or altered and abnormal blood condi- from foreign bodies in the circula- tion predisposing to coagulation or tion. producing irritation of the vessels. Location. If of cardiac origin, the embolus May affect any situation if an ex- most frequently lodges in the left citing cause exists. middle cerebral artery. If due to disintegrated coagula, the lungs and abdominal organs are more fre- quently involved. 03dema. GMema is seldom present as the 03dema is a common symptom arteries are chiefly involved. from obstruction to the venous re- turn. Paralysis. Sudden paralysis, usually hemi- Aphasia is not usually present in plegic, and aphasia are produced by cerebral thrombosis, and paralysis cerebral embolism. may be absent. DISEASES OF THE BLOOD- VESSELS. 29 ADHESIVE PHLEBITIS. SUPPURATIVE PHLEBITIS. Origin. This condition is primarily one This condition always begins in of the venous coats. tissues external to the vein. Development. It is usually a circumscribed dis- It is rapidly extended along the ease. course of veins, usually from the smaller toward larger trunks. General Health. It may occur in normal health. Occurs in abnormal conditions of the system or in debility, but never in robust health. History. It may follow injuries, ligature, It may follow any form of local amputations, or abnormal blood irritation, as in venesection, liga- conditions predisposing to irrita- ture of veins or the inclusion of vena tion. comites with large arterial trunks. It occurs in infants from ligating the funis. Pyemic Symptoms. Pysemic symptoms are absent, as Pysemic symptoms are usually the coagulum in the vein does not produced by disintegration of the disintegrate. thrombus formed in the vein, and by occlusion, from the loosened detri- tus, of capillaries in other organs. SYMPTOMS IN COMMON. Both may be associated with pain. " " " " " oedema. " tt a it a prominence of neighboring veins. DISEASES OF THE JOINTS. DISEASES OF THE JOINTS. The surgical Diseases of the Joints include A. Inflammatory Diseases. 1st. Of the synovial membrane : " Syno- vitis." 9 varieties. Acute. Subacute, Chronic. Scrofulous. Rheumatic. Gouty. Pysemic. Gonorrhceal. Syphilitic. Acute. r Acute. 2d. Of the general structures entering I rn^Q^n I Rheuma i [_ Syphilitic. into the formation of a joint: -j Eheumatic> "Arthritis." 4 varieties. B. Anchylosis—varieties, -I ' ~ (2. Oi 1. Fibrous. )sseous. C. Dropsy of Joints: "Hydrarthrosis." D. Articular Neuralgia. E. Loose Cartilages in Joints. F. Congenital and Acquired Malformations. The various forms of Synovitis differ in their symptoms only in degree and causation, and are chiefly diagnosed from each other by the previous history of the patient and the severity of the inflam- matory changes. I have, therefore, omitted many differentiations which might ap- pear strained or self-evident. I shall consider the various surgical affections of the joints in the following order: I. Diseases of Joints in general. II. Diseases of Special Joints. III. Congenital or acquired Deformities of Joints. 3 34 SURGICAL DIAGNOSIS. I. DISEASES OF JOINTS IN GENERAL. SYNOVITIS. RHEUMATISM. Is a purely local inflammation in- Is a disease dependent on an ab- dependent of blood condition. normal state of the blood. Locality. Is a unilateral affection as a rule. Is generally a bilateral affection. One joint only is affected. Several joints are usually involved simultaneously. Swelling. The swelling about the joint is The swelling about the joint is irregular, and due to the distension uniform, if severe. of the synovial pouches. Integument. The integument over the affected The integument over the affected joint is usually normal. joints is usually reddened. Secretions. The secretions are normal in re- The secretions are usually strong- action, ly acid in reaction. Pain. The pain is only of moderate se- The pain in the affected joints is verity. often excessive. Heart. Heart complications are seldom Heart complications are frequent- present ; if present they are of in- ly the result of the abnormal blood- dependent origin. condition. Temp, and Pulse. The constitutional disturbance is The constitutional disturbance is generally slight. often alarmingly severe. DISEASES OF THE JOINTS. 35 SCROFULOUS SYNOVITIS. HYDRARTHROSIS. Age Affected. Is usually a disease of youth. May occur at any age. Pain. The pain is at first slight and Pain may be present in the early often remote from the seat of ac- stages, if the disease is of inflam- tual disease. ma tory origin, but is often absent. In the latter stages, however, the A sense of distension within the pain becomes local and severe; is joint is, in the advanced stages, worse at night, and is increased by more often the only source of dis- impinging the articular surfaces of comfort. the joint. Appearance of Joint. The normal bony prominences of The normal bony prominences of the joint are concealed, and the the joint are still apparent, but the hollows normal to the joint are ef- synovial pouches are distended, faced. rendering them prominent. Motion. The normal movements of the Motion of the affected joint is joint are impaired. only slightly embarrassed. Skin. The skin over the affected joint The integument over the joint is is milky-white in color, shiny in of normal appearance. appearance, and the blue veins on the surface are apparent. Sinuses. Sinuses form in the latter stages. Sinuses seldom, if ever, exist. Crepitation. Crepitation appears as the joint Crepitation is absent, if no corn- undergoes disorganization. plications are present. Palpation of Tumor. The tumor is soft, doughy and The tumor is fluctuant, and elas- fluctuant before sinuses form. tic to the touch. History of Patient. History of scrofulous diathesis History of traumatism, rheuma- exists. tism, syphilis, etc. 36 SURGICAL DIAGNOSIS. ACUTE ARTHRITIS. CHRONIC RHEUMATIC ARTHRITIS. Pain. The pain is severe and acute in The pain is slight at first and in- the early stages. creases with the development of the disease. The pain is localized at the joint. The pain is not local, but follows the course of nerve-trunks. The pain is steady and constant. The pain is paroxysmal and usu- ally worse at night. Deformity. The deformity of the affected The deformity is marked and pro- joint is at first due only to a serous gressive, resulting in the distortion effusion within it; but in latter of bony prominences, relaxed liga- stages structural changes occur. ments, atrophied muscles, etc., etc. Motion. The motion of the joint is fre- The motion of the joint is usu- quently destroyed by suppuration. ally only impaired, and a stiffness is experienced. Crepitation. Crepitation occurs from necrotic Crepitation, when present, is due or carious changes within the joint, to denuded cartilages, or a deposit as the result of suppurative inflam- of osteophytes. mation. Age. This disease may occur at any age. Occurs most frequently about 50 th year of age. History. Arthritis follows low vitality, ex- This disease may follow high liv- posure to cold or dampness, or trau- ing, exposure, or injury. matism. DISEASES OF THE JOINTS. 37 ACUTE ARTHRITIS CHRONIC RHEUMATIC (continued). ARTHRITIS (continued). Location. Is not confined to any special Attachs the hip as a rule. In joints ; is frequent in the ankle, males it may affect any large joint, knee, and hip. while in females the small joints are sometimes involved. SYMPTOMS IN COMMON. Both are associated with pain. " " " " deformity. " " " " crepitation. " " " " impaired motion. 38 SURGICAL DIAGNOSIS. ACUTE ARTHRITIS. SYPHILITIC PERIOSTITIS NEAR A JOINT. Signs of Effusion. The synovial pouches are jDromi- No symptoms of effusion into the nent in the early stages of the disease, joint exist. Swelling. The swelling is generally diffused The swelling is localized, and around the joint. often confined to one side of the joint. Pain. The pain is severe and acute from The pain is moderate in severity the commencement. at the onset of disease. The pain is steady and constant. The pain always increases at night. Motion. The pain is affected by motion of The pain is not affected by motion the diseased joint. of the joint. Suppuration. Suppuration is frequent. Suppuration is rare. Disorganization of Joint. Disorganization of the joint is The joint seldom becomes impli- frequent. cated or disorganized. History of Patient. A history of exposure, scrofula, Evidences of syphilis are often or low vitality exists. detected in skin, bone, or organs. Effect of Treatment. Improvement slow under treat- Improvement marvellously rapid ment. under iodide of potassium. SYMPTOMS IN COMMON. Both are associated with pain. " " " " local swelling:. " " " " tenderness. " may be " " suppuration. DISEASES OF THE JOINTS. 39 ACUTE ARTHRITIS. SUPPURATION EXTERNAL TO A JOINT. Appearance of Joint. The swelling present in the joint The swelling in the vicinity of is bilateral. the joint is unilateral. Bony Prominences. The bony prominences normal to The bony prominences of the the affected joint are prominent in joint are usually masked by the ex- the early stages, unless complicating isting swelling in the vicinity of oedema exists. the joint. Synovial Pouches. The synovial pouches are promi- The synovial pouches of the joint nent in the early stages, from se- are not prominent. rous distension. Fluctuation. Fluctuation is often detected over Fluctuation is detected at the the distended synovial pouches. seat of swelling, without regard to its particular location. Motion. Motion is impaired in the late Motion is often limited, but only stages by destruction of the mech- by the mechanical impediments re- anism of the joint. suiting from the swelling. Disorganization of Joint. Disorganization of the joint is Grating, crepitus, looseness of common and extensive. the joint and other signs of dis- organization are absent. Constitutional Symptoms. The constitutional symptoms are No constitutional disturbance is marked. present—as a rule. Muscular Cramps. Muscular cramps and startings No symptoms referable to mus- in the sleep are prominent and cular irritability are present. severe. Termination. Frequently amputation is de- Seldom of serious import. manded. SYMPTOMS IN COMMON. Chills, pain on motion, unnatural attitude of joint, local heat, and swelling and tenderness on pressure are present in both. 40 SURGICAL DIAGNOSIS. BONY ANCHYLOSIS. FIBROUS ANCHYLOSIS. Pain. No pain is produced within the Pain is present if the patient joint by voluntary attempts at makes strenuous efforts to effect motion. motion in the anchylosed joint. No pain at the joint results from Marked and severe pain is ex- manipulation in the hands of the perienced by any surgical attempts surgeon, save at the direct points to produce mobility. compressed by the fingers. Motion. All evidences of mobility are ab- The fixation of the diseased joint sent, and complete solidity exists. is incomplete. Effect of Anaesthetics. Anassthesia is negative in its re- Ansesthesia frequently enables the suits, as no perceptible motion in surgeon to establish the normal lati- the joint can be thus produced, tude of motion, where it had pre- even under strong manipulation. viously been restricted. II. DISEASES OF THE SPECIAL JOINTS. Disease of the Hip Joint : "Morbus Coxarius." By this term is designated all the various types of disease con- fined to the hip joint, which are liable to follow inflammatory changes within that joint, whether these inflammatory changes pri- marily affect the bone, the cartilaginous structure, or the synovial membrane. By some authors a classification of Morbus Coxarius has been made into the Femoral, the Arthritic, and the Acetabular varieties, based upon the primary seat of origin of the inflammatory process. In all of these types, however, we have four prominent symptoms which are common to all of the varieties, and which are liable to be present. They vary somewhat, however, in degree and intensity, with the location of the primary changes within the joint, and are for that reason often of aid in the diagnosis of the particular type of disease then existing. DISEASES OF THE JOINTS. 41 These important symptoms are 1. Pain. 2. Suppuration. 3. Dislocation. 4. Anchylosis. Other common symptoms also co-exist in all of the varieties; among them may be mentioned Deformity, Lost or impaired motion and function, Change in the appearance of the nates, Change in the spino-pelvic angle, Abnormal relation between the two anterior superior spines of ilium, especially when in recumbent position, An antero-posterior curvature of the spine, and pos- sibly a lateral deflection, when the limb is ex- tended upon the trunk. But these symptoms are diagnostic rather of the disease in gene- ral, than of any particular seat of origin. In the following table will be shown in contrast those variations in the four above-mentioned symptoms, which will enable us pos- sibly to detect the seat of the primary inflammatory changes within the joint. 42 SURGICAL DIAGNOSIS. ARTHRITIC. Pain is acute from the onset of the disease, and is located in the joint. Is greatly in- creased by movement of the limb, concussion of femur, or pressure over the trochanter. ACETABULAR. 1st Symptom : Pain. Pain at first is re- ferred to the iliac fossa, or the side of the pel- vis. Later on in the dis- ease it becomes severe, and gnawing in char- acter, and is referred to the joint itself. It is increased in all stages by concussion of femur, abduction of limb, or pressure over the trochanter. 2d Symptom : Suppuration. FEMORAL. Pain is referred to the hnee joint in the early stages of the dis- ease, and is often slight at the onset. Suppuration may possibly be absent. An abscess of the in- tra-pelvic variety usu- ally forms. It may point in front, above, or below Pou- part's ligament;—or, by escaping through the sciatic notch, point behind, at the back part of the thigh. Pus, when formed, burrows either under the glutei muscles, and points behind, or on the outer aspect of the thigh ; or 2d, it burrows under the pectineus muscle, and points on the inner aspect of thigh. 3d Dislocation is rare. When present, it is due either to rupture of the capsule, or caries of the head of the bone. Symptom : Dislocation Dislocation into the pelvic cavity often oc curs from caries of the acetabulum. 4th Symptom Dislocation is fre- quent, and is due either to caries of the head of the femur, or new growth in the cavity of the acetabulum. Anchylosis. Not infrequent; usu- ally occurs within the acetabulum. Anchylosis is rare. Anchylosis often oc- curs in some abnormal position, following a dislocation of the fe- mur. DISEASES OF THE JOINTS. 43 The diagnosis of morbus coxarius in its early stages, before sup- puration occurs, is of vital importance, as the prospect of complete recovery depends, as a rule, upon its early recognition. The following guides to its diagnosis will therefore merit the closest attention: 1st. A change in the position of the affected limb and impaired function will exist in the earlier stages. 2d. The pelvis will be found inclined from a right angle to the spinal column, as shown by a line drawn between the two anterior superior spines of the ilium, and contrasted with the median line of the body. This pelvic inclination can, however, be restored to the normal position by manual pressure, or, possibly, by a muscular effort on the part of the patient. 3d. On placing the patient in the dorsal position upon the table, all attempts to straighten the affected limb until the popliteal space touches the table, will tend to elevate the back at the lumbar region from the same plane, so that frequently the hand can be placed be- tween the table and the spinal column. 4th. In the same position on the table the two anterior superior spines of the ilium will be seen not to be on the same level as they are in health, when the limb is extended; the affected side being elevated above the healthy side. 5th. Flexion of the thigh and leg, and an altered relation of the affected thigh to the pelvis will remove the pelvic inclination, will bring the spines of the ilium to the same level, and will cause the lumbar region of the spinal column to lie in contact with the couch. When these points are perfectly accomplished the normal relations are restored, and the actual existing deformity of the hip is made manifest. 6th. Extension of the affected limb will usually relieve the pain by separating the inflamed surfaces of the joint. 7th. Concussion upon the end of the affected femur with the palm of the hand, when the knee is flexed, will increase the pain by ap- proximating the inflamed surfaces. 8th. Pressure over the trochanter of the affected side will like- wise, as a rule, increase the sufferings of the patient. 9th. Motion of the affected limb at the hip joint will usually give pain, and especially will this be marked when motion in some par- ticular direction is attempted. Great credit is clue to Dr. Lewis A. Sayre, of New York, for the 44 SURGICAL DIAGNOSIS. present simplicity of diagnosis in obscure cases of morbus coxarius, as well as for his improvements in reparative appliances. Morbus Coxarius is to be diagnosed from 1. Congenital dislocation of the hip. 2. Psoas abscess. 3. Disease of the sacro-iliac articulation. 4. " " trochanter of femur. 5. Lateral curvature of the spine. 6. Rheumatic deformity of the hip. 7. Disease of the crest of the ilium. 8. Inflammation of a psoas bursa. 9. Infantile paralysis. DISEASES OF THE JOINTS. 45 MORBUS COXARIUS. CONGENITAL DISLOCATION OF HIP. Pain. Pain is present as a symptom in Pain is absent, the bone having all forms of the disease. an abnormal position, but being healthy. Effects of Pressure. Pain is produced by pressure over Pain is often absent on both pres- the trochanter, or concussion of the sure and motion. Concussion may femur. give slight pain. Shortening. An apparent shortening of the Actual shortening exists from affected limb appears early, due to the date of birth,—as shown by tilting of the pelvis. measurement from the ant. sup. Real shortening occurs, however, spine of ilium, to the internal mal- in the latter stages from absorption leolus at ankle. of the bone. This shortening is not affected by This shortening can often be in- upward pressure, after the muscles creased by upward pressure on the are firmly contracted. end of the femur. Extension of Limb. The apparent and real shorten- The shortening of dislocation ing are often reduced by extension, may often resist extension, and is seldom, if ever, completely reduced. Mobility of Limb. The mobility of the limb is great- The mobility of the limb does not ly impaired in late stages. vary, and is usually free in charac- ter. Spinal Column. A spinal deflection from con- The spinal column is normal. traction of the psoas muscle exists. 46 SURGICAL DIAGNOSIS. MORBUS COXARIUS CONGENITAL DISLOCATION (continued). OF HIP (continued). Relation of the Spines of Ilium. The anterior spines of ilium are The anterior spines of the ilium not upon the same level when the are upon the same level when pa- patient lies upon the back. tient is lying upon the back. SYMPTOMS IN COMMON. Both are associated with alteration in the length of limb. " '" " " pain on concussion. " " " " impaired mobility of the limb. DISEASES OF THE JOINTS. 47 MORBUS COXARIUS. PSOAS ABSCESS. History of Patient. No history of spinal disease can A well-marked history of spinal be elicited. disease is present. Pain. The pain at first is felt in the The pain is usually referred to knee, hip, or pelvis. the back or loins. Effects of Pressure. Pressure over the trochanter of Pressure over the trochanter of femur usually causes pain, especial- the femur gives no pain. ly so after perforation of the cap- sule of the hip. Motion. Motion of the femur is painful in Motion of the femur is painless, all stages of the disease. when the thigh is flexed to relieve pressure upon the tumor. Fold of Nates. The fold of the nates is altered The fold of the nates is normal from its normal position. in its position. Length of Limb. The length of the affected limb No change in the length of the is altered. affected limb can be detected. Condition of the Joint. The joint is often immovable in The joint is movable, even after advance stages, and there is an es- the abscess has discharged pus and cape of pus. established sinuses. SYMPTOMS IN COMMON. In both the contracted psoas affects the spinal curve. a a a re]ation of the pelvis to the spine is often altered. " " " evacuation of pus and the previous formation of a tumor in the thigh occur. " " " pain and impaired function of limb may exist. 48 SURGICAL DIAGNOSIS. MORBUS COXARIUS. SACRO-ILIAC DISEASE. Effects of Position of Limb. The altered relation of the pelvis The obliquity of the pelvis is not to the spine can be modified by the affected by the position of the limb. position of the limb. Effect of Pressure. The pain on pressure over the Pressure over the trochanter trochanter is felt in the hip joint. causes pain in the sacro-iliac articu- lation, but not in the hip joint. Pain. The pain in the hip on pressure is The pain on pressure and motion not controlled by fixation of the os is modified, or entirely controlled innominatum. by fixation of the os innominatum. Length of Limb. A change in the length of the The lengthening of the limb is limb affected is often present. never actual, but only apparently so. SYMPTOMS IN COMMON. Both may be associated with local pain. " " " " suppuration and the formation of sinuses. " " " " obliquity of the pelvis. " " " " detection of necrosed or carious bone, by the probe. " " " " apparent lengthening of the limb on affected side. DISEASES OF THE JOINTS. 49 MORBUS COXARIUS. DISEASE OF THE TROCHAN- TER OF THE FEMUR. Age Affected. Is chiefly a disease of childhood. Occurs chiefly during adult life. History. Occurs, as a rule, after some in- Follows rheumatism, gout, syphi- jury, as a fall, severe strain, or blow, lis, or some blood diathesis. Appearance of Nates. The fold of the nates is abnormal The fold of the nates corresponds in its position. with that of the opposite side. Pain in Knee. A pain in the knee is often a pro- No pain in the knee, or inner as- minent and an early symptom. pect of the thigh, is ever present. Appearance of Spine. The spine is usually curved from The spine is usually normal in contraction of the psoas. appearance. Position of Pelvis. The pelvis is usually tilted. The pelvis is usually normal. SYMPTOMS IN COMMON. Both are associated with pain on motion of the femur. " " " " " " pressure over trochanter. " " " " formation of abscess and sinuses. 4 50 SURGICAL DIAGNOSIS. MORBUS COXARIUS. LATERAL CURVATURE OF THE SPINE. Nates. The fold of the nates is abnormal The fold of the nates is unal- in position. tered. Length. The length of the limb is often No real alteration in the length altered on actual measurement. of the limb is ever present. Pain. Pain is present on pressure over No pain is produced by pressure the trochanter, or on concussion of over the trochanter, or by concus- the femur. sion of the femur. Abscess. Symptoms of abscess appear, fol- No symptom of abscess, or of the lowed by the escape of pus and the evacuation of pus occurs. formation of sinuses. Spinal Deformity. The spinal deformity, produced The spinal deformity is not af- by contraction of the psoas muscle, fected by position of the femur. is reduced by position of the limb. SYMPTOMS IN COMMON Both are associated with apparent shortening. " " " " altered pelvis. " " " " " spine. " " diseases of childhood. DISEASES OF THE JOINTS. 51 MORBUS COXARIUS. RHEUMATIC DEFORMITY OF HIP. Age. Is a disease chiefly of childhood. Seldom exists in the young. History. Is preceded by a history of in- Is preceded by a history of rheu- jury; and most frequently occurs matism. in scrofulous or weak children. Nates. The fold of the nates is abnormal The fold of the nates corresponds in position. with its fellow. Length of Limb. The length of the limb is usually The length of the limb is usually altered. normal. Abscess. Abscess and sinuses arc common Abscess is rare. symptoms. Complications. No disease is present simulta- Other joints are, as a rule, simul- neously in other joints. tancously involved. SYMPTOMS IN COMMON. Both are associated with impaired motion. " " " " possible immobility. " " " " " crepitus. " " " " pain on pressure. " " " " " " motion. 52 SURGICAL DIAGNOSIS. MORBUS COXARIUS. DISEASE OF THE CREST OF ILIUM. Length of Limb. The length of the affected limb is The length of the limb on the abnormal, as a rule. side affected corresponds with its fellow. Motion of Limb. The motion of the affected limb The motion of the limb is normal is either impaired or lost. on the side affected. Abscess. The abscess resulting from the The abscess resulting from disease diseased joint opens, as a rule, be- of the ilium points and evacuates low the level of the upper border of itself above the level of the hip the trochanter of the femur. joint. Probe. A probe when introduced usually A "probe when introduced finds detects carious bone at the hip, the seat of carious or necrotic after suppuration has occurred and changes to be above the articula- ble abscess has discharged. tion. Shape of the Hip. The shape of the hip is abnormal; The hip is normal in appearance ; and the nates are dissimilar. and the nates on each side corre- spond. SYMPTOMS IN COMMON. Both are associated with marked pain. " " " " the formation of abscess. " " " sinuses, in later stages. " " " " low vitality and emaciation. " may occur in the young. DISEASES OF THE JOINTS. 53 MORBUS COXARIUS. INFLAMMATION OF PSOAS BURSA. Shape of Hip. The hip is altered in its shape The hip is normal in shape and and appearance. appearance. Fold of Nates. The fold of the nates is displaced The fold of the nates is similar to on the affected side. that of the opposite side. Effect of Pressure. Pain on pressure over the tro- Pressure over the trochanter of chanter is perceived. affected side gives no pain. Knee Symptoms. Symptoms referable to the knee Symptoms referable to the knee appear early. are absent. Tumor. The tumor due to the pointing The tumor produced by the in- of pus appears late in the disease, flamed bursa appears early, is lo- and is usually painless to the touch, cated in the anterior part of the thigh, and is painful to the touch. SYMPTOMS IN COMMON. Both are associated with flexion of the affected limb. " " " " pain on motion of the limb. " " " " impaired, or restricted function in the joint. " may be associated with pelvic distortion. " " " " " spinal curvature. 54 SURGICAL DIAGNOSIS. MORBUS COXARIUS. INFANTILE PARALYSIS. Length of Limb. The shortening may, in some The shortening of the affected cases, be apparent only; while in limb is actual, as shown by meas- some stages even lengthening may urcment from anterior spine of exist. ilium to the inner malleolus of ankle. Spinal Curvature. The spinal curvature is more of The spinal curvature which often an antero-posterior character, as it exists is of the lateral variety. depends greatly upon contraction of the psoas muscle. Size of Limb. The affected limb may be normal The affected limb is atrophied in size. and smaller than its fellow, pro- vided one limb only be affected. Suppuration. Suppuration and the formation Abscess is seldom if ever present, of abscess are common. save as a complication. Mobility of Joint. The joint is often immovable in The joint is never fixed or im- the third stage of the disease. movable. History of Patient. A history of injury followed by A history of gradual loss of mus- pain in the knee, etc., is present. cular power is present. SYMPTOMS IN COMMON. Both may be associated with alteration in the length of the limb. " " " " " spinal curvature. " " " " " atrophy of the limb. DISEASES OF THE JOINTS. 55 Diagnostic Points of Tenderness on Pressure in Inflammation of the Larger Joints. All joints, when inflamed, or when an increased amount of syno- vial fluid is present, present certain special localities where an abnormal degree of sensitiveness to pressure exists. This local sensitiveness, if detected early, often confirms a diagnosis. I have enumerated below the anatomical situation of those diagnostic points which pertain to the five principal joints of the body. In the Hip. Close behind the trochanter, the fingers being shaped like a cone, and firm pressure made. " " Knee. On either side of the patella. " " Ankle. In front of the joint, slightly above the malleoli. " " Shoulder. The anterior aspect of the joint, pressure being made through the axillary coverings. " " Elbow. In front of the joint, over the head of the radius. III. DEFORMITIES OF JOINTS. The various deformities of joints which are liable to be met with in a surgical practice, may be divided into, 1st, those of congenital origin; and, 2d, those acquired after the date of birth. Under the first type, viz.: " Those deformities which are con- genital," may be enumerated A. Congenital Distortions ; under which I include 1. Club Foot, in all its varieties. 2. Club Hand, in all its varieties. 3. Sub Luxation, in all its varieties. 4. Distortions, dependent on paralysis. 5< « " " contracted muscles. B. Congenital Malformations; under which head may be enumerated 1. Atrophy of limb, with malformation of long bones. 2. Hypertrophy of phalanges. 56 - SURGICAL DIAGNOSIS. 3. Atrophy, or absence of phalanges. 4. Imperfect development of carpus, metacarpus, tarsus, or metatarsus. 5. Fusion of toes or fingers (syndactylus). 6. Valgoid malformation of upper extremities. 7. Supernumerary toes, digits, or even entire members. 8. Fusion of inferior extremities ("sympodia ; " " mono- podia "). Under the second type, viz.: "Acquired Deformities of Joints," may be enumerated 1. Deformities from wounds, accidents, rheumatism, and diseases of joints. 2. Deformities from rickets, weakness and curvature of bones. 3. Deformities from muscular contraction. 4. " " paralysis. 5. " " burns. 6. Spinal curvatures and deformities. Many of the types of malformations which exist under the con- genital variety, have been omitted, as they have no direct bearing upon the Joints. They are seldom of such a character as either to demand surgical diagnosis, which is usually self-evident, or to be benefited by surgical treatment. To those interested, however, in such deformities, I refer, for reference, to Henle's classification of Congenital Malformations. I pass to the consideration of Club-foot as the most frequent, and, possibly, the most important congenital deformity of the joints. Talipes. By " Club-foot," or " Talipes," is meant an abnormal condition of the tarsus, and frequently of the metatarsus, resulting in an altered relation of the axis of the limb to the axis of the foot. DISEASES OF THE JOINTS. 57 It is usually divided into the following varieties : 1. Talipes Equinus.........where the heel is raised and the foot extended upon the leg. 2. " Calcaneus........where the heel is project- ing and the foot flexed. 3. " Varus...........where the sole of the foot is turned inwards. 4. " Valgus...........where the sole of the foot is turned outwards. 5. " Equino-Varus.... where a combination of the equinus and varus deformities exists. 6. " Equino-Valgus... .where a combination of the equinus and val- gus deformities exists. Talipes. 8 distinct types. 7. Calcaneo-Valgus.. where a combination of Spurio-Valgus. the calcanean and val- gus deformities exists. or " Flat-foot," where the plantar arch is defi- cient. Of these types, the combined varieties, especially those of the Equinus type, can hardly be considered otherwise than as the sim- ple varus or valgus deformity associated with contraction of the muscles forming the tendo Achillis, and consequent elevation of the heel. The Gastrocnemius, Soleus, and Plantaris muscles, which form the tendo Achillis, are important factors in the varus deformity, being adductors of the foot as well as extensors. It is seldom, therefore, that Talipes varus fails to escape some elevation of the heel, although the term Equino-varus is not applied until this altered position of the heel becomes a marked element in the deformity. Talipes can hardly be confounded with any other deformity. I therefore confine the few following pages to its individual types only; my object being rather concisely to record the diagnostic points of each, than to infer the possibility of error in diagnosis. 58 SURGICAL DIAGNOSIS. TALIPES VARUS. TALIPES VALGUS. Frequency. As a congenital disease, this de- As a congenital deformity, Tali- formity is the most frequent form pes Valgus is rare. of talipes. Deformity, if Congenital. The foot is adducted, the sole The foot is abducted, the sole turned inwards, or upwards, and the turned outwards and often upwards, internal malleolus is obliterated. and the external malleolus is oblite- rated. Progress of the Deformity, if Acquired. The disease, if acquired after The disease usually first reveals birth, is first manifested by elevation itself by an elevation of the external of the internal border of the foot, border of the foot, due to contrac- from contraction of the two tibial tion of the peronei muscles, the muscles and the muscles of the tendo long extensors of the toes and the Achillis. muscles of the tendo Achillis. SYMPTOMS IN COMMON. Both are associated, if of long standing, with stiffness in the ankle joint. " " " " " " " a longitudinal furrow in the sole of the foot, from narrowing of the trans- verse arch of the foot. " " " " " " " a slight elevation of the heel. " " " " " " " the gradual formation of a soft, cushiony swelling on the dorsum of the foot where the pressure of walking occurs. " " " " " " " rigidity of tendons on the side of deflection of the foot. DISEASES OF THE JOINTS. 59 TALIPES EQUINUS (simple). TALIPES EQUINUS, with para- lysis of the extensor muscle of the toes and flexors of the tarsus. Position of the Foot in Walking. The patient walks upon the ends The patient walks upon the dor- of the metatarsal bones. sum of the foot, which is bent upon the ground with the sole looking backwards and upwards. Attitude of the Toes. The toes are drawn upwards. The toes are relaxed or flexed. Muscular Power. The muscles on the anterior part All flexion of the foot and exten- of leg can partly control the foot sor-muscular power over the toes and the toes. are lost. SYMPTOMS IN COMMON Both are associated with absence of any lateral displacement. " " " " increased width of the foot, from separation of the metatarsal bones. << " " " projection forward of the astragalus. " « " " elevation of the heel. " " " " contraction of the muscles of the calf. Both may occur in the young, and, possibly, in the adult. CO SURGICAL DIAGNOSIS. TALIPES VALGUS (Spurious). CALCANEO VALGUS of mode- rate severity. (The Chinese foot as example.) Plantar Arch. The arch of the sole of the foot The arch of the sole of the foot is is diminished. increased. Insteps. The instep is less prominent than The instep is increased in promi- normal. nence. Length of Foot. The front part of the foot is nor- The anterior portion of the foot mal in its length. is much shortened. Muscles of Calf. The muscles of the calf are nor- The muscles of the calf are atro- mal in size, and the tendo Achillis phied, and the tendo Achillis is is prominent. scarcely visible. Outer Margin of Foot. The outer edge of the foot be- A deep cleft exists on the outside comes elevated as the disease ad- of the foot at the peroneus longus vances. tendon, but the outer edge of the foot is not raised. SYMPTOMS IN COMMON Both are developed, as a rule, after birth. " " progressive in deformity. " " associated with altered gait. " " " " abnormal appearance of outer margin of foot. DISEASES OF THE JOINTS. 61 TALIPES VALGUS. SPURIOUS VALGUS ("Flat Foot"). Age. Is present at date of birth as a May commence in early life, but comparatively rare affection. seldom becomes a deformity till adolescence. Origin. It may be acquired, however, from If occurring after 18th year of infantile paralysis, convulsions dur- age, is due to rheumatism, excessive ing dentition, standing too long on standing or walking, or general feet, carrying heavy weights, etc. debility. Deformity. The external margin of the foot is elevated, the foot is twisted so that pressure falls upon the internal malleolus and inside of the instep, and the metatarsus and toes do not touch the ground. No projection of the astragalus, or widening of the foot is present. The length of the foot is dimin- ished, and the toes are often flexed. The outer margin of the foot is affected early in the disease, and locomotion is performed on the side of instep. The tarsal arch is destroyed through relaxation of the calcaneo- scaphoid ligaments, and those be- tween the scaphoid, and the cuboid and internal cuneiform bones. The astragalus projects in front, the foot is widened, and the convexity of the dorsum of the foot is lost. Eversion of the toes, and actual elongation of the foot occur. The outer margin of the foot be- comes raised late in the disease, and locomotion is mostly effected upon the heel, in the later stages. Length of Foot. Ankle Joint. The motion within the ankle joint The anhle joint remains useful is rapidly impaired. for a time, but gradually loses its capabilities of motion. Outer Margin of Foot. 62 SURGICAL DIAGNOSIS. TALIPES VALGUS SPURIOUS VALGUS (continued). ("Flat Foot") (continued). Pain. The pain is of an unimportant Pain exists previous to the com. character and is often absent. plete breaking down of the plantar arch at the internal malleolus and the sole of the foot from tension on the ligaments; but it ceases when full deformity is reached. This pain is more severe in slight cases than in severe ones. Effect of Standing. The act of standing increases the In the early stages the plantar deformity in a slight degree in the arch is effaced on standing, but re- early stages, but the normal atti- turns when the weight is removed. tude of joint is not reassumed, even in the recumbent position. DISEASES OF THE JOINTS. 63 SPURIOUS VALGUS SPRAIN OF ANKLE JOINT. ("Flat Foot"). Pain. The pain in the early stages is The pain is usually within the confined to the internal malleolus joint, or at either malleolus, and is and the sole of the foot. seldom if ever present in the sole of the foot. History. No history of sudden wrench or A history of some sudden or se- twisting of ankle is present, but vere exciting cause exists. rather of prolonged exertion or de- bility. Swelling. No swelling, with tenderness to Swelling and tenderness are the touch, exists in vicinity of marked in the vicinity of the ankle the ankle. joint. Effect of Standing. A marked alteration in the plan- No alteration in the shape of the tar arch appears from the weight of foot ensues from the standing posi- the patient when standing. tion. Results. Gradual deformity ensues, unless Gradual improvement and re- recognized early, and preventive stored function follow. treatment employed. SYMPTOMS IN COMMON. Both are associated with pain in the ankle. tt a tt a pain 0n standing or walking. " may be " " a history of excessive exertion or debility. ^ ti a a j0I1g duration and progressive symptoms. DISEASES of bone. 5 DISEASES OF BONE. The diseases which are confined to the bony structures of the body are frequently relieved by surgical measures only, and are properly classed as essentially surgical diseases. As an enumeration of the various types of diseases of bone liable to be encountered, I would mention : A. Inflammatory Diseases of Bone, comprising: 1. Simple inflammation of bone—" Osteitis." 2. Diffuse suppurative inflammation of the interior of the bone—" Osteo-myelitis." 3. Circumscribed suppuration of bone—" Abscess of bone." B. Inflammation of the Coverings of Bone, comprising: 1. Simple inflammation—" Periostitis." 2. Suppurative " —" Periosteal abscess." 3. Chronic —" Periosteal thickenings and nodes." C. Gradual Changes in, or Abnormal Deviations from the Healthy Type of Bome Structure : 1. Atrophy of bone. 2. Hypertrophy of bone. 3. Rachitic condition of bone. 4. Mollities ossium. 5. Caries of bone,—or ulceration of bone. 6. Necrosis of bone,—or gangrene of bone. 7. Spontaneous fracture. 8. Tumors of bone. The Tumors of Bone may be divided into two types : A. Non-malignant tumors, including 1. Enchondromata. 2. Exostoses. 67 68 SURGICAL DIAGNOSIS. 3. Cystic. 4. Fibrous. 5. Fibro-cystic. 6. Entozoa. B. Malignant tumors, including 1. Pulsatile tumors of bone. (Colloid, 2. Cancer of bone, 3 types : -< Encephaloid, and (Schirrus. 3. Malignant cysts—" Spina Ventosa." The diseases of bone are to be diagnosed 1st. From each other. 2d. " arthritic disease of joints. 3d. " diseases of the soft tissues. DISEASES OF BONE. 09 OSTEITIS. OSTEO-MYELITIS. Origin. It may result from disease, or Is always traumatic in origin; from traumatism. follows amputations, fractures, etc. It occurs in scrofula, syphilis, It occurs where the medullary rheumatism, and follows exposure, canal is exposed to the air, as a rule. Most Frequent Seat. The tibia, bones of the head, and ribs are most frequently affected. The long bones are most frequent- ly involved. Pain. The pain present is intermittent j is worse at night if syphilitic in origin, or is increased by dampness if of rheumatic origin. The pain is first perceived at the seat of injury, or in the stump in cases where amputation has been performed, and is accompanied by rigors. Changes in the Bone. The affected bone gradually en- larges in circumference. The bone becomes hard, irregu- lar in contour and incompressible. Pysemic symptoms often rapidly follow, associated Avith high fever, dryness of the stump, or arrested secretion at the seat of injury, if caused by fracture. The soft tis- sues are also often retracted. The bone undergoes necrotic changes and becomes infiltrated with pus. Termination. The disease often terminates in Recovery is rare. recovery. SYMPTOMS IN COMMON. Both may be associated with a traumatic history. " " " " marked pain. 70 SURGICAL DIAGNOSIS. CARIES. NECROSIS. Definition. Is a molecular death of bone Is a death of bone tissue in mass, tissue, and is analogous to ulcera- and not in molecules, and is analo- tion of the soft tissues. gous to gangrene of the soft tissues. Is a disease Avhich affects the can- Usually attacks the compact cellous tissue of bone. tissue of bone. Most Frequent Seat. Is most frequent in the articular Is most frequent in the shafts of extremities of long bones. .long bones. Etiology. Ahvays results from a low grade May be traumatic in origin, and of chronic inflammation, as in acute; is always due, hoAvever, to scrofula, syphilis, injury, or an defective nutrition of the bone extension of inflammation from tissue. other parts. Sinuses. Sinuses form slowly, as the Sinuses form rapidly after the disease is not often superficial in death of the bone has occurred. its early stages. Cavities in Bone. Tends to create cavities within Is usually superficial and seldom the bone. results in the formation of central cavities within the bone. Probe Examination. A fine, grating sensation alone is A smooth, denuded, and fre- detected by the probe on examina- quently loose sequestrum is de- tion. tected by the probe SYMPTOMS IN COMMON. Both may be associated with prolonged suppuration. " " " " " sinuses. "are " " abnormal sensations on probing. DISEASES OF BONE. 71 OSTEITIS. PERIOSTITIS. Pain. The pain which exists is deep, The pain is superficial in char- and diffused throughout the bone, acter, and usually circumscribed. Tumor. The bone undergoes a uniform The bone develops a local tumor. enlargement. Sensitiveness. The bone affected is moderately Extreme sensitiveness to pressure sensitive to pressure. exists over the affected portion. Causation. Is frequently the result of simple Is usually either traumatic or exposure. syphilitic in origin. Results. Amputation is frequently de- Amputation is seldom required, manded in severe types. as the disease usually subsides under treatment, or goes on to abscess and necrosis. SYMPTOMS IN COMMON. Both are associated with pain in the region of the bone affected. " " " " enlargement of the bone. " " " " sensitiveness to pressure. " " " " constitutional disturbance of ten. " " " often with traumatic history. 72 SURGICAL DIAGNOSIS. PERIOSTITIS NEAR A JOINT. ACUTE ARTHRITIS. Effusion. No symptoms of effusion into the Symptoms of effusion within the joint exist. joint are prominent. Swelling. The swelling is localized, and The swelling about the joint is often confined to one side of the generally uniform, and always bi- joint. lateral. Pain. The pain is moderate in severity The pain is severe and acute at the onset of the disease. from the commencement. The pain usually increases at The pain is steady and constant. night. Pain on Motion. No pain is produced by motion Great pain is often associated of the affected joint. with motion at the diseased joint. Suppuration. Suppuration is rare. Suppuration is frequent. Disorganization of the Joint. The joint seldom becomes impli- The joint rapidly undergoes dis- cated or disorganized. organization, unless the disease be arrested. Syphilis. Evidences of syphilis are often No evidences of syphilis are de- detected in the skin, bone or tected, as a rule. organs. Rapidity of Improvement. The improvement under the An improvement is only pro- iodide of potassium is often mar- duced by local measures. vellously rapid. SYMPTOMS IN COMMON. Both are associated with swelling near the joint. " " " " pain. " " " " abnormal sensitiveness to pressure. DISEASES OF BONE. 73 ABSCESS OF BONE. ARTHRITIS. Motion. ^ The motion of the neighboring The affected joint early manifests joint is seldom affected. pain wiien certain movements are demanded. Swelling. The disease is not externally re- The size of the joint increases vealed until late, being, as a rule, and becomes prominently affected exceedingly sIoav in its progress. in the early stages. Pain. The pain is usually deep seated The pain is located within the in the neighborhood of a joint, but joint and is usually steady and con- not within it. stant. Suppuration. When the circumscribed pus When suppuration occurs the reaches the surface the joint is sel- joint usually undergoes rapid dis- dom invoh'ed, but a continued es- organization. cape of pus through a sinus is lia- ble to remain indefinitely until the cause be relieved. SYMPTOMS IN COMMON Both are associated Avith pain in the vicinity of a joint in the early stages. Both may be associated with suppuration. " " " " " sinuses in late stages. " " " " " the detection of carious bone by probing. 74 SURGICAL DIAGNOSIS. RICKETS. MALACOSTEON. Osteomalacia.—Mollities Ossium. Time of Origin. Rickets commences, as a rule, in A softening of bone Avhich occurs infants from the sixth month to after puberty, usually in middle the close of the second year. It is life, or as age advances. rare after puberty. Deformity. The long bones of the body be- The disease may affect the whole come twisted or bent. bony system, or only portions of it. The flat bones become hypertro- The pelvis and the spine are its phied in their cancellous structure, frequent seats. especially at their edges, and a soft- The stature is often greatly di- ening is frequent at the centres of minished, if the legs or spine be ossification. affected. The face is often undeveloped in The facial bones are seldom af- proportion to the cranium. fected, and the proportion to the cranium is normal. Spinal curvatures are frequent, The pelvic deformities are char- and pelvic deformities Avith short- acterized by shortening of the trans- ening of the antero-posterior diame- verse diameters, but the bones are ters. normal as to development. The bones of the thorax become deformed from spinal changes and muscular action. The bones affected are often ar- The bones affected are normal in rested in development. size and appearance before the at- tack. Diathesis. Rickets is frequently associated No scrofulous diathesis, but a Avith a scrofulous diathesis. rheumatic history is frequently present, the disease seeming to con- sist in a fatty degenerative process. Termination. The disease frequently ends in The disease seldom tends towards recovery, and does not tend to short- recovery. May prove fatal, from en life. complications, within a few years. SYMPTOMS IN COMMON. Both result in deformities of the bony structures. " are due to impairment of normal health. DISEASES OF BONE. 75 EXOSTOSES OF BONE. CYSTS OF BONE (" Spina Ventosa"). Situation. Most frequently affect flat bones Most frequently affect the jaw and the shafts of long bones. and the articular heads of long bones. Shape. Are usually globular in shape, Are usually round or oval in but they may be pediculated. shape. Size. Are of moderate dimensions. Are often immense in size. They may reach the size of a child's head. Number. Are frequently multiple. Are usually single. Palpation. Are hard and incompressible. Crackle like parchment, in the late stages, when the bone is thinned. Development. Develop slowly and regularly. Develop rapidly, as a rule, but often irregularly ; often being sIoav in growth and then suddenly rapid, or vice versa. Fluctuation. The tumor never fluctuates. Fluctuation exists in localized spots during the advanced stages. Condition of Veins. The superficial veins are normal. The superficial veins are enlarged. Pain. No pain on pressure exists, as a Pain is often present on firm rule. pressure. SYMPTOMS IN COMMON. Both are associated with a local tumor of bone. tt a ti often Avith symptoms referable to irritation of nerves, muscles, joints, or vessels. 76 SURGICAL DIAGNOSIS. CANCER OF BONE. PULSATILE TUMORS OF BONE. Locality of Tumor. The disease affects the articular The tumor occurs in the line of heads of long bones, especially the some vessel. lower end of the femur. Condition of Tumor. The tumor is hard, irregular, in- The tumor is irregular in shape, compressible and painless in early and painful. stages. Consistence of Tumor. The tumor becomes elastic and The tumor is of uniform con- fluctuant in spots during the ad- sistence. vanced stages. Rapidity of the Growth. The tumor grows rapidly and The tumor grows slowly. often attains immense size. Effects of Pressure. The tumor is not affected by The tumor is modified in size and pressure, or by impeded A'ascular appearance by impeded circulation, supply. through pressure on the supplying vessel. Mobility. The tumor is immovably attached The tumor can often be partially to the bone. separated from the bone. Appearance of Veins. The superficial veins are marked- The superficial A'eins iare normal ly enlarged. in appearance. Pain. Pain is deep, lancinating, and Pain is slight, and is rather an constant, early in the disease. uneasy feeling than severe. DISEASES OF BONE. 77 CANCER OF BONE PULSATILE TUMORS OF (continued). BONE (continued). Pulsation. Pulsation is detected late in the Pulsation is detected early. disease, and is often absent. Fungoid. "Fungoid excrescences" are fre- No tendency to fungoid growth quent. exists. Cachexia. A marked cachexia exists. No cachexia is apparent. The neighboring glands are often The neighboring glands are nor- involved. mal. SYMPTOMS IN COMMON. Both are common in young people. " pulsate. " are indicated by a tumor. " may produce pain. 78 SURGICAL DIAGNOSIS. PULSATILE TUMORS OF ANEURISM. BONE. Mobility of Tumor. The tumor is firmly attached to The tumor is movable. the bone. Palpation of Tumor. Osseous plates are felt in the walls The Avails of the tumor are felt to of the sac. be soft and uniform in consistency. The edges of the tumor are os- The tumor is soft, elastic and seous. compressible throughout. Pulsation. The pulsation within the tumor The pulsation within the tumor is indistinct, and not markedly ex- is distinct, and expansive in char- pansive. acter. Outline of Tumor. The outline of the tumor is indis- The outline of the tumor is often tinct. distinct. Effects of Pressure. The tumor is only slightly af- The tumor is markedly decreased fected as to size or appearance by in size, and altered in appearance direct pressure or impeded arterial by direct pressure upon it, or by supply. obstructing its circulation by pres- sure upon the supplying vessel. SY3IPT0MS IN COMMON Both are associated with a tumor. " " " " pulsation. " " " often Avith symptoms referable to irritation of joints, nerves, muscles, or vessels. DISEASES OF BONE. 79 SPECIAL TYPES. ABSCESS OF ANTRUM. SOLID TUMORS OF ANTRUM. Deformity. The antrum is equally distended. The antrum is unequally dis- tended. Inflammatory Symptoms. Acute inflammatory symptoms are No acute inflammatory symp- present, such as Chills, Great pain, " sensitiveness to touch, CEdema of face, Increased pulse, and " temperature. toms are present (such as pain, oedema, great sensitiveness and con- stitutional disturbance). Fluctuation often appears in ad vanced stages. Fluctuation. Fluctuation is absent, as a rule. Discharge into Mouth or Nose. No tendency towards a sponta- neous discharge of the contents of the cavity of the antrum is appa- rent. A tendency to the discharge of pus through the teeth sockets, or through the nostril during forced expiration, or in certain positions of the body exists. Exploring Needle. The exploring needle in cases of The exploring needle gives nega- doubt decides the diagnosis. tive results. SYMPTOMS IN COMMON. Both are often associated with projection of the eyeball. " effacement of the nostril. depression of roof of mouth. bulging of the cheek. closure of the lachrymal duct. interference with mastication. " " deglutition. parchment-like crepitus when the bone becomes thin. 80 SURGICAL DIAGNOSIS. SPECIAL TYPES. CYSTIC TUMOR OF ANTRUM. MALIGNANT TUMOR OF ANTRUM. Rapidity of Growth. The tumor grows slowly. The tumor grows rapidly. Age. The tumor occurs in the young. The tumor occurs late in life, as a rule. Pain. The tumor is painless. Great pain is present of a peculiar lancinating character. Palpation of Tumor. The tumor is smooth, hard and The tumor has no elasticity, but elastic. may be hard, or fluctuant in spots in late stages. Mucous Membrane of Mouth. The mucous membrane of the The mucous membrane of the mouth is healthy. mouth is involved as a rule. Hemorrhage. No tendency to hemorrhage ex- Hemorrhages occur frequently ists. and are often severe in character. SYMPTOMS IN COMMON Both may be associated with protrusion of eyeball. " " depression of roof of mouth. " " effacement of nostril. " closure of lachrymal duct. " impairment of mastication. " " " " "deglutition. " bulging of the cheek. DISEASES OF BONE. 81 SPECIAL TYPES. EXTRACRANIAL TUMORS. INTRA-CRANIAL TUMORS. Respiratory Movements. The tumor shows no respiratory The tumor shoAvs " respiratory movements. movements," rising with expiration, and falling with inspiration, from pressure on the vessels. Size of Tumor. The tumor is constant in its size, The tumor is frequently enlarged save as its growth causes it to en- in size during fits of coughing or of large. crying. Reducibility. The tumor cannot be made to The tumor can be reduced within disappear on direct pressure. the skull, either entirely or in part, by pressure upon it. Effects of Pressure. No cerebral symptoms of com- Cerebral symptoms indicative of pression are produced by pressure compression often occur on attempts upon the tumor. at reduction of the tumor. The tumor is constant in its size, The tumor returns after reduc- either under pressure, or when pres- tion when the pressure is removed. sure is remoAred. Abnormal Aperture in Bone. No aperture in the cranial bones An aperture in the bone is often can be detected. felt after the tumor has been re- duced. SYMPTOMS IN COMMOJS. Both may be associated Avith an absence of cerebral disturbance. " " " " similar feel and consistence. " " " " rapid or slow formation. " " " " absence of apparent causation, or knowledge of congenital defect. 6 82 SURGICAL DIAGNOSIS. SPECIAL TYPES. EXOSTOSES OF CRANIUM. SEBACEOUS TUMORS. Palpation of Tumor. The tumor has a characteristic The tumor is often tense and hard, bony hardness. but has elasticity. Mobility of Tumor. The tumor is immovable under The tumor moves freely under the skin. the integument. Condition of Ducts. No abnormal condition of the An obstruction to the ducts is ducts of the part is perceived. evidenced by a small black spot 0ATer the seat of the tumor. Effects of Pressure. Firm pressure causes no change Firm pressure often evacuates the in the tumor. contents of the sac, causing a foul, offensive-smelling, cheesy-like ma- terial to exude. SYMPTOMS IN COMMON Both are frequently multiple. " "of slow growth. " " distinctly circumscribed in outline. DISLOCATIONS. • DISLOCATIONS. By the term dislocation is meant "a solution of the contiguity of bone." Dislocations may be either complete or partial. To the latter type the term subluxation is applied. Dislocations may result from five distinct classes of causes : 1. Direct violence. 2. Indirect violence. 3. Muscular contraction. 4. Disease of the articular surfaces of the bone. 5. Destruction of the ligaments by ulceration, suppura- tion, or injury. The general symptoms of dislocation are 1. Deformity of the joint. 2. Impaired function of the joint. 3. Change in the axis of the injured limb. 4. Disturbed relation of the bony prominences of the joint from their normal bearing to each other. 5. Difficult reduction. 6. Local pain and altered sensibility of parts supplied by special nerves. Dislocations may be classified into the following varieties : A. Simple Dislocations, where the articular surfaces of a joint are displaced, but the surrounding tissues are normal. B. Compound Dislocations, where the displaced articular surfaces of the joint are in communication with the external air. C. Complicated Dislocations, where nerves, vessels, muscles, cavi- ties, or organs are implicated, from injury produced by the displacement. D. Spontaneous Dislocations, where the displacement of the ar- 85 86 SURGICAL DIAGNOSIS. ticular surfaces of a joint occurs from disease, without apparent external causation. E. Congenital Dislocations, where the articular surfaces of a joint are not in their normal position at the time of birth. Dislocations of special joints will be considered in this volume in the following order: 1st. Dislocations of the Inferior Maxilla. 2d. " " Shoulder Joint. 3d. " " Clavicle. 4th. " " ElboAv Joint. 5th. " " Wrist Joint. 6th. " " Hip Joint. 7th. " " Knee Joint. 8th. " " Ankle Joint. Many types of these varieties are often obscure, and are sources of frequent error in diagnosis. Each source of doubt as to the variety of injury present Avill be considered as the special dislocations are revieAved, since it is im- possible to group into a general classification the many points of differentiation Avhich pertain to individual localities. DISLOCATIONS OF THE JAW. The dislocations of the inferior maxilla may be unilateral or bi- lateral. The condyle of the jaw slips from the glenoid fossa into the zygo- matic fossa, and the coronoid process of the inferior maxilla im- pinges upon the malar prominence. This type of dislocations ensues either from spasmodic contrac- tion of the depressor muscles of the chin, or from blows delivered upon the chin when the mouth is Avidely open. Dislocations of the jaw are to be diagnosed from each other, and from 1. Congenital sub-luxation of one side. 2. Chronic rheumatic arthritis of the tempero-maxillary articulation. Dislocations of the jaw are quite frequently met with in surgical practice, and having once occurred are liable to occur again. DISLOCATIONS. 87 UNILATERAL DISLOCATION BILATERAL DISLOCATION OF JAW. OF JAW. Separation of Teeth. The teeth are displaced, but are The teeth are Avidely separated, not widely separated. and the mouth is open. Displacement of Chin. The chin is deflected towards the The chin is projected forwards, affected side. but is not deflected. Appearance of Cheek. The coronoid process produces The cheeks are flattened. a bulging of the cheek on the af- fected side. Holloav at Ear. An indistinct hollow is felt at An empty space is felt in front of the ear. and below each ear. Poaver of Articulation. The articulation of words is only The articulation of labials is im- slightly embarrassed. possible. Masseter Muscle. The masseter muscle is slightly Both masseter muscles stand out prominent on side affected. in bold relief. Temporal Fossa. The temporal fossa on the affect- The temporal fossae on both sides ed side is nearly normal in appear- are filled with the displaced tempo- ance. ral muscles. Facial Expression. The expression of the face is one The expression of the face is one of simple distortion. of distress and alarm. SYMPTOMS IN COMMON. Both are associated Avith deformity and pain. " " " " impaired mobility. " " articulation of Avords. " " " " " mastication. " " " " salivation. " " change in expression. " " " " projection of the under teeth. 88 SURGICAL DIAGNOSIS. UNILATERAL DISLOCATION CONGENITAL DISLOCATION OF JAW. OF JAW. Mobility. The movements of the jaAV are Movement of the jaw is but greatly embarrassed. slightly impaired,—is often normal. Teeth. The teeth are separated and the The upper teeth project beyond chin is deflected. the under teeth. Salivation. Salivation is present, and is often Salivation is slight, and may annoyingly profuse. often be absent. Appearance of Cheek. The cheek is prominent on the The fulness of the cheek is absent, affected side. from osseous and muscular atrophy. Length of Face. The two sides are not markedly One side of the face is markedly altered in length. longer than the opposite. Alteration of Feature. The features are slightly altered The features are twisted, and are by the deflection of the chin, and not symmetrical. the prominent cheek. SYMPTOMS IN COMMON. Both may be associated with abnormal position of the teeth. " " " " salivation. " " " " alteration in feature. " " " " absence of perfect symmetry of the two sides of the face. DISLOCATIONS. 89 DISLOCATION OF THE JAW. CHRONIC RHEUMATIC AR- THRITIS of the Tempero-Max- illary Articulation. Advent. The disease is of sudden advent. The disease comes on slowly. Pain. The pain felt is not referred to Constant pain at the seat of arti- the region of the glenoid fossa. eulation exists ; increased by damp- ness, or atmospheric changes. Age. Dislocation occurs at any age ; It occurs in the old, as a rule. is frequent in adult life. Effects on Function. The function of the jaAv is de- The functions of the joint are stroyed, in the bilateral variety. embarrassed, but not destroyed. Glenoid Fossa. An empty space exists in front of The enlarged condyles can fre- the ear. quently be felt in front of, and be- low the ears. Glandular Enlargement. No glandular enlargement is pres- Enlargement of the parotid, and ent. of the glands behind the ear often exists. Salivation. Salivation is present, and is pro- Salivation is usually absent. fuse. SYMPTOMS IN COMMON. Both are associated with facial distortion. "' " " " projecting under teeth. " " '' " pain. '" " " " impaired function. 90 SURGICAL DIAGNOSIS. DISLOCATIONS AT THE SHOULDER JOINT. The upper end of the humerus may be dislocated in five direc- tions, as follows : A. Downwards, called the "Sub-glenoid" dislocation; the head of the bone lying beloAv the glenoid cavity, and felt in the cavity of the axilla. B. Downwards and Backwards, called the " Sub-spinous " dislo- cation ; the head of the humerus lying underneath the spine of the scapula. C. Downwards and Inwards, called the " Sub-coracoid " dislo- cation ; the head of the humerus lying deep down un- derneath the coracoid process. D. Forwards and Inwards, called the " Sub-clavicular " dislo- cation ; the head of the humerus lying under the clavi- cle. E. Upwards and Inwards, called the " Supra-coracoid " dislo- cation; the coracoid process being fractured by the humerus, and the articular head of that bone being ap- parent above the clavicle. This dislocation, hoAvever, is very rare. The anatomical names applied to the various dislocations of the humerus out of the glenoid cavity are based, as can be seen by the above, on the abnormal location of the displaced articular head of the humerus. I shall employ them in the folloAving diagnoses as they best convey, to my mind, the condition of body, which they are intended to express. Dislocations of the Shoulder Joint are to be diagnosed 1st. From each other. 2d. " separation of the greater tubercle of the hu- merus. 3d. " fracture of the neck of the humerus. 4th. " " " " " scapula. DISLOCATIONS. 91 SUB-GLENOID DISLOCATION. FRACTURE OF THE NECK OF HUMERUS. Acromion. The acromion process of the sea- The acromion process is only pula is pointed and prominent. slightly prominent, since the upper fragment of the humerus is still in its normal position. Depression at Shoulder. A distinctly marked depression An indistinct depression exists a exists immediately below the aero- short distance beloAV the acromion mion. process, at the seat of fracture. Tumor in Axilla. A large, smooth and rounded An irregular and pointed tumor tumor is felt high up in the axilla, is felt low doAvn in the axilla,— —(displaced head of bone). (lower fragment of humerus). Crepitus. Crepitus is usually absent. Crepitus can be easily obtained, but is transient if the extending force be removed. Length of Aral ' The length of the arm is in- The length of the arm is dimin- creased. ished. Direction of Elboav. The elboAV cannot be made to The elbow can easily be approxi- touch the affected side of the chest, mated to the side of the chest. Axillary Fold. The anterior fold of the axilla is The axillary walls are normal in often prominent. appearance. Reducibility. Reduction is difficult, butperma- Reduction is easily accomplished, nent Avhen accomplished. but is transient if the force be re- moA'ed. 92 SURGICAL DIAGNOSIS. SUB-GLENOID DISLOCATION FRACTURE OF THE NECK (continued). OF HUMERUS (continued). History. A history of a fall upon the hand A history of direct violence is or elboAv, Avhen removed from the usually present. chest; or of a direct blow down- wards on the upper part of the hu- merus exists. Motion. Voluntary motion is lost, and Voluntary motion is lost, but communicated motion is limited in communicated motion is very free its extent. under an anaesthetic. DISLOCATIONS. 93 SUB-CLAVICULAR DISLO- SUB-SPINOUS DISLOCATION. CATION. History. Occurs in falls upon the shoulder Occurs in falls upon the shoulder or elboAV, Avhen the arm is directed or elbow, when the arm is directed backwards. forwards. Acromion Process. The acromion process and the de- The acromion process and the pression underneath it are most depression underneath it are most marked posteriorly. marked anteriorly. Length of Aral The length of the arm is short- The length of the arm is normal, ened. or occasionally lengthened. Position of Elbow. The elbow is directed backAvards, The elboAV is directed forwards, and is separated from the chest. and separated from the chest. The forearm is usually also flexed upon the arm. Pain. The pain is severe in character, The pain is only severe when at- and is usually constant. tempts at motion are made. Voluntary Motion. The voluntary motion is very Voluntary motion is less limited limited. than in any other dislocation. COAIMUNICATED MOTION. Communicated motion is restrict- • Communicated motion is restrict- ed outwards and forwards. ed bachwards only. Head of Humerus. The displaced head is felt as a The displaced head of the hu- tumor rotating Avith the humerus, merus is felt to rotate under the below the clavicle. spine of the scapula, near its angle. SYMPTOMS IN COMMON. Both are associated Avith deformity. iC a tt a altered axis of limb. " " " " pain. tt a tt a p0SSible crepitus. « tt tt a increased circumferential measurement of the joint. a tt it a impairment of function. 94 SURGICAL DIAGNOSIS. "SUB-SPINOUS " DISLOCA- SEPARATION OF THE GREAT TION. TUBERCLE. Tumor. The tumor felt upon the scapula The tumor upon the scapula is is large and rounded,—(displaced small,—(displaced tubercle). head). The tumor rotates with the hu- The tumor is not affected by rota- merus. tion of humerus. Age. Is frequent at all periods of life. Is frequent in youth, under 15th year. Glenoid Cavity. The glenoid cavity is empty as The glenoid cavity is filled. felt through the axilla. Prominence of Acromion. The acromion and coracoid pro- The acromion and coracoid pro- cesses are prominent. cesses are not markedly prominent. Depth of Shoulder. The shoulder affected is not al- The affected shoulder is greatly tered in its antero-posterior mea- increased in depth, and the deltoid surement. region is distorted in its appearance. Communicated Movements. Elbow cannot touch the side of The elbow can be made to touch chest. the side of the chest, and the hand The hand cannot touch the top can be placed by the surgeon in al- of head. most any position. The hand cannot touch the oppo- site shoulder. Reduction. Reduction is accomplished by ex- Reduction is accomplished by out- tension and motion. ward rotation of the humerus and pressure over the humerus and the fragment. Tendency to Return. The reduction is permanent when The reduction is transient if the accomplished. force be removed. SYMPTOMS IN COMMON. Both are associated Avith deformity. " " " " pain. " " " " impairment of function. " " " a history of accident. DISLOCATIONS. 95 " SUB-CORACOID " DISLO- " SUPRA-CORACOID " DISLO- CATION. CATION. Origin. Occurs in falls upon the shoulder Occurs from the same form of ac- or elboAV Avhen the arm is directed cident, but Avith force enough to backAvards. usually fracture the coracoid pro- cess. Shortening. The arm is slightly shortened. The arm is usually markedly shortened. Mobility of Aral Motion of the arm is restricted The motion of the arm is re- outivards as the bone impinges upon stricted forwards and outAvards. the coracoid process. Location of Tumor. The tumor is felt underneath the The tumor is felt upon the coraco- coracoid process of the scapula and acromial ligament, touching ex- is obscure in its outline. ternally the inner border of the acromion, and projecting under and raising the deltoid muscle, and pos- sibly piercing it. Position of Elbow. The elbow is directed backwards The elbow is not directed mark- and is separated from the chest. edly backAvards, but is slightly separated from the chest. Acromion. The acromion process is most The acromion process may be prominent posteriorly and the de- mashed anteriorly by the deltoid pression under it is more notice- prominence over the dislocated head able behind than in front. of the humerus. SYMPTOMS IN COMMON Both are associated Avith deformity. impairment of function. abnormal axis of limb. pain. restricted movement. history of an accident. 96 SURGICAL DIAGNOSIS. DISLOCATIONS OF THE CLAVICLE. The dislocations possible to the clavicle are of seven varieties. Three of these are confined to the sternal end, three to the acromial end, while a rare case of simultaneous dislocation of both ends has been recorded. The sternal end of the clavicle may be dislocated upwards, for- wards, or lackivards ; the displaced head being separated from its normal sternal attachments, and the axis of the bone being no longer symmetrical with that of its fellow. The dislocations of the acromial end of the clavicle are as folloAvs: 1. ". Supra-acromial,"—A\dien the clavicle rests upon the upper surface of the acromion process.—(This va- riety is most frequent.) 2. "Infra-acromial,"—where the clavicle is, by some violent wrench, slipped underneath the acromion process.—(Very rare.) 3. " Infra-coracoid,"—Avhen the outer end of the clavicle is wedged underneath the coracoid process of the scapula.—(Very rare.) The dislocations of the outer end of the clavicle are of far greater frequency than those of the sternal extremity, although any of the displacements of the clavicle are rare when compared with fractures of that bone. Dislocations of the clavicle are, as a rule, easy of diagnosis. The deformity produced by the displaced extremity of the bone, the shortening of the shoulder, the impaired motion and local pain will usually render the diagnosis positive. The dislocation of the sternal end backwards may perhaps lead to some confusion in diagnosis, and deserves, therefore, special men- tion. This displacement has been known to result from severe direct blows, such as a kick of a horse, a violent fall upon the shoulder, be- ing crushed between a carriage and a Avail, etc., etc., and also to oc- cur independently of any accident, by progressive lateral curvature of the spine. Its importance, in a surgical aspect, lies in the alarming symp- toms which may be produced by the pressure exerted upon the trachea, oesophagus and large blood-vessels, by the displaced head of the sternum. Thus, in several cases, have symptoms of ap- DISLOCATIONS. 97 proaching death been relieved only by rapid reduction, and by ap- propriate surgical appliances for the maintenance of the bone in its normal position. The absence, then, of the normal prominence of the sternal end of the clavicle, following a severe injury, or occurring with lateral curvature, should always lead towards a suspicion of partial or com- plete luxation, and especially so if symptoms indicative of impeded respiration, circulation, or deglutition accompany the deformity. The so-called dislocations of the scapula are too often only par- tial luxations of the acromial end of the clavicle. In fact it is al- most an anatomical impossibility for the scapula to be turned upon its edge, thus allowing the latissimus dorsi muscles to slip behind it, without an altered relation at the clavico-scapular articulation. In this condition, however, the scapula stands out from the back like a rudimentary wing, and causes a most marked and striking deformity. DISLOCATIONS OF THE ELBOW JOINT. The dislocations at the elbow joint may be divided into two great varieties: A. Where both bones of the forearm are simultaneously dis- placed. B. Where only a single bone of the forearm is displaced from its normal position. Under the^rs£ class, A, may be enumerated : 1. Dislocation of both bones of the forearm directly bach- wards. This dislocation is the most common form, and is not infrequently associated with fracture of the coro- noid process of the ulna. 2. Dislocation of both bones of the forearm backwards and inivards. 3. Dislocation of both bones of the forearm backwards and outwards. 4. Dislocation of both bones of the loxz-axm forwards. This dislocation is very rare, and when present is usually associated with fracture of the olecranon process of the ulna. 7 98 SURGICAL DIAGNOSIS. 5. Dislocation of the ulna backwards and the radius/or- wards. This type of dislocation is infrequent. Under the second class, B, may be enumerated : 1. Dislocation of the ulna backwards. 2. " " " imvards. 3. " " " forwards. 4. Dislocation of the radius backwards. 5. " " " outwards. 6. " " " forivards. Of these last-named dislocations of single bones of the forearm, many are rare; and some, if present, are too easily recognized to cause possible error in diagnosis. Should doubt exist in these cases, however, the impaired mobility of the joint, the deviation from the normal appearances of the bony prominences as compared with those of the uninjured member, and the alteration in length either of the forearm, or of the upper ex- tremity, will easily confirm the diagnosis of dislocation. I have enumerated in detail in the following pages, therefore, only those dislocations of the elbow joint which are liable to be con- founded with each other, or to be mistaken for either fracture or severe contusion in the immediate neighborhood of the elbow. DISLOCATIONS. 99 BOTH BONES OF FOREARM FRACTURE ABOVE THE CON- BACKWARDS. DYLES OF THE HUMERUS. History of Accident. Occurs in falls upon the hand, or Occurs in falls upon the elbow. on the forearm, Avhen the humerus is fixed. Anterior Tumor. A large, oval-shaped tumor (the A small pointed tumor (the up- lower end of the humerus), is felt per fragment of humerus), is felt anteriorly beloio the crease of the anteriorly, lying above the crease of elbow. the elbow. Posterior Tumor. A tumor is perceived posteriorly A large posterior tumor is per- which exhibits the outline of the ceived, Avhich exhibits the outline displaced bones. of the tAvo condyles and the olecra- non process. Olecranon. The olecranon process is sepa- The relation between the olecra- rated from the condyles of the hu- non process and the condyles of the merus. humerus is normal. Mobility. The joint is usually immovable. The humerus is normal in length on measurement from the acromion process to the external condyle. Extreme mobility is present. The humerus is shortened, as de- tected by measurement from the acromion process to the external condyle. Crepitus. Crepitus is either absent, or, if Crepitus is always present, and present, is of a rubbing character. is of that fine grating character characteristic of fracture. Length of Humerus. 100 SURGICAL DIAGNOSIS. BOTH BONES OF FOREARM FRACTURE ABOVE THE CON- BACKWARDS DYLES OF THE HUMERUS (continued). (continued). Reduction. Reduction is difficult, but per- Reduction is easily produced by manent when effected. extension, but is transient if the force be removed. SYMPTOMS IN COMMON. Both are associated with shortening of the entire limb. " " " " a tumor in front of normal situation of joint. " " " " a tumor behind the " " " " " " " pain. " " " " history of an accident. " " " " alteration in the normal mobility. " " " " impaired function. DISLOCATIONS. 101 BOTH BONES OF FOREARM BACKWARDS. RADIUS FORWARDS AND ULNA BACKWARDS. Motion of the Joint. Extension and flexion of the joint All motion is lost in the affected may be retained to a slight degree. joint. Position of the Forearal The forearm is not tAvisted from The forearm and hand are slight- its normal attitude. ly flexed and tAvisted inwards. Diameters of the Joint. The transverse diameter of the The antero-posterior diameter of joint is normal, and the antero posterior diameter only slightly in creased. Condition of Tendons the joint is markedly increased, and the transverse diameter diminished. The biceps tendon is tense. The biceps and triceps tendons are both relaxed. Anterior Tumor. The anterior tumor which exists The anterior tumor is small, and is large, and below the crease of the is above the crease of the elbow. elbow. Posterior Tumor. The posterior tumor exhibits the The posterior tumor exhibits the contour of the two displaced bones, contour of the projecting olecra- non. History of Accident. A history of a fall upon the hand, A history of a fall upon the hand, or upon the forearm Avhen the hu- associated Avith tAvisting of the fore- merus Avas fixed, is present. arm exists. SYMPTOMS IN COMMON. Both are associated Avith altered relations betAveen the bony prominences of the joint. " greatly impaired motion. " an anterior and posterior tumor. " alteration in the diameters of the joint. " pain. " shortening of the entire limb. " normal lensrth of the humerus. 102 SURGICAL DIAGNOSIS. BOTH BONES OF FOREARM BOTH BONES OF FOREARM FORWARDS. BACKWARDS. Frequency. Is of very rare occurrence, and is Is a frequent dislocation, and may usually associated Avith fracture of be associated Avith a fracture of the the olecranon process of the ulna. coronoid process of the ulna. Condyles of Humerus. The condyles of the humerus are The condyles of the humerus are prominent posteriorly. prominent anteriorly. Tension of Parts. The parts anterior to the joint are The biceps tendon is tense, but very tense. the integument is normal. Projection of the Olecranon. The projection of the olecranon The projection of the olecranon process is absent. process is present, posteriorly. Mobility of Forearm. The forearm can be extended The forearm may possibly admit straight, and even more than of slight flexion and extension, and straight; so as to render the coro- may, in some cases, be immovable. noid process and the head of the radius prominent. Length of Forearm. The forearm is usually lengthened. The forearm is shortened. Position of Forearai. The forearm is slightly flexed, The forearm is extended, as a or it may be extended. rule. Circumference of Joint. The circumference of the joint is The circumference of the joint is diminished. usually markedly increased. Crepitus. Crepitus exists, if fracture be Crepitus may exist, if the coro- present. noid be fractured. DISLOCATIONS. 103 BOTH BONES OF FOREARM FORWARDS (continued). BOTH BONES OF FOREARM BACKAVARDS (continued). Pain and Savelling. The pain and SAvelling are very The pain and swelling are mode- severe, rate in severity. SYMPTOMS IN COMMON. Both are associated with prominence of the condyles of the humerus. " localized tension of soft parts. " alteration in the length of forearm. " altered circumference of the joint. " possible crepitus. " local pain and swelling. 104 SURGICAL DIAGNOSIS. BOTH BONES OF FOREARM ULNA ALONE, BACKWARDS. BACKWARDS. Appearance of Elbow. An anterior tumor exists below An anterior depression exists over the crease of the elbow. the seat of the ulnar articulation. Head of Radius. The head of the radius is dis- The head of the radius is normal. placed. Effects on Motion. Pronation and supination are lost. Pronation and supination are normal. Flexion and extension of the joint Flexion and extension of the joint are lost, or very limited. are difficult and very painful. Length of Forearm. Both sides of the forearm are The ulnar side of the forearm is equally shortened. shortened. Axis of Forearm. The forearm is usually in the The forearm and hand are slight- direct line of the arm. ly flexed. Position of the Hand. The hand is supinated. The hand is turned inwards. Swelling. The swelling is marked, and oc- The swelling is slight, as a rule. curs early after the accident. Circumference of the Joint. The circumference of the joint is The circumference of the joint is often greatly increased. nearly normal. SYMPTOMS IN COMMON. Both are associated with an abnormal projection of the olecranon. " " " " relaxation of the triceps muscle. " " " " impaired function of the joint. " " " " pain and sAvelling at the joint. " " " "a history of an accident. " " " " shortening in the forearm. " " " " alteration in measurements of the joint. DISLOCATIONS. 105 RADIUS BACKWARDS. RADIUS FORWARDS. Frequency. Is a rare deformity. Is the most common displace- ment of the radius. Position of the Hand. The hand is pronated, and the The hand is twisted inwards, as arm turned outwards. a rule. Location of Tumor. A tumor is felt behind the elbow, A tumor is felt in front of the which rotates on motion of the ra- elbow, which rotates with a similar dius. motion in the radius. Abnormal Depression. A depression exists anteriorly A depression exists posteriorly, over the normal seat of the head of which is most marked at the exter- the radius. nal condyle. Motion of Hand. Supination of the hand is lost; Pronation of the hand is free, but and flexion of the forearm is diffi- supination is very painful. cult, or absent. Biceps Tendon. The biceps tendon is very tense. The biceps tendon is relaxed. History of Accident. A history of a fall upon the hand A history of a fall upon the hand Avhen pronated and extended, ex- Avhen supinated and extended, is ists. present. SYMPTOMS IN COMMON. Both are associated with free but painful extension of forearm. " inability to permit of flexion to a right angle. " an abnormal tumor. " " " depression. " impaired motion of hand and pronation. " pain at elboAV joint. 106 SURGICAL DIAGNOSIS. ULNA BACKWARDS. ULNA FORWARDS. Deformity. An anterior depression exists over A posterior depression and an an- the seat of the normal articulation terior tumor are produced. of the ulna, Movement of Hand. Pronation and supination are Pronation and supination are normal. liable to be someAvhat impaired. Motions of Forearm. Extension and flexion of the fore- Extension and flexion are painful, arm are difficult and painful. but not markedly restricted, as the olecranon is usually broken. Position of Forearai. Forearm and hand often slightly The forearm is usually markedly flexed. flexed. Swelling. Swelling slight, as a rule. The swelling about the joint is severe. Olecranon. Olecranon process felt displaced The olecranon is usually frac- backAvards. tured; it may be normal in posi- tion, or loose and freely movable. Crepitus. No crepitus is discovered. Crepitation is often present, as the ulna is usually fractured. SYMPTOMS IN COMMON. Both are associated Avith shortening of the ulnar side of forearm. " normal position of radius. " • impaired function of joint. " " " " local pain and SAA'elling. " " " " history of an accident. DISLOCATIONS. 107 DISLOCATIONS AT THE WRIST. A. The carpus may be dislocated in four directions from the radius : 1. Dislocations of the carpus Forwards. 2. " " " Backwards. 3. " " " Inwards. 4. " " " Outwards. Dislocations of the wrist joint are to be diagnosed from 1st. Sprain of the wrist joint. 2d. Colles' Fracture. 3d. Transverse Fracture of both bones of the forearm close to the joint. 4th. Separation of the Epiphyses of the ulna and of the radius. B. All the separate bones of the carpus may, in rare cases, be indi- Addually displaced; but the " os magnum," only, is commonly dis- located. The other carpal bones are so seldom altered in position as to be safely excluded from probable sources of error in diagnosis. C. The lower end of the ulnar may be displaced upon the radius and carpus. This displacement may be either forwards or backwards. It is not infrequently associated with fracture of the radius, and follows violent attempts at pronation or supination of the hand. 108 SURGICAL DIAGNOSIS. DISLOCATION OF THE COLLES' FRACTURE. CARPUS. Deformity. The deformity is bilateral, and The deformity is confined to the has none of the peculiar "silver radial side of the Avrist, and has fork" displacement. been likened to the "silver fork" in common use, the finger being analogous to the tines. Crepitus. No crepitus is present. Crepitus is present, unless the impaction is firm. Abnormal Tumor. An abnormal tumor is present on An abnormal tumor exists on each one surface only of the forearm. surface of the forearm. This tumor is smooth and round. These tumors are sharp and pointed. Length of Radius. The radius is normal in length. The radius is shortened. Length of Upper Extremity. The limb is shortened. The limb is normal in length on the ulnar side. Styloid Process of Ulna. The styloid process of the ulna is The styloid process of the ulna is higher than that of the radius. lower than that of the radius. The styloid process of the ulna is The styloid process of the ulna is not markedly prominent. markedly prominent. SYMPTOMS IN COMMON. Both are associated with a history of a fall upon the hand. " " " " deformity near the Avrist. " " " " local pain and swelling. " abnormal appearance of the styloid process of the ulna. " " " " loss of function. DISLOCATIONS. 109 DISLOCATION OF THE SPRAIN OF THE WRIST CARPUS. JOINT. Deformity. The deformity is of a marked The deformity is often slight, but character, and is due to bone as de- if severe is due to swelling ; no ab- tected by the touch. normal bony tumor being present. Shortening. The forearm, including the hand, No shortening can be detected by is found to be shortened, by mea- measurement. surement from the inner condyle of the elboAV to the tips of the fingers. Mobility of Joint. The joint is less movable than The joint shows normal mobility normal, even under an anaesthetic. under anaesthetics. Development of Symptoms. The symptoms appear immedi- An interval of time often elapses ately after the accident. between the accident and the de- velopment of symptoms. Duration of Symptoms. The symptoms are permanent, The symptoms are often relieved when once developed, until reduc- by simple local applications. tion is effected. SYMPTOMS IN COMMON Both are frequently associated with great pain. a a a a a a swelling. " " " " " deformity about the joint. " " " " " history of an accident. " tt tc a a impaired motion. 110 SURGICAL DIAGNOSIS. DISLOCATION OF THE TRANSVERSE FRACTURE OF CARPUS. BOTH BONES CLOSE TO THE WRIST. Seat of Displacement. The seat of displacement can be The seat of displacement is above located below the radius. the styloid process of the radius. Tumor. The bony projection is smooth The bony projections are rough, ir- and broad. regular in shape, and often pointed. Length of Inferior Tumor. The inferior tumor attached to The inferior tumor attached to the hand is short, consisting only the hand is long, consisting of the of the carpus. carpus and lower fragments of the bones of the forearm. Condition of Tendons. The tendons on one surface of the The tendons of the forearm are forearm are tense. relaxed on both surfaces. Styloid Processes. The styloid processes of the radius The styloid processes of the radius and ulna are prominent, and abnor- and ulna are not prominent, and are mal in their bony relations. normal in their relations. Length of Radius and Ulna. The radius and ulna are normal The radius and ulna are both in length. shortened. Mobility. The joint is partially fixed. Great mobility exists at the seat of fracture. Crepitus. Crepitus is absent as a rule. Crepitus is well marked. Reduction. Reduction is permanent. Reduction is transient, when the extending force is removed. SYMPTOMS IN COMMON. Both are associated Avith shortening of the upper extremity. " " " "' local pain. " " " " " SAvelling. " " " " " deformity. " " " " impaired function. DISLOCATIONS. Ill DISLOCATION OF THE SEPARATION OF THE EPI- CARPUS. PHYSES OF RADIUS AND ULNA. Age Affected. Occurs at any age. Occurs in the young. Bony Tumor. The bony projection is regular The bony projections are often in contour, the separate individual distinct, and can be felt as two bones being indistinguishable. smooth tumors. Seat of Displacement. The seat of displacement is below The displacement occurs above the radius. the styloid process of the radius. Tendons. The tendons are tense on one sur- The tendons are relaxed on both face of the forearm. surfaces of the forearm. Length of Radius and Ulna. The radius and ulna are of nor- The-bones of the forearm are mal length. found shortened on measurement. Styloid Processes. The styloid processes of the radius The styloid processes of the bones and ulna are prominent. of the forearm are normal in their relation to the carpus. SYMPTOMS IN COMMON Both are associated Avith the absence of crepitus. tt tt a shortening of the upper extremity. i( tt a smoothness of the tumor. i( tt tt impaired function. " " " history of an accident. t( tt a local pain and SAvelling. t( ti a easv reducibility. 112 SURGICAL DIAGNOSIS. LOWER END OF ULNA LOWER END OF ULNA BACKWARDS. FORWARDS. History of Accident. Occurs during forced pronation Occurs during forced supination of the hand. of the hand. Location of Styloid Process of Ulna. The outline of the lower end of The outline of the lower end of the ulna is felt behind the joint ly- the ulna can be detected as an ab- ing slightly across the radius. normal tumor in front of the joint. Motion of Hand. Supination of the hand is impos- Pronation of the hand is impos- sible, sible. Position of Hand. The hand is markedly pronated. The hand is in a position of forced supination. SYMPTOMS IN COMMON. Both are associated with a diminished transverse diameter of the joint, " << " "an increase in the antero-posterior diameter of the joint. tt f a "an internal displacement of the hand. " « " " normal regularity in the line of the ulna. « " " " limited and painful flexion and extension of the hand. tt a tt a shortening from inner condyle of the elboAV to the tip of the little finger. tt a tt a normal length from inner condyle to styloid process of ulna, " " " " flexion of forearm, hand and fingers. " « " " altered axis between styloid process of ulna and metacarpal bone of little finger. tt tt a tt absence of crepitation. " " " " increased circumference of joint. " " " " local pain, swelling and ecchymosis. DISLOCATIONS. 113 DISLOCATION OF THE " OS GANGLION AT WRIST. MAGNUM." History of Causation. Is usually produced by a fall Is usually the result of excessiA'e upon the hand Avhen in a state of use of the tendons, as in piano play- flexion. . ing, etc., etc. Situation of Tumor. The tumor is situated in a line The tumor is not confined to any with the metacarpal bone of the definite locality, and may be on middle finger,. and ahvays on the either surface of the Avrist. back of the wTrist. Variation in Size of the Tuaior. The size of the tumor is often The size of the tumor is not ac- augmented by fiexion of the hand. tually increased by flexion of the hand. The size of the tumor is often No diminution in the actual size diminished by extension of the of the tumor follows extension of hand. the hand. Palpation of Tumor. The tumor is hard and bony on The tumor is highly elastic to palpation. the touch. Reducibility. The tumor is reducible by direct The tumor is not reducible, save pressure. by rupture of its sac. SYPMTOMS IN COMMON. Both are associated with a tumor at Avrist. " " " " freedom of motion. " " " " little pain or discomfort. 8 114 SURGICAL DIAGNOSIS. DISLOCATIONS AT THE HIP JOINT. The head of the femur may be dislocated from the cavity of the acetabulum in four directions, as follows : A. Backwards, called the " Sciatic Notch " dislocation; the head of the femur lying within the great sciatic notch. B. Backwards and Upwards, called the "Dorsum Ilii" dis- location ; the head of the femur lying upon the dorsum of the ilium. C. Downwards and Inwards, called the " Thyroid," or " Obtu- rator " dislocation ; the head of the femur lying within the obturator, or thyroid foramen. D. Upwards and Inwards, called the " Pubic " dislocation ; the head of the femur lying upon the ramus of the pubes, underneath the psoas and iliacus muscles. Dislocations of the femur are to be diagnosed 1. From each other. 2. " fracture of the femur with inversion of the foot. 3. " intra-capsular fracture of the femur. 4. " severe contusion over the trochanter. In the following pages I shall employ, in speaking of the various dislocations of the femur at the hip joint, those anatomical names given to each from the location of the head of the femur in its dis- placed position, and mentioned above. DISLOCATIONS. 115 "DORSUM ILII." "SCIATIC NOTCH." Position of the Limb. The large toe of the affected side The large toe of the affected side rests upon the opposite instep. rests upon the opposite large toe. Position of Tumor. An abnormal tumor is felt plain- An abnormal tumor is very in- ly on the posterior portion of the distinctly perceived posteriorly, and ilium. in fat subjects it is often not de- tected. Shortening. Shortening of the limb is marhed. Shortening of the limb is slight. Inversion of the Foot. The foot is markedly inverted. The inversion of the foot is of moderate extent. Deformity at the Hip. The deformity at the hip is very The deformity of the hip is apparent. slight, and often scarcely per- ceptible. Flexion of the Thigh. The flexion of the thigh upon the The thigh is markedly flexed pelvis is slightly marked. upon the pelvis, and attempts at extension of the thigh produce an arching of the back. SYMPTOMS IN COMMON. Both are associated Avith displacement upwards of the fold of the nates. fi " " " shortening of the limb. " " " " inversion of the foot. " " " " displacement of the trochanter. " " " " impaired voluntary motion. " " " " impossibility of abduction of the limb. tt a a tt a tt outward rotation of the limb. " " " " flexion of the thigh upon the pelvis. tt a tt a a a Jeg a a thigh. 116 SURGICAL DIAGNOSIS. "SCIATIC NOTCH." FRACTURE OF THE FEMUR, WITH INVERSION OF THE FOOT. Mobility of Limb. The affected limb is impaired as The mobility of the injured limb to its mobility. is often increased. Reducibility. Reduction of the deformity is Reduction of the deformity is difficult, but permanent when ef- easy by simple extension of the fected. limb, but is transient if the force be not maintained. Crepitation. No crepitus is present. Crepitus is present, unless ex- treme impaction exists. Shortening. Slight shortening of the limb is The shortening is well marked. present. Abnormal Tumor. An abnormal tumor exists which The upper fragment often fails is felt to rotate on motion of the to participate in the movements of femur. the femur. History. Is most frequent in middle life, If intracapsular in variety it may and is associated with direct vio- occur in the old, and from slight lence. and indirect violence. Inversion of Foot. Inversion of the foot is perma- The foot may become everted nent until reduction of the disloca- after extension of the limb, if the tion is accomplished. inversion be due to impaction of the fragments. SYMPTOMS IN COMMON Both are associated with inversion of the foot. " " " " shortening of the limb. " " " " an abnormal tumor. " a history of an accident, (as a rule). " " " " impaired function. " " " a normal position of the trunk. DISLOCATIONS. 117 "PUBIC" DISLOCATION. "THYROID" DISLOCATION. History of the Accident. Occurs from direct violence to the Occurs in falls associated with back of the thigh during abduction violent abduction and inward rota- of the femur ; or from the body be- tion of the femur ; as in falls where ing thrown backwards, Avhile the the limbs are separated, especially thigh is fixed. Avhen a burden is upon the back. Fold of Nates. The fold of the nates is raised. The fold of the nates is loivered. Location of Head of Feaiur. The head of the femur is felt un- The head of the femur is felt be- der the psoas and iliacus muscles. Ioav the groin, and almost in the perineum. Position of Trochanter. The trochanter of the femur is The trochanter of the femur is carried fonvards, and is almost in a carried backwards, vertical line with the anterior supe- rior spine of the ilium. Length of Limb. The affected limb is frequently The affected limb is lengthened. shortened. Position of Foot. The foot is everted. The foot points straightforwards. SYMPTOMS IN COMMON. Both are associated with pain which is very severe. " " " " tension of the psoas and iliacus. " " " " limited voluntary motion. " " " " 'loss of the poAver of adduction. " " " " " " " " rotation outwards. " " " " the axis of the femur pointing downwards and outAvards. " " " " the history of an accident. 118 SURGICAL DIAGNOSIS. " PUBIC " DISLOCATION. FRACTURE OF THE NECK OF THE FEMUR. Trochanter. The trochanter of the femur is The trochanter is never displaced carried forwards. towards the median line in front. The trochanter is less prominent The trochanter is normal in its than normal. prominence. Head of Femur. . The head of the femur is felt in The head of the bone is felt to a displaced position. be normal in its situation. Crepitation. No crepitus is perceived. Crepitation is distinctly obtained. Reducibility. The reduction is difficult, but per- The reduction is easy under sim- manent when effected. pie extension, but is transient if the force be not maintained. Mobility of Limb. The mobility of the affected limb The "mobility of the injured limb is impaired. is increased. SYMPTOMS IN COMMON. Both are associated Avith eversion of the foot. impaired voluntary motion. shortening of the limb. a history of an accident. severe local pain. swelling and possible ecchymosis. DISLOCATIONS. 119 DISLOCATION AT THE CONTUSION OVER THE HIP JOINT. TROCHANTER. Length of the Limb. The limb is always altered as to The limb is apparently shortened, its length, by actual measurement, due to relaxed ligaments and mus- cles, and pelvic inclination to re- lieve the pain. Motions of Joint. The motions of the injured femur Free and normal movement can are restricted, even under anaBsthe- be established under anaesthetics. tics. Trochanter. The trochanter is altered from The trochanter is normal in its its normal relation. position. Head of Feaiur. The head of the femur is felt to The head of the femur is normal be displaced. in its position. Effects of Rest. The symptoms due to the dis- The symptoms disappear with rest placement only are constant until and local applications. relieved by reduction. SYMPTOMS IN COMMON. Both may be associated with severe local pain. " " " " extensive ecchymosis. " (t tt a ]oss 0f function and voluntary motion in joint. " tt tt a apparent shortening of limb. " << " " the history of an accident. " " " " eversion of the foot. 120 SURGICAL DIAGNOSIS. TABLE OF DISLOCATIONS AT THE HIP JOINT. "SCIATIC." "DORSUM ILII." "THYROID." "PUBIC." Length of Limb. Slight shortening. Marked shorten- Lengthening. ing. Toe on opposite toe. Slight flexion of the thigh and leg. The femur points inwards. Little affected. Position of the Foot. Foot straight. Toe on opposite instep. Slight shortening. Foot everted. Position of the Limb. Slight flexion of Leg extended, ab- Limb is abducted the thigh and leg. ducted and brought and extended, or The femur points forwards. slightly flexed. inwards. The femur points The femur points downwards and out- downwards and wards. Position of the Trunk. Little affected. Bent forwards. Psoas and iliacus tense. Location of Head of Femur. Behind lum. acetabu- Behind and above acetabulum. Below the groin. Fold of the Nates. Raised and car- ried backwards. Lower than nor- mal. Effects upon Motion. Adduction and Abduction int. rotation easy. Adduction and ro- tation easy. Abduction and Abduction and outward rotation ext. rotation impos- impossible. sible. and flexion easy. Adduction, ex- tension and int. ro- tation impossible. Appearance of Hip. Hip is prominent. Prominent raised. and Flattened and sun- ken. Position of Trochanter. Looks forwards. Looks forwards. Is inclined back- wards. Is less prominent. Is less prominent. Is less prominent. Is approximated Is approximated Is removed from to ant. spine of to the ant. spine of ant. spine of ilium. ilium. ilium. slightly outwards. Bent forwards. The psoas and ilia- cus are tense. At upper part of the groin. Raised. Abduction and rotation out. easy. Adduction and rotation inwards im- possible. Flattened. Is carried forwards and inwards. Is nearer the me- dian line. Is less prominent. DISLOCATIONS. 121 DISLOCATIONS AT THE KNEE. Two bones may be dislocated at the knee joint, viz. : the Tibia and the Patella. The dislocations of the tibia from its normal relation to the lower end of the femur may be of five varieties : A. Dislocation of the Tibia forwards, the lower end of the femur impinging upon the popliteal space, and its nerves and vessels. B. Dislocation of the Tibia backwards, the popliteal space being made tense by the backward projection of the tibia. C. Dislocation of the Tibia outwards. D. Dislocation of the Tibia inwards. E. Dislocation of the Tibia from rotation of that bone, which is very rare, but of Avhich several cases have been re- ported. Of these five dislocations the forwards and backivards dislocations are those most commonly met with in surgical practice. The dislocations to which the patella is subject may be of four varieties : A. Dislocation of the Patella outwards, the bone lying to the outer side of the knee joint. B. Dislocation of the Patella inwards, the bone lying to the inside of the knee joint. C. Dislocation of the Patella upa\tards, the inferior ligament of the patella being ruptured and the bone displaced by the contraction of the quadriceps extensor muscle of the thigh. D. Dislocation of the Patella between the Femur and the Tibia,—called the "Rotary Displacement." In this case the patella is tAvisted upon itself, turned upon its edge, and impacted between the two bones forming the articu- lation at the knee joint. Of the dislocations to Avhich the patella is subject the lateral dis- placements are, by far, the most common; and of the tAvo lateral displacements the outward variety is the one most frequently en- countered. 122 SURGICAL DIAGNOSIS. Dislocations of the patella are more frequently produced by mus- cular action than displacements of any other bone, save the inferior maxilla. They may be complete, or only partial in extent, and can never be produced without more or less extensive laceration of the cap- sule of the joint as an existing complication. (Experiments of Professor Streubel.) The various dislocations at the knee joint admit of little opportu- nity for error, save in accurately determining the variety and amount of luxation. The upward dislocation of the patella might possibly be confounded with a transverse fracture of that bone, when the seat of fracture was low down, near its inferior border, or when the dislocation is masked by SAvelling, thus rendering palpation negative in its results. In this latter case, hoAvever, the disappearance of the swelling would reveal the smooth contour of the dislocated bone high up above the knee, while in the former case the small remnant of bone attached to the inferior ligament of the patella might at first be overlooked, but subsequently would be discovered by a care- ful examination of the joint. DISLOCATIONS. 123 TIBIA BACKWARDS. TIBIA FORWARDS. Appearance of Joint. The condyles of the femur are The condyles of the tibia project felt in front of the joint. in front. Patella. The anterior surface of the pa- The anterior surface of the pa- tella looks downwards and back- tella looks upwards and forwards. wards. Popliteal Space. The tibia encroaches upon the The femur is driven into the popliteal space, which is separated popliteal space as a wedge, if the from the femur. dislocation be complete. Ligament of Patella. The ligament of the patella is The inferior ligament of the pa- not prominent. tella is prominent and tense. Axis of Liaib. The axis of the limb is markedly The axis of the limb is not greatly irregular. altered. Length of Liaib. The length of the limb is normal. The length of the limb is dimin- ished. Voluntary Motion. Voluntary motion is destroyed. Voluntary motion may exist to a slight degree. Coaiaiunicated Motion. Communicated motion is very Communicated motion is possible limited and very painful. in the antero-posterior direction, but it is very painful. SYMPTOMS IN COMMON Both are associated Avith pain. " " " " local numbness and oedema. " " " " ecchymosis. " " " " increased circumference of the joint. " " " " absence of crepitation. " " " " displacement of the patella. " " " " impaired function. " " " " " motion. 124 SURGICAL DIAGNOSIS. TIBIA IN ROTARY DISLO- LATERAL DISLOCATION OF CATION. TIBIA. Frequency. A very rare type of dislocation. Not a rare dislocation. Deformity. The inner condyle is generally The condyles of the tibia project separated from the femur by rota- laterally, Avith a corresponding de- tion, the outer condyle being nor- pression upon the side opposite. mal; or both condyles may be simul- taneously rotated from their normal relations. Position of Foot. The foot is either everted or in- The foot is usually normal in its \-erted, and the tubercle of the direction, and the tubercle of the tibia is displaced. tibia points forwards. Position of Limb. The limb is semiflexed, as a rule. The limb is often extended, but may be rotated and slightly flexed. Diameters of Joint. The antero-posterior diameter of The lateral diameter of the joint the joint is usually increased at one is usually augmented. side. Fibula. The head of the fibula is dis- The head of the fibula is normal placed. in its relation to the tibia. SYMPTOMS IN COMMON Both may be associated with lateral displacement of patella. " " " " normal length of limb. " " " " impaired motion. " " " "a history of accident. DISLOCATIONS. 125 PATELLA INWARDS. PATELLA OUTWARDS. Frequency. A very rare accident. A common form of injury. Origin. Occurs from falls upon some pro- Occurs often in muscular efforts, jecting body which drives the pa- as in springing sideAvays to avoid an tella forcibly imvards. accident, from Avrestling, or it may follow injury from sudden falls upon the knee, especially if the inner side of the patella be struck. Capsular Ligaaient. The capsular ligament is always The capsular ligament may es- lacerated, and, if the dislocation be cape laceration, even if the disloca- complete, extensively injured. (Ex- tion be complete. periments of Streubel.) Reducibility. Is reduced with great difficulty Is reduced easily. from tension of the ligaments. SYMPTOMS IN COMMON. Both are associated with increased breadth of the knee. " " " " slight flexion. " " " " fixation of the joint. (( tt a a marked pain on communicated attempts at mo- tion. " " " " abnormal anterior aspect of joint. " " " " abnormal lateral projection of edge of the pa- tella. 126 SURGICAL DIAGNOSIS. PATELLA ROTATED. PATELLA UPWARDS. Origin. Occurs most frequently from di- Occurs either from violent muscu- rect blows upon the patella, Avhen lar effort to prevent falling bach- the knee is bent, but it has been wards Avhich results in rupture of knoAvn to occur from muscular the inferior ligament of the patella, action in jumping. or from traumatic division of this ligament. Position of Limb. The limb is forcibly extended and The limb cannot be voluntarily the knee joint is immovable. extended, nor bear the slightest weight upon it. Position of Patella. The patella is tAvisted so that its The patella is carried upwards lateral borders take the position of upon the anterior surface of the fe- its upper and loAver borders. The mur, and a marked hollow exists outer edge is frequently buried be- beloAV it at the anterior aspect of tween the condyles. the joint. Reducibility. The patella is reduced with diffi- culty. It is performed either by forcible flexion of the knee, by pres- sure upon the edges of the bone Avhen the leg is extended, or by cut- ting the tendon of the quadriceps extensor muscle. Occasionally the joint has to be opened and an eleva- tor used to replace the bone. Is reduced easily by elevation of the heel and strong extension upon the quadriceps extensor muscle. DISLOCATIONS. 127 DISLOCATIONS AT THE ANKLE. The astragalus may be displaced from its normal situation be- tween the malleoli of the tibia and the fibula, in one of five different directions, as follows : A. Dislocation of the Astragalus forwards, the bone slipping partially or wholly out of its attachments to the bones of the leg. B. Dislocation of the Astragalus backwards. C. Dislocation of the Astragalus outwards, the internal mal- leolus being often fractured, and the deltoid ligament either ruptured, or put upon extreme tension. D. Dislocation of the Astragalus inwards, the external mal- leolus being usually fractured. E. Dislocation of the Astragalus upwards between the two bones of the leg, causing their separation, and increased circumferential measurement of the joint. (This dislo- cation is very rare.) Of these dislocations the last three are liable to be associated with fracture, since in the outward or inward displacements the mal- leoli are frequently chipped off by the astragalus as it is tAvisted from its normal position, and in the upward displacement the fibula is frequently fractured by the wedge-like action of the astragalus as it is driven betAveen the bones of the leg. Dislocations of the astragalus are to be diagnosed 1. From each other. 2. " fracture of both bones. 3. . " severe sprain of joint. 4. " congenital deformities. 5. " acquired " 128 SURGICAL DIAGNOSIS. ASTRAGALUS BACKWARDS. ASTRAGALUS FORWARDS. Length of Foot. The foot is markedly shortened. The foot is markedly lengthened. Prominence of the Heel. The heel is made prominent. The heel projection is diminished. Abnormal Tumor. The articular surface of the astra- The articular surface of the astra- galus is felt behind the malleolus. galus is felt in front of the joint. Tendo Achillis. The tendo Achillis is tense and The tendo Achillis is relaxed and prominent. concave. Displacement of Malleoli. The malleoli are displaced for- The malleoli are displaced back- wards and downwards towards the wards and downwards towards the sole of the foot. sole of the foot. Appearance of the Toes. The toes are flexed. The toes are drawn upwards. Position of the Heel. The heel is elevated. The heel is depressed. SYMPTOMS IN COMMON. Both may be associated with crepitus from fracture of the malleoli. " are associated with alteration in the axis of the foot to that of the leg. " " " " alteration in the length of the foot. " " " " impaired function of the joint. " " " " local pain and swelling often. " " " " history of an accident. I DISLOCATIONS. 129 ASTRAGALUS UPWARDS. FRACTURE OF BOTH BONES. Seat of Fracture. The fibula is usually fractured, Both bones are felt to be dis- but the tibia is intact as a rule. placed, and often the line of fracture can be perceived in each. Position of Malleoli. The malleoli are carried doAvn- The relation between the malleoli wards towards the sole of the foot. and the sole of the foot is normal. Mobility of Ankle. The mobility at the ankle joint is The ankle joint has freedom of greatly impaired. movement. Circumference of Joint. The circumference of the ankle The ankle corresponds in circum- joint is greatly increased. ference Avith its fellow. Breadth of Joint. The breadth of the ankle joint is The breadth of the ankle joint is greatly increased. normal. Pain and Swelling. Great pain and swelling are pres- Pain, SAvelling and ecchymosis ent within the joint. exist at the seat of fracture. Crepitus. If the fibula is not fractured no Crepitation is very marked and crepitation will exist. easily obtained. SYMPTOMS IN COMMON. Both are associated Avith shortening of the leg. " " " " severe pain. a tt a a marked and rapid swelling. " " " " crepitus, as a rule. iC tt a a history of an accident. 9 130 SURGICAL DIAGNOSIS. ASTRAGALUS EXTERNALLY. ASTRAGALUS INTERNALLY. Sole of Foot. The sole of the foot is turned out- The sole of the foot is directed wards. inwards. Seat of Fracture. The internal malleolus is often The external malleolus is usually fractured. fractured. Swelling and Pain. The swelling and tenderness are The pain and tenderness on pres- most marked over the internal mal- sure, as well as the swelling, are leolus, and are due both to frac- usually most marked at the external ture and rupture of the deltoid malleolus. ligament. Abnormal Tumor. The articular surface of the astra- The articular surface of the astra- galus is often felt underneath the in- galus is perceived underneath the ternal malleolus. external malleolus, if the disloca- tion be complete. SYMPTOMS IN COMMON. Both are associated with crepitation, as a rule. " " " " local pain and swelling. " " " " impaired function of the joint. " " " "a history of accident. " " " "an abnormal attitude of foot. DISLOCATIONS. 131 DISLOCATION AT ANKLE. SEVERE SPRAIN. Crepitation. Crepitus is frequently detected Crepitation is never present in from a fracture of the malleolus. simple sprain. Attitude of Joint. An abnormal attitude of the foot The foot will assume a normal is present even, under an anaesthe- position, if the pain is relieved by tic. an anaesthetic. Time of the Appearance of Deformity. The deformity appears immedi- Some interval of time may elapse ately after the occurrence of the ac- before the deformity appears, even cident. though the accident be severe. Mobility of the Joint. The mobility of the joint may be The normal mobility of the joint seriously impaired even under anass- will be revealed by anaesthetics. thetics. Effect of Rest. The symptoms and deformity are The symptoms often subside on not affected by rest, and are only rest and local applications. relieved by a reduction. . SYMPTOMS IN COMMON. Both may be associated with severe local pain. " " " " constitutional disturbance. " " " " extensive sAvelling. " " " " altered attitude of joint. " " " " impaired function of joint. " " " " impaired mobility. " " " "a history of accident. 132 SURGICAL DIAGNOSIS. DISLOCATION OF ANKLE. CONGENITAL OR ACQUIRED DEFORMITY, with injury. History of Patient. A normal joint has previously A history of previous deformity existed. will be present. Condition of the Bones. The bones will be normal in de- The bones Avill probably be dis- velopment. torted. Mobility of Joint. The normal movement in tarsus Anchylosis may exist in the and metatarsus will be perceived. smaller articulations, from disuse. Reducibility. The deformity can be reduced The deformity 'Avill probably re- easily, as a rule. sist all well-directed attempts at reduction. Condition of Muscles. The muscles of the region will Atrophy and contracture of cer- exhibit no unnatural conditions, tain muscles, or sets of muscles, save, possibly, laceration. will doubtless exist if the deformity be of long standing. Appearance of Integument. No abnormal thickening of in- An abnormal thickening of the tegument will be discovered. integument, or a cushion of fat will have been developed, if locomotion has been admitted of upon the de- formed member. FRACTURES. FEACTURES. By the term " Fracture," is meant " a solution of the continuity of a bone." The varieties of fracture possible to long bones may be A. Simple Fracture, where the bone is normal, save at the direct seat of the fracture, and the surrounding tissues are uninjured. B. Compound Fracture, where the seat of the fracture com- municates with the external air. C. Comminuted Fracture, Avhere the bone is broken into frag- ments of small size. D. Multiple Fracture, Avhere the shafts of long bones are broken in several distinct localities. E. Complicated Fracture, where either joints, vessels, muscles, cavities, or organs are involved. F. Incomplete Fracture, called also the "green-stick" frac- ture, where the fracture is incomplete but is still ap- parent from abnormal direction of the bone, or from a false point of motion existing. G. Impacted Fracture, where the fragments of the injured bone are driven into each other by a continuation of the force producing the original injury. The flat bones, when injured, may present the following varieties of fracture: A. Simple Fracture, where the bone is not displaced from its normal position, or the surrounding tissues involved. B. Depressed Fracture, where a displacement of the bone's fragments exists. C. Comminuted Fracture, where separate fragments of the bone are detached from their normal position. 135 136 SURGICAL DIAGNOSIS. D. Fissures of Bone, where a bone is simply split, without displacement. E. Punctured Fracture, where a sharp instrument depresses or loosens a circumscribed portion only of the injured bone. F. " Fractures by Contre-coup," where a force directly applied produces, by transmission, a fracture at a point remote from the seat of direct injury. As we deal, however, almost exclusively with fractures of long bones, save in injuries of the cranium, and as the particular forms of fracture pertaining to flat bones will be considered in detail under the "Injuries of the Head," I shall, hereafter, in speaking of fracture, confine my remarks to fracture of the long bones only. Fracture of long bones may be divided, also, according to the direction of the line of fracture, into 1st. Longitudinal Fracture. 2d. Transverse Fracture. 3d. Oblique Fracture. Symptoms of Fracture. The general symptoms of fracture common to most of its varieties may be thus enumerated: 1. Crepitus, by which term is meant a peculiar grating sensation, perceived by the touch and, in some cases also, by the ear, on approximating the fragments and causing them either to rub together, or rotate upon each other. This symptom may in cases of impac- tion, or in parts deeply imbedded in tissues, pos- sibly be undetected, but Avhen present it is a most characteristic and positive evidence of the existence of a fracture. 2. A False Point of Motion. This symptom of frac- ture may also be undetected in some cases, es- peciallyin the incomplete and longitudinal varieties. It may also be unperceived, or imperfectly recog- nized when fractures occur in the immediate vicinity of joints, which are deeply imbedded in muscles, FRACTURES 137 and where, for that reason, the exact point from which motion proceeds can easily become a subject of question, or of doubt. In these cases, however, the simultaneous appearance of crepitation is often of the greatest diagnostic value, even if the crepi- tation be in itself obscure. 3. Deformity. Fractures, as a rule, are characterized by marked deformity. Especially-is this the case when the fractured bone is superficial in its situa- tion, and the seat of injury uncovered by muscular tissue. The extent of the deformity depends partly upon the relation of the insertion of muscles to the seat of fracture, though it may also be influenced by the variety of injury received, and by the region of the body at which the fracture is located. 4. Impaired Function of the Limb, or Part Affected. This symptom is modified greatly by circumstances. It is not a positively diagnostic indication of frac- ture, as a severe contusion, or sprain Avill often pro- duce an equal effect upon the usefulness of a mem- ber or some special anatomical region. 5. Localized Pain. The seat of pain is often indicative of the location of a fracture, although by pressure upon nerve trunks by displaced fragments, a sense of extreme pain may occasionally be produced at a part distant from the actual seat of injury. 6. Localized Swelling and Tenderness to Pressure. This symptom, if associated with the previously mentioned local pain in the same locality, is of value as a confirmatory evidence, provided there be suffi- cient reason to suspect the existence of a fracture; but it is of little actual diagnostic value in itself, as it may be associated with any accident resulting in inflammatory changes. 7. Possible Change in the Length and Axis of the Limb. It is not infrequent in both dislocation and fracture, that alteration does occur both in the nor- mal length and in the axis of the injured member. In 138 SURGICAL DIAGNOSIS. fact, so common is this deformity in both, and so seldom does it exist without them, that it becomes at once a most important diagnostic symptom in either. Dislocation can, however, in obscure cases be often excluded by the partial or complete immobility of the limb, and by the difficult reduction of the de- formity. 8. Ecchymosis. This is liable to occur when a force is applied to produce a fracture that would more than suffice to result in a severe contusion. It can there- fore be considered of confirmatory value only in the diagnosis of fracture. Fracture as a general surgical condition can be confounded in diagnosis only with dislocation or severe contusion. The special fractures are to be diagnosed, however, from the vari- ous surgical conditions liable to affect that particular region of the body where the fracture may exist. These Avill be considered in connection with the various parts of the body, and in the following order : A. Fractures of the Skull. b. tt tt Face. c. It It Shoulder D. 11 11 Huaierus at Shoulder. E. tl AT THE Elbow Joint. F. il a Wrist u G. it n Hip il H. it n Knee It I. tl it Ankle it J. tl n Trunk. I pass first then to the consideration of the diagnoses pertaining to fractures of the skull. 9 FRACTURES. 139 FRACTURES OF THE SKULL. The skull may be fractured either at its convexity, sides, or base. Fractures of the skull may result from direct or indirect violence. They may be either simple, depressed, comminuted, compound, fis- sured, or punctured in variety, and may be classified on a basis either of their location or of the mode of their origin. I prefer, however, to enumerate without any special basis several forms of fracture of the skull, which often demand a special diag- nosis, and which are indicated by a modification of the symptoms common to the ordinary varieties of fracture. Fractures of the skull can be thus divided into A. Fractures of the Outer Table only, in which type a de- pression of the bone is perceived, but no symptoms of compression of the brain are produced. It is a frequent form of fracture, and, when the depression is slight in degree, ordinary examination Avill usually fail to detect it proATided the scalp is not lacerated, as it is often masked by swelling of the scalp and the periosteal cov- ering. B. Fracture of the Outer, Middle and Inner Tables, con- stituting the so-called " fracture with depression, and with symptoms of compression of the brain." This form is fre- quently associated with laceration of the scalp and peri- osteum, and can be readily diagnosed by a careful digital examination, and by the rational symptoms of the pa- tient. C. Fracture of the Inner Table only, constituting " fracture with symptoms of compression of the brain, but with the absence of external depression." This class of injury can seldom be positively diagnosed, save by exclusion. It is to be differentiated from traumatic concussion of the brain, from meningeal hemorrhage, and from a pos- sible apoplectic attack associated with traumatism. D. "Fracture by Contre-coup," or " Fracture by Transmitted Force." This usually occurs from violence applied to some portion of the cranium where the bone is of extreme 140 SURGICAL DIAGNOSIS. thickness, as at the occiput or the parietal eminence. The most frequent.seat of this type of fracture is un- doubtedly at the base of the skull, though the frontal re- gion and the temporal region may also be fractured by transmission of force applied at a seat remote from these localities. The outline of fractures resulting from contre-coup is usually of the stellate, or radiating type. E. Punctured Fractures of the Skull. This type of frac- ture is the result of direct injury received from a pointed instrument. It may consist of a distinctly circum- scribed depression of a small portion of bone, or a radi- ating fracture with a marked indentation at the seat of the injury. Its surgical importance rests chiefly upon the cerebral disturbance immediately resulting from it, and also in the peculiar tendency which this class of fractures possesses in developing epilepsy, and diseases dependent on cerebral irritation or pressure in later years. F. Fissures of the Skull. This variety of injury is often un- detected during life if the scalp or the periosteum be not involved. In that case the symptoms of a possible complicating hemorrhage of the meninges of the brain, or the devel- opment of symptoms of local abscess within the skull at the seat of injury, might give grounds for a reason- able conjecture. When the scalp and periosteum are involved, how- ever, the edge of the fissure can often be detected by the finger nail, or by a careful examination by a probe. Frequently, hoAvever, an incised Avound of the perios- teum, if cleanly cut, may resemble a fissure of the bone so closely, that nothing but an enlargement of the super- ficial wound Avill enable the surgeon to make a positive exclusion of fracture. G. Fracture of the Base of the Skull. Fracture at the base of the skull is usually the result of transmitted violence, either through the spinal column, by falls upon the feet, or by direct violence to the occiput, producing fracture by " contre-coup." Its peculiar symptoms are the only means of diagnosis, as no digital examination can, of FRACTURES. 141 course, be made; but the results of the fracture are so distinctly apparent in the appearance of the patient and the local and general manifestations present, that little doubt as to diagnosis can exist, provided the fracture is extensive. Fractures of the skull in general can hardly be confounded with any other surgical condition, save contusion or a laceration of the pericranium, in the latter of which the possibility of fissure or masJced fracture may be suspected, or the existence of such wrongly diagnosed from the rigidity of the periosteal wound, its marked outline, and its traumatic origin. I have added to the following set of diagnostic tables, appertain- ing purely to fractures of the skull, the symptoms of cerebral com- pression and concussion in contrast, as they must, of necessity, be mentioned in generalities in connection with fracture, and are of too great surgical importance to be incompletely given. 142 SURGICAL DIAGNOSIS. FRACTURE OF SKULL FRACTURE OF THE OUTER (COMPLETE). TABLE. Appearance of the Fracture. The seat of fracture, on exami- The depressed portion of the nation, usually reveals a projecting bone merges gradually into the sur- edge of bone in the healthy or un- rounding parts; no free or Avell-de- injured portion ; or an apparent fined edge being discovered on pal- orifice opening into the cavity of pation. the cranium may possibly be per- ceived. Mobility of Fragments. The depressed portion of the bone The depressed portion of the bone is frequently movable. exhibits no mobility as a rule. Condition of Scalp. The soft tissues are usually lace- The soft tissues are frequently rated. not involved. Syaiptoms of Compression. Symptoms indicative of cerebral Symptoms indicate of cerebral compression are usually present, if compression never exist. the amount of depression at the seat of fracture is excessive. SYMPTOMS IN COMMON. Both may be associated with a history of injury to the head. " " " " external symptoms of contusion. " " " " depression of bone. FRACTURES 143 FRACTURE OF OUTER FRACTURE OF INNER TABLE. TABLE. Depression and Crepitus. External evidences of injury to No external evidences of injury the skull are present on palpation ; of the skull are discoA'ered. and possible crepitus may be de- tected. Cerebral Symptoms. No symptoms of cerebral com- Brain symptoms are usually pres- pression, or cerebral irritation are ent indicative of cerebral compres- present. sion, or cerebral irritation. Convulsions. Convulsions are seldom if ever Convulsions of the epileptic type produced. are liable to result as sequela? ; or they possibly may exist at the time of the injury. SYMPTOMS IN COMMON. Both are associated Avith a history of injury to the head. " may be " " external symptoms of contusion. " " " " constitutional disturbance. 144 SURGICAL DIAGNOSIS. FRACTURE OF INNER APOPLEXY, WITH INJURY. TABLE. Previous History. No symptoms of a cerebral charac- A history of cerebral symptoms, ter have existed. as syncope, coma, vertigo, aphasia, etc., may have existed. Atheroma. No arterial atheroma can be per- Atheroma of the superficial ves- ceived. sels may be detected. Brain Symptoms. Coma, paralysis, stertorous Symptoms of cerebral compres- breathing, irregularity of the pu- sion will usually be well marked, if pils, and other symptoms of com- the hemorrhage has been sufficient pression may be absent, or may ap- to produce a state of sudden coma, pear some time after the injury, or of injury from falling, and will Symptoms also of simple local pres- usually exist from the commence- sure on special nerves may exist. ment of the attack. Skin. The skin may not be markedly The skin is usually flushed, es- altered. pecially in the region of the head. Age. May occur at any age. Occurs usually after 40th year of age. SYMPTOMS IN COMMON. Both may be associated with injury of the scalp. " " " " absence of external evidences of depression of bone. " " " " cerebral symptoms, such as convulsions, coma, paralysis, etc. FRACTURES. 115 FRACTURE OF THE BASE CEREBRAL CONCUSSION. OF SKULL. Condition of Insensibility. Delirium is frequently present, The patient is usually in a state of a noisy character and associated of coma from which he can be only with jactitation. partially aroused. The special senses are often un- The special senses act feebly. affected. The state of coma if present tends The coma tends to decrease rap- to increase and deepen. idly. Temperature. The temperature is normal, or The temperature is lowered. elevated. Paralysis. Paralysis is often present. Paralysis is absent. Escape of Blood. Blood escapes from the ears, nose, No blood or cerebro-spinal fluid or mouth ; and an escape of the escapes from the ear, nose, or cerebro-spinal fluid also takes place mouth. from the ears, if the petrous portion of the temporal bone be fractured. Ecchymosis. Sub-conjunctival ecchymosis ap- No ecchymosis is present, unless pears in lower eyelid within 24 dependent on direct traumatism. hours after the injury as a rule. SYMPTOMS IN COMMON. Both may be associated with a history of indirect violence. " " " " coma. a tt it tt alteration in temperature. tt a tt it impairment of special senses. 10 146 SURGICAL DIAGNOSIS. CEREBRAL COMPRESSION. CEREBRAL CONCUSSION. Insensibility. The coma is profound. The coma is incomplete. " " may not directly fol- " " " usually immediate. Ioav the injury. " " is stationary or increas- " " rapidly decreases, as a ing. rule. The special senses are in abey- The special senses act feebly. ance. Temperature. The temperature is normal, or in- The temperature is lowered. creased. Motion and Sensation. Motion or sensation can be each Paralysis is absent. The limbs affected separately, or in common. are simply A^eak and flaccid. Hemiplegia, occasionally para- plegia, or local paralysis may be present. Convulsions, in severe cases, may exist, with paralysis on the side op- posite. Pulse. The pulse is usually full and The pulse is feeble, rapid and in- slow, termittent. Respiration. The breathing is slow and ster- The breathing is feeble and sigh- torous. ing in character. Eyelids. The eyelids are usually closed and The eyelids are usually open and immovable. movable. Pupils. The pupils are either natural, di- The pupils are usually contract- lated, or irregular ; but they are al- ed; but they act feebly, and are Avays sluggish and show decreased generally sensible to light. sensibility to light. FRACTURES. 147 CEREBRAL COMPRESSION CEREBRAL CONCUSSION (continued). (continued). Sphincters. The urine is retained as a rule, Incontinence of urine and invol- and the boAvels are obstinately con- untary evacuations occur. stipated. Stomach. Vomiting is rare. Vomiting is frequently present, as the effects of concussion pass away. 148 SURGICAL DIAGNOSIS. FRACTURES OF THE UPPER JAW. The superior maxillary bone may be fractured either through di- rect violence, or from injury indirectly transmitted. It is frequently complicated with laceration of the face, and the gums are, in the majority of cases, involved. It may be either of the simple, com- pound, or comminuted varieties. Little error can possibly exist in diagnosis, save when the fracture is masked by severe swelling, and unassociated with any injury to the mucous membrane of the mouth. In such an event, the reduc- tion of the swelling will disclose the existence of a probable de- formity, although even in the absence of displacement, or before the swelling can be reduced, a possible crepitus may be detected through the swollen parts, and thus an early diagnosis can positively be made. The embarrassment to mastication would probably be also less marked in contusion, than if a complicating fracture were present, and this alone should be a valuable guide in case justifiable doubt exist. The deformity, in case of fracture of the superior maxillary bone, varies somewhat with the seat of fracture and the form of violence to which it is due. The face will usually be seen to present a markedly altered ap- pearance, when contrasted with the healthy side, and the laceration of the gums, the displaced teeth, their imperfect articulation Avith those of the lower jaw, and a possible fissure along the hard palate, will attract even the patient's attention, from the abnormal sensa- tions produced. FRACTURES OF THE LOWER JAW. The lower jaw may be fractured either in its body, ramus, con- dyle, or coronoid process. The fracture may be transverse, or oblique in direction; uni- lateral or bilateral in situation; simple, compound, or comminuted in variety. It is almost invariably the result of direct violence. If the fracture occur at the ramus, slight deformity will exist. If at the condyle, the chin will be deflected towards the injured side, in which respect it differs from dislocation of the bone, and an abnormal hollow will exist behind the ear. If the coronoid process be fractured, displacement of the fragment FRACTURES. 149 by the temporal muscle will ensue, and the separated portion of the bone will be felt to be so displaced by examination of the injured bone through the mouth. In fractures of the body of the inferior maxillary bone, the an- terior fragment is usually displaced either to the inside of the posterior fragment, or beloAV it. The mobility of the fragments is most marked in the bilateral variety, while in the fracture of the condyle, and also that of the body of the jaw, the rigidity of the bone is markedly decreased. In fracture of the ramus, however, and also in that of the coronoid prdcess, the bone retains nearly its normal poAver of resistance, save in those cases where comminution exists, in which case great mobility is often present. Fractures of the loAver jaw are liable to be mistaken for dis- location of that bone only, as no other surgical condition can pre- sent symptoms which could possibly lead to error. 150 SURGICAL DIAGNOSIS. FRACTURE OF LOWER JAW. DISLOCATION OF JAW. Line of the Teeth. The line of the teeth is often ir- The teeth are perfectly normal. regular. Gums. The gums are often lacerated. The gums are never involved. Bleeding. Bleeding from the mouth is com- Bleeding from the mouth is rare. mon. Crepitus. Crepitation can be detected at Crepitation is usually absent, but the seat of fracture. it may be felt at the coronoid pro- cess. Motion. The movements at the articula- The movements of the jaw are tions are normal. restricted. Depression at Ear. No depression exists in front of A depression is present over the the ear. glenoid fossa. Tumor. No tumor is present at the cheek. The coronoid process, when dis- placed, becomes prominent. Chin. The chin is normal in position. The chin is deflected to the side in the unilateral variety; and dis- placed forwards in the bilateral va- riety. SYMPTOMS IN COMMON. Both are associated with loss of the power of mastication. " may be associated Avith dribbling of saliva. " " " " impairment of power of articulation. " are " " deformity. " " " " history of traumatism. FRACTURES. 151 FRACTURES AT THE SHOULDER. The fractures at the shoulder include all varieties liable to exist either in the Scapula, Clavicle, or Humerus. The scapula is seldom, if ever, fractured through indirect vio- lence. A seA-ere accident is usually required to cause serious injury to the bone, as it is protected by its muscular coverings, except at the acromion, coracoid, and spinous processes. The scapula may present the folloAving varieties of fracture : A. Fracture of the Body of the Scapula. B. « « Neck C. " Acromion Process. D. " " Coracoid E. " « Spinous Fractures of the scapula are to be diagnosed 1. From each other. 2. " contusion. 3. " fracture of the neck of humerus. 4. " dislocation of the humerus. From contusion the diagnosis of fracture of the body of the scapula is made chiefly on the presence of crepitus, on localized pressure being made over different portions of the bone. We may have, however, in extensive comminution a change also in the relation of the fragments, on pressure outwards being made upon the angle of the scapula Avhen the shoulder is fixed, and possibly even the edges of the separate fragments may be detected through the investing muscles. Auscultation also is of value, as crepitus may often thus be per- ceived from the movements of the fragments during inspiration, as a result of the action of the serratus muscle, when it cannot be de- tected on palpation. The other points of differential diagnosis pertaining to fractures of the scapula will be found enumerated in the following pages. 152 SURGICAL DIAGNOSIS. FRACTURE OF THE BODY FRACTURE OF THE SPINE OF THE SCAPULA. OF THE SCAPULA. Relation of the Fragaients. The fragments of the bone can, Overlapping of the fragments, if in some cases, be felt to overlap present, cannot be discerned, as the each other. muscles attached to the spinous fos- sae conceal the displacement. Pain. The local pain is markedly in- The pain is increased by the mo- creased by pressure, coughing and tions involving the deltoid and tra- by movements of the arm. pezius muscles, but is not affected by coughing to any perceptible de- gree. Crepitus. Crepitus can be detected often by Crepitus is slightly marked, and fixation of the shoulder and move- often absent. ment being communicated to the loAver angle of the scapula, or by direct palpation when the arm is moved. Bony Prominences. The acromion, coracoid and spin- The acromion process may reveal ous processes are normal. No frac- abnormal mobility, if the spine is ture of the humerus can be detected, greatly comminuted ; and an irreg- and still crepitation and pain on ularity in the spine can be detected motion exist. often by the finger. SYMPTOMS IN COMMON. with a history of seA'ere contusion. " restricted and painful motion of arm. " absence of the symptoms of fracture of the hu- merus. " local pain and swelling over the scapula. Both are associated tt a tt ti it tt tt tt it FRACTURES. 153 FRACTURE OF THE NECK FRACTURE OF THE NECK OF SCAPULA. OF HUMERUS. Proaiinence of the Acroahon. The acromion process is very The acromion process is usually prominent. normal in its appearance. HOLLOAV BELOAV ACROAIION. A hollow exists below the aero- No IioIIoav exists immediately be- mion process, but less marked than low the acromion process. in dislocation dowmvards into the axilla. Coracoid Process. The coracoid process moves with The coracoid process moves with the humerus, and not with the the scapula, and not with the hu- scapula. merus. Crepitus. Crepitation is detected by raising Crepitation is detected by exten- the elboAV, and rotation of the hu- sion and subsequent rotation, or by merus Avhile the other hand is placed carrying the elboAV inwards, while upon the shoulder. extension is continued. Reducibility. Reduction of the deformity is Reduction is effected by simple produced by raising the elboAV. extension of the arm. Length of Arm. The arm is lengthened. The arm is shortened. SYMPTOMS IN COMMON. Both are associated with a history of violence. " " " " easy reduction and crepitus. " " " "a marked tendency towards return of the de- formity. " " " " severe pain in shoulder, and often in the hand. " " " " marked sAvelling in shoulder, and often in the hand. " " " " change in length of arm. 154 SURGICAL DIAGNOSIS. FRACTURE OF THE NECK DISLOCATION OF HUMERUS. OF SCAPULA. Length of Liaib. The arm is lengthened. The arm may be lengthened or shortened. Reducibility. The reduction is easy and is The reduction is difficult and is effected by simply raising the elbow, effected by extension and manipu- lation. The reduction is transient when The reduction is permanent if the force is not maintained. once accomplished. Elboav. The elbow can be made to touch The elbow of the affected limb the side. cannot be approximated to the chest. Axis of Liaib. The axis of the injured limb is The axis of the affected limb is parallel with the median line of the abnormal. body. Crepitation. Crepitation is present. Crepitation is absent. Mobility. Abnormal mobility exists at the Impaired mobility of the affected shoulder. side is present. SYMPTOMS IN COMMON. Both are associated with a history of traumatism. " " prominence of the acromion. " "a holloAv beneath the acromion. " change in the length of the arm. " local pain and swelling. " " " " impaired function. FRACTURES. 155 FRACTURES OF THE CLAVICLE. The clavicle may be fractured in one of three situations : 1. At the sternal end. 2. In its body. 3. At its acromial end. The varieties of fracture which may affect the clavicle are the simple, compound (very rare), comminuted and the incomplete. Fractures of the clavicle are more often met with in surgical prac- tice than those of any other bone in the body excepting the radius. They most frequently occur from indirect violence, especially from falls upon the shoulder, or upon the hand when the arm is out- stretched ; although the bone may be broken from violence directly applied, and, in rare cases, from muscular action. The most frequent seat of fracture of the clavicle is near the mid- dle of the bone. The acromial end comes next in frequency, while those of the sternal end are comparatively rare. When the bone is fractured near its middle, the inner fragment is usually retained in nearly its normal position by the strong liga- ments located at its sternal end which prevent great latitude of movement, and by the muscles attached to that portion which are nearly counterbalanced. It may hoAvever be elevated in position. Fractures of the clavicle are extremely common in youth, nearly one-half of all the cases occurring before the fifth year terminates. When adults are subjected to fracture, the preponderance of males affected to females is large, although among children the sexes seem to be equally subject to the accident. Fractures of the clavicle are associated Avith many symptoms that are common to all of its varieties to a greater or less degree; among these may be mentioned: 1, local pain; 2, impaired motion of arm in the antero-posterior direction; 3, inability to touch the head without assistance; 4, inclination of the neck and head towards the affected side, and 5, a desire to support the elbow of the affected limb. These symptoms are usually present Avhether the displacement is marked, or very slight in degree, and are of diagnostic value when the finger of the surgeon cannot positively detect any apparent ir- regularity in the line of the injured clavicle. 156 SURGICAL DIAGNOSIS. It is seldom, however, that the clavicle is broken without giving in itself distinctive signs of deformity; still Avhen the bone is trans- versely broken, between the conoid and the trapezoid ligaments, by which the clavicle is bound to the coracoid process of the scapula, no displacement occurs, and the line of the clavicle affords no out- ward evidence of injury, save by the rational symptoms mentioned above, FRACTURES. 157 FRACTURE OF CLAVICLE IN- FRACTURE OF THE CLAVI- SIDE OF THE CORACOID CLE OUTSIDE OF THE PROCESS. CORACOID PROCESS, NEAR THE CONOID LIGAMENT. Deformity. A marked deformity is present, The deformity which exists is due to the projection of the inner slight. The finger can only detect fragment, and the displacement of a slight irregularity in the frac- the outer fragment doAvnwards, for- tured bone. Avards and inwards. Appearance of Shoulder. The shoulder is sunken and draAvn The shoulder is normal in its ap- inwards towards the chest. pearance and position. Length of Clavicle. The clavicle is shortened. The clavicle is of normal length, or possibly slightly shortened. Position of the Aral The arm is rotated inwards and The arm is normal in its attitude hangs by the side. The forearm and in its relations to the trunk. being usually supported by the op- posite hand. Crepitus. Crepitation is detected on raising Crepitation is obscure, and is de- the arm and drawing the shoulder tected chiefly by manipulation of backwards and outwards. the fragments. Motion at Shoulder. The motion of the arm is re- The movements of the arm are stricted or lost, especially in the nearly normal, unless marked dis- movements of ele\'ation and circum- placement exists. duction. Pain. Pain is present on attempts to Pain is markedly present, and touch the head or the opposite located at the seat of injury. shoulder with the hand of affected side. Savelling and Ecchymosis. SAvelling and ecchymosis are pres- SAvelling and ecchymosis are often ent and are especially marked if the absent. fracture be due to direct injury. 158 SURGICAL DIAGNOSIS. FRACTURES OF THE HUMERUS, NEAR THE SHOULDER JOINT. The humerus may present at its upper third five distinct varie- ties of fracture which claim special surgical attention, and which often demand accuracy of diagnosis. These may be enumerated as follows : A. Simple Intra-capsular Fracture, where the head of the humerus is separated by violence from the shaft of the bone within the insertion of the capsular ligament of the shoulder joint, and remains as a distinct fragment, but not entirely deprived of nutrition. B. Impacted Intra-capsular Fracture, where the humerus is broken in the same locality as in the preceding fracture, but where the fragments are again united by impaction of the upper fragment into the lower. C. Simple Extra-capsular Fracture, where the humerus is broken just beloAV the tuberosities at its surgical neck, and where the fragments remain separated and distinct. D. Impacted Extra-capsular Fracture, in which the anatomi- cal location of the fracture is the same as that of the one preceding, but where the lower fragment is driven into the upper fragment of the bone, thus causing an absence of the unnatural mobility which otherwise would exist. E. Separation of the Greater Tubercle. This is essentially a fracture of youth in which the epiphysis becomes de- tached from the bone, and is displaced upon the scapula by the action of the muscles inserted into its three facets. Each of these fractures has distinctive diagnostic symptoms, and each Avill therefore be specially considered. Fractures of the upper end of the humerus may be confounded with each other, with frac- tures of the scapula, with dislocations at the shoulder joint, and with severe contusions of the deltoid region. FRACTURES. 159 SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HU- FRACTURE OF THE HU- MERUS. MERUS. ACROAIION. The acromion process is slightly The acromion process of the sea- prominent, pula is normal in its appearance. Appearance of Shoulder. The shoulder is less round than The shoulder is marked by a hol- normal. low one or tAvo inches below the acromion. Position of Elboav. The elbow easily touches the side The elbow stands out, but can be of the chest. made to touch the chest. Length of Arm. No shortening of the arm is usu- The arm is markedly shortened. ally detected. Mobility. No unnatural point of motion A false point of motion is clearly can be perceived. detected. Upper Fragment. The head of the bone cannot be The head of the bone is felt to be felt displaced. separated from the shaft, and fails to rotate Avith it. Crepitus. Crepitus is obtained only on care- Crepitation is marked on exten- ful manipulation, combined with sion being applied to the arm, and pressure over the joint and rotation the elboAV being carried inward to- of the arm. Avards the chest. Pain and Savelling. Pain and swelling are present in Pain and SAvelling are present the vicinity of the joint only. both at the seat of fracture, and often in the hand and fingers. 160 SURGICAL DIAGNOSIS. SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HU- FRACTURE OF THE HU- MERUS MERUS (continued). (continued). Ecchyaiosis. Ecchymosis is infrequent. Ecchymosis is usually present. DlSPLACEAIENT. The lower fragment only is dis- The upper fragment is displaced placed inwards. upAvards and outwards, and the lower fragment inwards. SYMPTOMS IN COMMON. Both are associated Avith a history of injury. " " " " crepitus. " " " " altered appearance of shoulder. " " " " pain and swelling. FRACTURES. 161 IMPACTED INTRA-CAPSULAR IMPACTED EXTRA-CAPSULAR FRACTURE OF THE HU- FRACTURE OF THE HU- MERUS AT SHOULDER. MERUS AT SHOULDER. Acromion. The acromion process is quite The acromion process is normal, prominent. or very slightly prominent. Hollow at Shoulder. The holloAv beneath the acromion No holloAv beneath the acromion is marked. is present. Length of Arm. The arm is shortened. The arm is normal in length, as a rule. Huaierus. An irregularity in the upper part An abnormal condition of the of the humerus is felt in the axilla, 'bone is often undetected. Relation of Fragments. The relation of the head of the The relation of the fragments is bone to the shaft is often altered. frequently a normal one. Crepitus. Crepitation, if present, is due Crepitation is usually obscure, usually to comminution of the and if obtained, it is perceived by great tuberosity, in Avhich case, holding the joint firmly, while an pressure over it, combined Avith ro- assistant rotates the arm, with the tation of the arm will give crepitus, forearm flexed. Motion. Motion is greatly impaired, but The use of the arm is entirely is not entirely lost. lost, in the majority of cases. Pain and Swelling. Pain is severe, but little SAvelling Great pain and marked swelling is present. and ecchymosis are usually present. SYMPTOMS IN COMMON Both are associated Avith a history of traumatism. " " " " impaired function of limb. " " " " local pain and swelling. " " " " crepitation, in some instances. " " " " frequent prominence of the acromion. 11 162 SURGICAL DIAGNOSIS. FRACTURE OF THE NECK SUB-GLENOID DISLOCATION. OF THE HUMERUS. Depression at the Shoulder. An indistinct hollow exists at a A distinct hollow exists imme- short distance below the acromion, diately below the acromion. Acromion Process. The acromion process is not The acromion process is pointed markedly prominent. and very prominent. Axillary Tumor. An irregular and pointed tumor A large, smooth and rounded is felt Ioav down in the axilla : tumor is felt high up in the axilla : (lower fragment). (displaced head of humerus). Crepitus. Crepitus is easily obtained by ex- Crepitus is usually absent. tension and movement of the arm. Length of Aral The length of the arm is short- The length of the arm is in- ened. creased. Position of Elboav. The elbow can easily be made to The elbow cannot be approxi- touch the chest. mated to the chest. Axillary Walls. The axillary walls are normal. The anterior fold of the axilla is prominent. Reducibility. Reduction is easily accomplished, Reduction is difficult, but per- but transient if the force be not manent when once effected. maintained. Communicated Motion. Communicated motion, under an- Communicated motion is limited aesthetics, is free. in its extent. History. Is usually the result of direct Is produced by falls upon the violence. hand or elbow when removed from the chest; or by a direct blow, downwards, upon the upper part of the humerus. FRACTURES. 163 FRACTURE OF NECK OF THE FRACTURE OF THE NECK HUMERUS. OF THE SCAPULA. Acromion. The acromion process appears The acromion process is very normal. prominent. Hollow below Acromion. No hollow exists immediately be- A hollow exists immediately Ioav it, but one may exist loAver under the acromion process which down. is well marked. Coracoid Process. The coracoid process is immova- The coracoid process moAres with ble, save Avith scapula. the humerus, and not with the scapula. Crepitus. Crepitation is perceived on ex- Crepitation is detected by raising tension of the arm and carrying the the elbow, and rotation of the arm elboAV towards the chest. when the hand of the surgeon grasps the shoulder. Reducibility. Reduction is effected by direct Reduction is effected by raising extension of the arm. the elbow. Length of Arm. The arm is shortened. The arm is lengthened. SYMPTOMS IN COMMON Both are associated Avith a history of traumatism. " " " crepitus. " " " easy reduction, but of a transient character. " " " loss of motion. " " " seA-ere pain in the shoulder and hand. " " " marked SAvelling in the shoulder and hand. " " " a change in the length of the arm. 164 SURGICAL DIAGNOSIS. SEPARATION OF THE GREAT SUB-SPINOUS DISLOCATION TUBERCLE OF THE HU- OF THE HUMERUS. MERUS. Tumor on Scapula. A small tumor is felt upon the A large, round tumor is detected scapula, Avhich, however, fails to upon the scapula, which partici- rotate with the shaft of the hu- pates in all the motions communi- merus. cated to the shaft of the humerus. Age Affected. Is liable to occur only in youth. Is present in all stages of life. Glenoid Cavity. The glenoid cavity is found to be The glenoid cavity is found filled. empty. Acromion and Coracoid. The acromion and coracoid pro- The acromion and coracoid pro- cesses are not markedly prominent, cesses are very prominent. Position of Elbow. The elbow can be approximated The elbow cannot be approxi- to the chest. mated to the chest. Capabilities of Movement. The hand can be made to touch The hand cannot be made to the top of the head, and can be touch the top of the head, or be placed upon the opposite shoulder, placed upon the opposite shoulder. Reducibility. The reduction of the deformity is The reduction of the deformity is effected by rotation of the arm out- effected by extension of the arm and wards, combined with pressure over manipulation. the fragment. Return of Deformity. The deformity shows a marked The reduction is permanent if tendency to return, when the force once effected. is discontinued. SYMPTOMS IN COMMON. associated with a tumor on the scapula. " " absence of crepitus. " " impaired functions. " " history of an accident. " " local pain in region of the shoulder. Liotn ar< FRACTURES. 165 FRACTURES AT THE ELBOW. The fractures which occur in the vicinity of the elbow joint may be confined either to the lower end of the humerus, or to the upper ends of the ulna and the radius. The humerus at its lower third may be fractured in five distinct localities, to each of which surgical attention may be directed, and of each of which an accurate diagnosis can generally be made. These five varieties of fracture can be thus enumerated : A. Fracture of the Outer Condyle of the Humerus. In which the separation of the outer condyle becomes ap- parent at the external aspect of the joint and the move- ments of the radius may possibly be interfered with. B. Fracture of the Inner Condyle of the Humerus. In which the separation is felt as a movable fragment at the inner aspect of the joint, and symptoms, referable to in- jury of the ulnar nerve, may possibly exist in the hand and along the internal border of the forearm. C. Transverse Fracture above the Condyles. In this variety of fracture a displacement of the forearm participates in the injury and many symptoms arise leading towards suspicion of a dislocation of both bones of the forearm backwards upon the humerus. It is by no means an in- frequent form of fracture, and is liable, in some cases, to become compound in variety from perforation of the in- tegument. D. The so-called T-shaped fracture, consisting of the above- named transverse fracture of the humerus complicated Avith a fissure running downwards between the condyles and frequently involving the joint. E. Fracture of the Epitrochlear Process of the Humerus, which can often be detected as a small, detached and movable fragment. Fractures of the humerus near the elbow are to be diagnosed 1st. From each other. 2d. " dislocation at the elbow. 3d. " fracture of the ulna or radius. 4th. " severe sprain or contusion of the joint. 166 SURGICAL DIAGNOSIS. FRACTURES OF THE ULNA, AT THE ELBOW. The ulna if fractured in the vicinity of the elbow may be broken either in its shaft, below the coronoid process, or the olecranon and coronoid processes may be individually fractured. Fractures of the ulna as a single bone in the vicinity of the elbow are more commonly a complication of dislocations at the elbow joint than a primary affection. The bone if broken by ordinary violence is usually affected in its shaft, either in the forearm at its middle, or nearer the wrist joint. In fact it is difficult for the ulna to be fractured at either of its processes in the vicinity of the elbow joint without displacement occurring at the same time, since no longer does any barrier exist to prevent the bone from slipping from its articulating surface. It can only be, then, in cases of a severe form of violence directly ap- plied to the bone that uncomplicated fracture of the ulna in the vicinity of the elbow can occur. As I propose to consider all the diagnoses pertaining to fractures in the vicinity of the elbow in consecutive order, I pass to the enu- meration of the fractures of the radius. FRACTURES OF THE RADIUS, AT THE ELBOW. The radius is seldom fractured in the vicinity of the elbow, as an individual bone. It is more commonly associated with fractures of the ulna occurring from direct violence. It may however be broken either below its articular head, or im- mediately below its tubercle. If below the tuberosity, the seat of fracture becomes at once ap- parent from the action of the biceps muscle upon the upper frag- ment of the bone. FRACTURES. 107 TRANSVERSE FRACTURE OF DISLOCATION OF BOTH HUMERUS ABOVE THE CON- BONES OF FOREARM DYLES. BACKWARDS. History. Occurs in falls upon the elboAV. Occurs in falls upon the palm of the hand, or upon the forearm when the humerus is fixed. Anterior Tuaior. An anterior tumor exists which is An anterior tumor exists (lower small and pointed (upper fragment), end of humerus), Avhich is broad and lies above the crease of the elbow, and large, and lies below the crease of the elbow. Posterior Tuaior. A posterior tumor is felt which is A tumor is felt posteriorly which large, and discloses the outlines of discloses the distinct outlines of the the condyles and the olecranon. two displaced bones of the forearm. Olecranon. The olecranon is in its normal re- The olecranon is separated from lation to the condyles of the hume- the condyles of the humerus. rus. Mobility. ExtensiAre mobility is present. The joint is usually immoATable. Crepitus. The crepitus, which is always de- Crepitus may be absent, or, if tected, is of the grating character, present, is of a rubbing character. characteristic of fracture. Length of Huaierus. The humerus is shortened, if The humerus is of normal length, measured from the acromion to the as revealed by the same measure- external condyle. ments. Reducibility. Reduction of the deformity is easy The reduction of the deformity by simple extension, but is tran- is difficult, but permanent Avhen sient if the force be removed. effected. SYMPTOMS IN COMMON. Both are associated with shortening of the upper extremity (as a Avhole). tt a a tt an anterior and posterior tumor. " " " " impairment of function. tt ft ti a a history of an accident. " " " " possible crepitus. a tt a tt iocai pajn an(j swelling. 168 SURGICAL DIAGNOSIS. FRACTURE OF OUTER CON- FRACTURE OF INNER CON- DYLE OF HUMERUS. DYLE OF HUMERUS. Change in Condyle. The prominence of the outer side The prominence of the internal of the elbow is lost, and a movable aspect of the joint is lost, and a fragment is perceived. movable fragment is felt. Relations of Bones of Forearai. The radius is frequently displaced The ulna is usually retained in from its normal position. its normal relation to the humerus. Nerve Symptoais. No symptoms due to injury of Symptoms due to injury of the nerves are liable to be present. ulnar nerve usually exist in the fore- arm and hand. SYMPTOMS IN COMMON. Both are associated Avith a displacement of the fragment toAvards the pos- terior surface of the joint during extension of the forearm ; but on flexion the displacement tends to disappear. Both are associated with a prominence of the humerus at its lower extre- mity at the seat of fracture during extension of the forearm, which also disappears on flexion. Both are associated with pain on flexion and extension. " imperfect or impaired motion in the elbow. " " crepitus, by pressure being made over the frac- tured condyle, and flexion and extension being performed. " " history of an accident. " local swelling and tenderness on pressure. FRACTURES. 169 FRACTURE OF CORONOID FRACTURE OF THE OLE- PROCESS OF THE ULNA. CRANON PROCESS OF THE ULNA. History. A history of indirect violence, as A history of direct violence, as in in falls upon the palm, exists. falls upon the elboAV Avhen the arm is bent, is present. Presence of Dislocation. It is rarely unassociated with dis- It may occur Avithout displace- location of the ulna or of both bones ment of the ulna, or the ulna may backwards. be dislocated forwards. Displacement. The displacement is often very The amount of displacement va- slight if dislocation be absent. A ries with the extent of injury done simple fulness in front of the joint to the triceps expansion over the and a small, hard, movable body olecranon. are all that are discovered. If dislocation is present, a special deformity will be produced which will be characteristic. Deformity. The condyles and the projecting The point of the elboAV is gone olecranon are normal and preserve and the arm is usually semi-flexed, the shape of the joint. though the fragments are often closely approximated on extension of the forearm. Crepitus. Crepitation is often absent, but Crepitation is detected by exten- Avhen present it is perceived on ex- sion of the forearm, and rubbing tension and local pressure in front the fragments together. of the joint being exerted. Motion. Flexion at the elbow is always The power of extension of the impaired, if the radius be dislocated, forearm is entirely lost. SYMPTOMS IN COMMON. Both are associated Avith deformity. " " " " possible dislocation. " " " " impaired function. " " " " crepitus. " " " " history of an accident. " " " " local pain and SAvelling. 170 SURGICAL DIAGNOSIS. FRACTURE OF THE OLE- RUPTURE OF THE TRICEPS CRANON PROCESS OF THE TENDON. ULNA. Tumor. The tumor on the back of the The tumor at the back of the arm is of bony hardness. arm, due to contraction of the tri- ceps, is not bony in character. Length of Olecranon. The length of the olecranon is The olecranon process is of nor- diminished. mal length. Relations of Olecranon. The olecranon no longer is ad- The olecranon process is adherent herent to the ulna, nor are its rela- to the ulna, and is normal in its tions to the condyles of the humerus relation to the condyles. normal. Crepitus. Crepitus can be detected by ex- No crepitus can be detected. tension of forearm and manipula* tion. Pain and Savelling. The pain and swelling are often The swelling and inflammatory severe. symptoms are slight. SYMPTOMS IN COMMON. Both are associated with loss of the power of extension of the forearm. " " " "an empty space behind the elbow. " " " " a tumor high up behind the joint. " " " " a history of traumatism. " " " " local pain. " " " " local swelling. FRACTURES. 171 FRACTURE OF THE UPPER FRACTURE OF THE UPPER END OF THE RADIUS. END OF THE ULNA. Deforaiity. No displacement of the upper A displacement will be easily de- fragment will exist, if the seat of tected, as a rule, on the posterior fracture be above the tubercle of part of the forearm, on account of the radius ; but if beloAV it, a marhed the superficial position of the bone displacement is apparent on exten- in that locality, although it may sion of the forearm, from tension of not be discovered on the anterior the biceps tendon. surface. Crepitus. Crepitation can be detected by Crepitus will be detected on ro- fixation of the condyle, and rota- tation of the lower fragment, and tion of the lower fragment of the possibly on flexion and extension of radius. the forearm. Motion. Flexion is difficult, or incom- The motions of the forearm may plete. be only slightly impaired if the fracture be transverse. Position of the Hand. The hand is pronated. The hand has no fixed position. SYMPTOMS IN COMMON. Both are associated with a history of traumatism. « tt tt a marked swelling. a a f " severe local pain. « tt a tt frequent ecchymosis. " " " " crepitus. « tt ti a impaired function and motion. a a ft ft altered, or a fixed position of the hand. 172 SURGICAL DIAGNOSIS. FRACTURES NEAR THE WRIST JOINT. The fractures which may occur in the vicinity of the wrist joint are as follows : A. " Colles' Fracture," by which term is meant that peculiar type of fracture of the radius located from | of an inch to \\ inches from its lower articular extremity, and asso- ciated Avith the so-called " silver-fork" deformity. It is usually of the impacted variety of fracture, the upper fragment being driven into the lower fragment, which is therefore frequently comminuted. It is also associated often with an outward displacement of the hand and Avrist. It results most frequently from falls upon the palm of the hand when the arm and the forearm are extended. B. " Barton's Fracture," by which term is meant a rare type of fracture located at the lower articular extremity of the radius, in which the styloid process of that bone and an adjacent portion of the articulating surface of the radius are separated from the shaft of the bone, and the Avrist joint opened. This form of fracture is so ex- tremely rare, that I know of but two bony specimens indicative of its previous existence in the various ana- tomical museums. It can be doubtless easily over- looked during life, as the fragments are too Ioav down to admit of great displacement, and crepitation might easily be absent. As the condition is one of extreme infre- quency little is known of its symptoms, save on theo- retical speculation. C. Fracture of Both Bones of Forearm, transversely near the wrist. This type of fracture is by no means un- common. It may occur from indirect violence applied to the hand, carpus, or forearm; or from a direct bloAV received over the seat of injury. It is to be diagnosed from Cones' Fracture and from dislocation of the carpal bones. D. Separation of the Epiphyses at the Wrist. Like all sepa- FRACTURES. 173 rations of the epiphyses of bones, this accident occurs in youth. It may result from direct or indirect violence ; and is to be diagnosed from transverse fracture of both bones, and from dislocations of the carpus. E. Fracture of the Lower End of the Ulna. This variety of fracture may be confined simply to the styloid pro- cess of the ulna, or the shaft of the bone in the imme- diate vicinity of the wrist joint may be involved. It can hardly be confounded Avith any other surgical condition, save contusion, when the swelling conceals the deformity, and when crepitation is indistinct. The fractures in the vicinity of the wrist joint are of very frequent occurrence. Probably no bone in the body is so frequently broken as the radius, and no fracture is so often brought to the surgeon's notice as that first described by Colles, and known by his name. Fractures in the vicinity of the wrist are to be diagnosed 1. From each other. 2. " dislocations of the carpus. 3. " dislocations of the ulna, (lower end). 4. " severe sprains and contusions about the joint. 174 SURGICAL DIAGNOSIS. COLLES' FRACTURE. DISLOCATION OF THE WRIST. Location of Deformity. The deformity present is confined The deformity affects both sides to the radial side. of the forearm. Appearance of Radial Border. The so-called " silver forh " ap- No abnormal curves in the line of pearance, due to the displacement the radius are perceiA'ed. of the fragments of the radius, is seen by examining the radial border of the forearm. Crepitus. Crepitus is present, provided im- No crepitus can be detected. paction does not exist. Tumor. An abnormal tumor is perceived An abnormal tumor is present on on both surfaces of the forearm, only one surface of the forearm, which are both sharp and pointed. Avhich is smooth and rounded. Length of Radius. The radius is shortened. The radius is normal in length. Length of Liaib. The limb is normal in length The limb is shortened on both the upon the ulnar side. radial and ulnar sides. Styloid Processes. The styloid process of the ulna is The styloid process of the ulna is lower than that of the radius. higher than that of the radius. The styloid process of the ulna is The styloid process of the ulna is markedly prominent from displace- not markedly prominent. ment of the carpus. SYMPTOMS IN COMMON. Both are associated with an alteration in the length of the limb. " " " "an abnormal tumor. " local pain and SAvelling. " " " " impaired function. " a history of an accident. FRACTURES. 175 FRACTURE OF BOTH BONES DISLOCATION OF THE NEAR THE WRIST. WRIST. Seat of Displaceaient. The seat of displacement is located The seat of displacement is located above the styloid processes. at the carpal articulation. Deformity. The bony projection or tumor is The bony tumor is smooth and rough and irregular. rounded. The inferior projection is long, The inferior projection is short, as it includes the carpus and loAver as it includes only the carpus. fragments. Condition of Tendons. The tendons of both surfaces of The tendons upon one surface of the forearm are relaxed. the forearm are tense. Styloid Processes. The styloid processes are not The styloid processes are promi- prominent, and are normal in their nent, and are abnormal in their re- relations to the carpus. lation to the carpus. Length of Forearm. The radius and ulna are both The radius and ulna are both of shortened. normal length. Mobility. Great mobility exists at the seat Partial fixation of the joint is of fracture. present. Crepitus. Crepitation is present. Crepitation is absent. Reducibility. Reduction is easily made by ex- Reduction is more difficult, but tension, but the deformity returns, is permanent if once accomplished. SYMPTOMS IN COMMON. Both are associated with deformity near the wrist. " " " " impaired function. " " " " local pain and swelling. " " " "a history of an accident. " " " " shortening of the limb (as a whole). 176 SURGICAL DIAGNOSIS. SEPARATION OF THE DISLOCATION AT THE EPIPHYSES. WRIST. Age Affected. Occurs only in the young. Occurs at any age. Bony Tumor. The bony projections are often The bony projection is distinct indistinct and can be felt as two and can be felt as a rounded mass. smooth tumors. Seat of Displacement. The displacement occurs above The displacement occurs below the styloid processes of the radius the styloid processes of the radius and the ulna. and the ulna. Tendons of the Forearm. The tendons are relaxed upon The tendons are tense upon one both surfaces of the forearm. side of the forearm. Length of Forearai. The bones of the forearm are The bones of the forearm are nor- shortened, on measurement from mal in length. condyles at elboAV to styloid pro- cesses. Styloid Processes. The styloid processes of the ulna The styloid processes of the radius and the radius are not prominent, and ulna are prominent. but are normal in their relation to the carpus. SYMPTOMS IN COMMON. Both are associated with the absence of crepitus. " shortening of the upper extremity. " smoothness of the tumor at the wrist. " " " " impaired function. " local pain and swelling. " " " " easy reduction. " a history of an accident. FRACTURES. 177 COLLES' FRACTURE. TRANSVERSE FRACTURE OF BOTH BONES ABOVE WRIST. Deformity. The deformity is apparent upon The deformity is apparent on both the radial side, and has the charac- sides of the forearm. teristic " silver-forh" appearance. Length of Bones of Forearai. The ulna is normal in length, Both sides of the forearm reveal but the radius is shortened. shortening. Length of Liaib. The limb is shortened on the The limb is shortened on both radial side, if measured from the sides, if measured from the acro- acromion to the styloid process. mion to the styloid processes. Styloid Processes. The styloid process of the ulna is The styloid processes are both prominent. normal in their appearance and re- lations. Crepitus. Crepitus is often absent from im- Crepitus is almost invariably pres- paction of the fragments. ent, as impaction is rare. Mobility. The mobility is not markedly in- Excessive mobility exists at the creased at the seat of fracture. seat of fracture. Relation of Carpus. The carpus is usually displaced The carpus is normal in its rela- outwards. tion to the inferior fragments. Reducibility. The reduction is sometimes diffi- The reduction is always easy, if cult. simple extension is applied. SYMPTOMS IN COMMON. Both are associated with deformity at wrist. " impairment of function. " alteration in the length of bones. " crepitus. " local pain and swelling. " history of an accident. 12 178 SURGICAL DIAGNOSIS. FRACTURES OF THE HIP. The femur is the bone most frequently involved in injury to the hip joint. The pelvic bones are too heavy and solid in their structure to often become implicated, save Avhen the violence is terribly severe and so directed as to impinge upon the ossa innominata. The femur may exhibit the following five distinct types of frac- ture in the upper third of that bone : A. Simple Intra-capsular Fracture of the Femur. This form of fracture occurs at the anatomical junction of the head of the bone to its neck, inside of the attachment of the capsular ligament of the hip joint. It is most com- monly present in the aged, and is usually the result of indirect and slight violence. It is seldom followed by osseous union, and is often a permanent source of impairment to the usefulness of the limb. B. Impacted Intra-capsular Fracture of the Femur. In this form of fracture the location is identical with the frac- ture preceding, but the condition of the bone is altered by the lower fragment being driven forcibly into the can- cellous tissue of the head of the femur. Impaction of the fragments in intra-capsular fracture of the hip is of great surgical importance. Upon its existence depends greatly the hope of osseous union, and the prognosis is proportionately favorable when im- paction can be clearly and positively diagnosed. R. IV. Smith, of Dublin, in his great essay upon fractures in thei vicinity of joints, questions if osseous union impossible in any other condition save impaction, provided the frac- ture of the femur be located within the capsule of the hip joint. C. Simple Extra-capsular Fracture of the Femur. This form of fracture of the femur is usually the result of a direct form of violence which is generally severe in FRACTURES. 179 character. It is most common in middle or adult life. Its location varies from a point immediately in relation with the capsular attachment, to a line corresponding to the junction of the middle and lower third of the bone. It is associated, as a rule, with marked deformity, great impairment of function of the injured limb, and severe local manifestations. D. Impacted Extra-capsular Fracture of the Femur. This form of fracture differs but little from the preceding variety in its origin or its location. It may possibly present equal deformity in case the impaction is oblique or in- complete ; and may also be associated with severe local manifestations. It is, however, characterized by the absence of a false point of motion, and the general impairment of function may be less marked. In case of rotary impaction of the fragments, an ab- normal position of the foot may ensue, which will fre- quently disappear after firm extension has loosened the impacted fragments. E. Fracture of the Great Trochanter of the Femur. This variety of fracture occurs as a separate type in cases of falls upon the hip, and also more frequently as a com- plication of extra-capsular fracture of the neck of the femur. So frequently does the trochanter become involved in this latter accident that it is considered an almost uni- versal rule, that more or less comminution of the trochan- ter accompanies every fracture of the neck, from an impaction which primarily occurs, and is subsequently loosened by a continuation of the violence producing the original impaction. Should the violence, however, be slight in amount, this impaction may remain permanent and the trochanter thus escape comminution. We may safely exclude all fractures of the pelvic bones from the causes of error in diagnosis of injuries received in the region of the hip joint, proAdded no evidences of previous disease are present, since, if the fracture of these bones be severe and extensive, the lo- cation of the crepitus and symptoms referable to the pelvic viscera will easily remove all doubt. Should the fracture be of a local char- 180 SURGICAL DIAGNOSIS. acter, however, and not of the comminuted variety, it is often im- possible to either positively diagnose the existence of a fracture, or to locate its situation, provided even that crepitus be obtained. Fractures of the upper third of the femur are to be diagnosed chiefly from each other, and also from 1. The "pubic " dislocation of the hip. 2. " "sciatic notch" " 3. Acute rheumatic arthritis with contusion. 4. Severe contusion over the trochanter, in the aged. In the following pages will be found enumerated the chief points of diagnosis in a condensed form. FRACTURES. 181 INTRA-CAPSULAR FRAC- EXTRA-CAPSULAR IMPACT- TURE OF THE HIP, WITH ED FRACTURE OF THE IMPACTION. HIP. History of Accident. A history of slight violence and A history of severe violence, di- usually of the indirect character is rectly applied, exists. present, in the majority of cases. Position of Foot. The foot is markedly everted. The foot is slightly eA'erted, or normal in its attitude. Crepitus. Crepitus is frequently detected, as Crepitus is either absent, or is the fragments may overlap and rub very obscure. upon the acetabulum. Effect of Extension. Extension relieves the shortening Extension, when moderately ap- of the limb. plied, fails to relieve the deformity. Age. Is most frequent in old age. Is most frequent in adult life. SYMPTOMS IN COMMON. Both are associated with shortening of the limb. " eversion of the foot. " local pain near seat of fracture. " swelling and possible ecchymosis. " a history of an accident. " a possible crepitus. 182 SURGICAL DIAGNOSIS. INTRA-CAPSULAR FRAC- TURE OF THE HIP. CHRONIC RHEUMATIC AR- THRITIS WITH CONTUSION. History. No previous history of disease of the hip, or impairment of the func- tion of that joint is present. A previous history of pain, de- formity about the joint, and im- pairment of function, precedes the accident. Subsequent Power. The patient slowly, if ever, re- gains the power present within the joint pieA'ious to fracture. The patient regains the amount of power and motion which he pos- sessed within the hip previous to the accident, as soon as the effects of the contusion disappear. Both are assoc SYMPTOMS IN COMMON. ated Avith crepitus. " loss of power and loss of voluntary motion. " local pain in the region of the hip. " swelling and possible ecchymosis. " a history of an accident. " advanced years, " eversion of the foot. FRACTURES. 183 SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HIP. FRACTURE OF THE HIP. Age Affected. Is rarely present in patients under May occur at all ages. fifty years of age. Sex Affected. Is most frequent in females. Both sexes are equally affected. History. Is the result of slight and indi- Is usually associated Avith severe rect violence. and direct violence. Shortening. The shortening of the limb is at The shortening of the limb is first not severe, but it steadily tends markedly apparent immediately af- to increase, from absorption of ter the occurrence of fracture, but bone. is stationary. False Point of Motion. A false point of motion is ob- A false point of motion is ap- scure. parent. Crepitus. Crepitation is obscurely detected. Crepitation is well marked. Poaver of Motion. The poAver of motion of the limb The poAver of motion within the is always impaired, but not always limb is usually lost. destroyed. Arc of Rotation. The trochanter rotates in nearly The arc of rotation of the tro- its normal arc. chanter is diminished, as the femur is detached from its neck. Pain. Pain of a slight but deep charac- Pain of a severe and superficial ter is present. character is present. 184 SURGICAL DIAGNOSIS. SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HIP FRACTURE OF THE HIP (continued). (continued). Ecchyaiosis. Ecchymosis is usually slight or Ecchymosis is usually extensive. absent. Swelling. Swelling is not markedly appa- Swelling is frequently severe. rent. Rapidity of Union. Union occurs slowly, if at all. Union occurs rapidly and per- fectly, as a rule. SYMPTOMS IN COMMON. Both are associated Avith the history of an accident. " " " " impairment of function. " " " " shortening of the limb. " " " " crepitus. " " pain and possible ecchymosis. FRACTURES. 185 FRACTURE OF THE HIP WITH " SCIATIC NOTCH " DISLOCA- INVERSION OF THE FOOT. TION OF THE FEMUR. Mobility of Limb. The mobility of the injured mem- The mobility of the limb is great- ber is increased. ly decreased. Crepitus. Crepitus is present. Crepitus is absent. Shortening. Shortening of the limb is well Shortening of the limb exists only marked. to a slight degree. Inversion of the Foot. The inversion of the foot is often The inversion of the foot is per- ehanged to eversion, after extension manent, and is only restored to a of the limb has loosened the im- normal position by reduction of the paction of fragments, to which the dislocation. inversion is most frequently due. Abnormal Tuaior. The separated trochanter often The abnormal tumor produced fails to participate in the motions by the displaced head of the femur of the shaft of the femur. rotates Avith motion communicated to it through the shaft of that bone. Reducibility. The reduction of the deformity The reduction of the deformity is easily effected by extension, but is difficult, but Avhen once accom- is transient if the force be not main- plished no tendency to return is tained. manifested. History of Accident. Is often produced by indirect Is usually produced by direct violence. violence. SYMPTOMS IN COMMON Both are associated with shortening of the limb. " " " " inversion of the foot. " " " " local pain in the region of the hip. " " " " impairment of function. " " " " swelling, and possible ecchymosis. " " " " history of an accident. 186 SURGICAL DIAGNOSIS. FRACTURE OF THE NECK "PUBIC" DISLOCATION OF OF THE FEMUR. THE FEMUR. Position of the Trochanter. The trochanter of the femur is The trochanter of the femur is normally prominent, and is not dis- carried forwards, and is much less placed towards the median line of prominent than normal. the body. Position of the Head of Femur. The head of the bone is felt to The head of the femur is felt as be in the acetabulum. an abnormal tumor in the groin, at its upper portion. Crepitus. Crepitus can easily be detected. No crepitus is present. Mobility of Liaib. The mobility of the injured limb The mobility of the limb in the is increased, but its poAver of motion movements of adduction and rota- is greatly impaired or entirely de- tion inwards is greatly impaired. stroyed. Reducibility. The reduction of the deformity is The reduction of the deformity is easily accomplished by direct exten- difficult, but if once effected no ten- sion, but is transient if the force be dency toAvards a return is apparent. discontinued. SYMPTOMS IN COMMON. Both are associated Avith eversion of the foot. " " " " shortening of the limb. " " impaired function. " " " " seA'ere local pain. " " history of traumatism. FRACTURES. 187 FRACTURES AT THE KNEE AND ANKLE. The fractures which may occur at the region of the knee may be confined either to the femur in its lower third, to the tibia and fibula at the upper portion of both bones, or to the patella. The femur if fractured either in its middle or loAver third is gene- rally broken by some form of direct violence. In its lower third, it is liable to present the following types of fracture : A. Fracture of the outer condyle. B. " " inner C. Transverse fracture above the condyles. These fractures of the femur in this region are generally easily detected by the deformity and the location of the crepitus. It is not infrequent that fractures of the femur in this vicinity are complicated by Avounds of the knee joint, and amputation is often required provided extensive comminution exists, or the symptoms of the patient seem to demand it. Impaction in these fractures is occasionally present, and, provided comminution of the lower fragment does -not ensue, this impaction may not be associated with any serious deformity. FRACTURES OF THE BONES OF THE LEG IN THE VICINITY OF THE KNEE. The tibia, although the stronger and larger bone of the leg, is by far the more frequently fractured. This is partly due to its exposed position, but chiefly to the fact that the fibula is extensively protected by muscles. The tibia, also, is much more liable to receive injury from violence transmitted through the heel and the tarsus, than the fibula. The variety of fracture which is most frequently present at the upper third of the tibia is the transverse, and this seldom, if ever, occurs except from the application of direct violence. If both bones are simultaneously involved, the presence of crepi- tus, marked deformity, false point of motion, and shortening renders the diagnosis easy; but if either is fractured singly, the opposite 188 SURGICAL DIAGNOSIS. bone acts as a splint, and prevents displacement and shortening. In this case an irregularity in the line of the tibia can easily be de- tected by the finger, if that bone be fractured ; but if the fibula be broken, the investing muscles render the diagnosis obscure, pro- vided the seat of fracture be above the middle third of the bone. A deep-seated crepitus can, hoAvever, be often detected by care- ful manipulation, and the seat and presence of fracture be thus dis- covered. Fractures of the bones of the leg in the region of the knee can hardly be mistaken for any other existing surgical affection. Con- tusion may possibly so mask the symptoms of fracture by its ac- companying swelling as to leave doubt as to whether the bone is broken, but it could hardly be mistaken for it. FRACTURES OF THE PATELLA. Fractures of the patella most frequently occur from muscular action in an effort being made by the patient to save himself from falling when slipping, or in falls when the knee is bent. It may, however, also occur from falls directly upon the knee, or from any other form of violence directly applied. Fractures of the patella may be transverse, longitudinal, or ob- lique in direction; and simple, or comminuted in variety. The transverse fracture is usually the form met with when due to mus- cular action, and is by far the one most frequently present in sur- gical practice. The fractures of the patella can hardly be mistaken for other forms of injury, when they are well defined. The two portions of the bone, in case of transA^erse fracture, are separated by the action of the quadriceps extensor muscle, and the space between the frag- ments is increased by flexion of the knee. All power to extend the leg upon the thigh is lost, and endeavors to stand upon the in- jured leg are fruitless. In the comminuted variety local crepitus can usually be discerned, but in the transverse form, the fragments can hardly be sufficiently approximated to yield marked crepitus, except the position of the thigh be so modified as to relax the rectus muscles, and extension be applied to the upper fragment of the bone. Fractures of the patella are more common among males than females, and are seldom present in youth. This is explained on the theory of previous structural change within the bone substance, FRACTURES. 189 (Mcdgaignc), but it can hardly be considered as proven. A better explanation of the frequency of fracture of this bone seems to be the lack of support which the upper half of the patella receives when the knee is in a state of flexion, as in this position the upper edge is projected forwards, and the posterior surface of the upper half of the bone is totally separated from contact with the femur. FRACTURES AT THE ANKLE. The fractures which may occur in the bones of the leg at their lower third, or in the immediate vicinity of the ankle joint are more common than those occurring in the immediate vicinity of the knee. This is partly due to the bones gradually diminishing in size as they approach the ankle, and partly to the greater frequency of in- direct violence occurring in the vicinity of that joint from trans- mission through the bones of the foot, and from the leverage exerted by the astragalus upon the malleoli of the leg bones, in case of its displacement. Fractures of the leg in the vicinity of the ankle may be thus enumerated: A. Transverse Fracture of Both Bones. This form of injury is perhaps less common than the oblique variety of frac- ture Avhich is so frequently present in the shafts of the leg bones, since a natural tendency seems to exist in fractures occurring in the tibia or fibula below their upper third to approach a longitudinal direction, and thus to cause a greater or less obliquity, even if the force be so applied as to tend towards a directly trans- verse separation of the fragments. Still, in speaking of transverse fracture I include all those forms which more nearly approach the horizontal than the perpendicular plane, without entering into too many fine distinctions as to the absolute direction of the line of fracture. In this type of fracture near the ankle, we may have either slight or marked displacement existing. The degree of this displacement is the most extensive when the fracture is obliquely directed across the bone, since in this condition the fragments glide more easily upon each other; and it is the least apparent in that form of fracture where an absolutely transverse separation is present, in which case the bones may often be retained 190 SURGICAL DIAGNOSIS. in almost their normal position, and the line of the frac- ture may for that reason be more clearly discerned by the location of the crepitus than from any evidence per- ceived by the careful inspection and examination of the contour of the injured member. B. " Pott's Fracture " of the Fibula. This type of fracture is located in the shaft of the fibula, at a point usually about three inches above the external malleolus. The seat of the fracture may, however, vary somewhat in its location, as it is often much nearer the malleolus. It is associated, as a rule, with an outward dislocation of the astragalus, and the internal malleolus is fre- quently broken. The internal lateral, or deltoid ligament, of the ankle is usually severely stretched or ruptured, and the deformity due to the displacement of the astra- galus, is aggravated often by marked local SAvelling. This form of fracture of the leg is extremely frequent, probably the most frequent of any fracture of the leg bones. It is produced by twisting of the foot, by catch- ing of the foot in a hole while running, by jumping from a height upon the feet, or from a carriage Avhile in motion. It may also result from violence directly ap- plied. The deformity which characterizes Pott's Fracture, is one of ordinary fracture combined Avith that of an exter- nal dislocation of the foot. A depression is perceived on the external border of the leg opposite the seat of fracture, and the sole of the foot is either directed out- wards, or the external border of the foot is elevated. The internal malleolus is either prominent, or can be felt as a detached and movable fragment; and crepitus can often be detected on extension of the leg and inver- sion of the foot, thus bringing the fragments into ap- proximation. C. Fracture of the Internal Malleolus. This form of frac- ture at the ankle may be associated with a normal position of the foot, or with a partial dislocation of the astragalus inwards, resulting either in severe stretching, or rupture of the external lateral ligament of the joint. It is complicated, as a rule, with marked SAvelling at the external portion of the joint, and is not infrequently FRACTURES. 191 associated with a partial or complete fracture of the fibula. D. Compound Fractures of the Ankle Joint. This form of accident is one of serious import, commonly requiring amputation if associated with dislocation or seA*ere lace- ration of the soft tissues. The tibial arteries are not infrequently involved, and serious hemorrhage may exist. Gangrene of the parts supplied by these arteries may also follow the arrest of the hemorrhage, from the defec- tive nutrition which is liable to result in consequence of the impaired blood supply, and thus additional danger to the patient may ensue. It is ahvays important therefore in the diagnosis of this accident to investigate the condition of the supply- ing vessels to the foot, before deciding as to the methods of treatment which are best indicated, or expressing an opinion as to the general prognosis. Fractures in general in the vicinity of the ankle joint can hardly admit of great confusion in diagnosis. Ob- scure injuries to the astragalus, or tarsal bones will often fail to give positive evidence of fracture, even when such exists; but the history of the accident, the general de- formity, the presence of some of the prominent symptoms of fracture, and the length of duration required for re- covery will, in time, remove doubt, in cases where an early and positive diagnosis is impossible. I shall not attempt therefore to arrange all the pos- sible fractures of the bones of the leg and foot in the vi- cinity of the ankle joint, in a form of contrast, since many of the most positive symptoms of each are capable of great variations, and in the majority of cases, the bones themselves will disclose from their superficial location the seat and extent of the injury received. I should suggest, however, in case the deformity were slight, and the other symptoms so obscure as to create doubt as to the existing condition of the parts injured, that the opposite member be always used in comparison with the one injured, before deciding as to the actual de- formity present, and that repeated examinations under anaesthetics and without them be employed, till a satis- factory conclusion can be reached. 192 SURGICAL DIAGNOSIS. FRACTURES OF THE TRUNK. Fractures of the trunk may affect the vertebrae, ribs, sternum and pelvis; of these four, fractures of the sternum are extremely rare, and usually occur where a severe injury is received, which directly impinges upon the chest, or in cases where the body is suddenly bent backwards or forwards, as in a fall. It is of surgical impor- tance however, when present, since complication of the pericardium, heart, pleura, lungs, and injuries of the great vessels and fractures of the ribs, or spine, may be also thus produced, and greatly modify, when present, the prognosis as to life. As many of these complications, however, can also exist with frac- tures of the ribs, they will be specially considered under that head. Fractures of the sternum may be associated with most of the symptoms common to fracture in general. Crepitus may be de- tected possibly on palpation and on auscultation. FRACTURES OF THE STERNUM. Displacement of the fragments, abnormal mobility, localized pain at the seat of fracture, and dyspnoea may all be present, even with- out the existence of any serious complication of organs or the se- rous cavities, though subsequent inflammatory changes are always liable to follow any violence to the chest which is sufficient to pro- duce so serious an injury. It is therefore to be diagnosed chiefly from its complications, and especially from inflammatory changes in the pleura or pericardium. Fractures of the sternum have in several reported cases been pro- duced by muscular action. Chaussier reports two cases resulting from resting upon the head and heels only, during parturition. Faget and Gurlt report each a case resulting from attempting to lift weights with the teeth, with the body bent backwards. FRACTURES OF THE VERTEBRAE. Fractures of the vertebrae may result from direct injuries to the spine, or from force indirectly applied, as in case of falls upon the feet, knees, pelvis, or head. In the first set of causes, viz. : those producing fracture from FRACTURES. 193 direct violence, the injury is, of necessity, received upon the back, since in front the spine is most thoroughly protected. This class of injury almost without exception results in a com- plicating dislocation of the vertebrae in addition to the fracture re- ceived, since the anterior ligamentous attachments of the bodies to each other are ruptured by the direct force of the blow, altering the normal spinal curve, while at the same time the spinous pro- cesses and laminae of the vertebrae are comminuted by the com- pression exerted in endeavoring to resist such an alteration in the spinal axes. In the second class, viz. : those dependent upon force indirectly applied to the spine, the fracture is found to be usually located at a distance from where the shock was first received. Dislocation of the vertebrae will, as a rule, be absent, but the articular surfaces will generally be comminuted, and the spinous and transverse pro- cesses frequently fractured. In very severe cases, however, where the force transmitted through the spinal column is of a violent character, the bodies of the vertebrae may be comminuted, and displacement from this cause will often be detected. In either variety, however, we can judge of the location of the fracture and its severity by the combined local and spinal symp- toms. The heal symptoms will consist of probable crepitus, deformity, detached and movable fragments, local ecchymosis, and local pain. The spinal symptoms will vary with the seat of fracture and the portion of the cord compressed, or injured. Thus, if above the origin of the phrenic nerve, death may ensue from respiratory paralysis, provided both lateral halves of the spinal cord are in- jured. If above the origin of the lumbar and sacral plexuses, symp- toms of paralysis of the limbs and pelvic organs will be apparent. The paralysis of muscles may be of the hemiplegic or paraplegic type, as the pressure on the cord is lateral or bilateral, or possibly even local paralysis may result, if special spinal nerves be affected, and the cord be not involved. In some cases where dislocation of the vertebrae exists in connec- tion with fracture, extension of the spine by suspension of the pa- tient, if practicable, if not, by ordinary means, will often reduce the dislocation, and possibly an audible click will be heard when the reduction is effected. Fractures of the spine are frequently fatal. The result of the injury depends more upon the severity of the 13 194 SURGICAL DIAGNOSIS. spinal symptoms produced by injury to the cord, than upon the location of the fracture or its extent. If dislocation be present, the immediate vertebra will usually reveal the seat and extent of the displacement by the altered relation of the displaced bone. Should the displacement be but slight, the spinal cord may possibly escape injury, and reduction may be followed by recovery without para- lysis. Fracture of the spine can hardly be mistaken for any other type of local injury, as the symptoms are usually unmistakable, and the history of the accident would probably warrant a most justifiable suspicion of fracture from its severity, even before the local mani- festations were determined. FRACTURES OF THE RIBS. Fractures of the ribs occur rarely among the young, as the elas- ticity of the ribs is great in youth, but are most frequent in elderly people, or in adult life. They occur as a rule from external injuries applied to the chest wall, as in blows, falls, the passage of wheels over the chest, or from pressure between two opposing forces. In rare instances fracture of the ribs has occurred from muscular effort, as in attacks of coughing; but in these cases a structural change had probably ensued within the bone, before the fracture occurred. The ribs may be broken in one of two ways : either by the direct force of the injury, in which case the seat of fracture will correspond probably with the seat of the external contusion, and one or two ribs only will be implicated, the fractured ends being driven in- wards ; or the ribs may be fractured at a point remote from the seat of injury by an indirect force, causing excessive bending of the bones. In these cases the ribs are usually broken at about their middle, and the fractured ends of two or three bones are simulta- neously displaced outwards. Fractures of the ribs may be also di\Tided into the complete, and the incomplete. In the former variety, the separation of the frag- ments is such as to allow of displacement and marked crepitus. In the latter, either the bone itself is imperfectly fractured, or the periosteal coverings still remain intact and prevent any displace- ment, and often conceal all symptoms of local injury to the bone. Fractures of the ribs may be unilateral or occasionally bilateral, FRACTURES. 195 in situation; simple, comminuted, or compound, in variety. The middle ribs are the most frequently involved, and the first three ribs are seldom fractured. Fractures of the ribs may be uncomplicated, or complicated. If complicated, the integument may be lacerated, producing a com- pound variety of fracture. The bone may be shattered by gun-shot Avounds, etc., resulting in the comminuted variety of fracture. The pleura may be involved, producing pleurisy, etc. The lung-tissue may be penetrated, thus inducing pneumo-thorax, pneumonia, pul- monary hemorrhage, emphysema, etc. The heart and pericardium may become implicated. The inter- costal vessels may be Avounded, and finally the diaphragm and the abdominal \dscera may be injured, provided the lower ribs be in- volved and greatly displaced. The proportion of uncomplicated cases of fractured ribs to the total number of recorded cases, is very large,—at least seventy-five per cent. The balance usually recover, hoAvever, provided the com- plication is not of a markedly serious and severe type. Fractures of the ribs are to be diagnosed from many pulmonary affections, especially if connected with, or created by a severe con- tusion of the chest wall, or some variety of direct injury. Among the diseases which are liable to be confounded with a fracture of the rib, are pneumo-thorax if traumatic in origin, pleuritic inflamma- tion and emphysema of tissues. In the following pages Avill be enumerated the distinctive diag- nostic points of each in contrast, with those of fracture of the rib. In closing the subject of fracture I also append a differential diagnosis between Fracture and Dislocation of bone, as a general resume of the symptoms common to both. 19G SURGICAL DIAGNOSIS. FRACTURE OF THE RIBS. PLEURITIC INFLAMMATION, (in the dry stage associated with contusion). Appearance of Chest. The projecting edges of the frag- No projecting fragments can be ments of the fractured ribs can of ten discovered, or any irregularity in be detected, or an irregularity in the course of the rib. the course of the rib may result from its displacement, in case no fragments can be discovered. The chest wall is often locally de- The chest wall is normal, until pressed in case of fracture. effusion into the pleural cavity pro- duces bulging of the affected side. Palpation. Crepitus may often be felt on pal- Palpation is negative in its re- pation. suits. Auscultation. Auscultation yields the fine grat- Auscultation perceives a harsh ing noise of crepitation. friction sound, before the fluid separates the inflamed pleural sur- faces. Cough. Cough is absent, if no complica- Cough, without expectoration, is tion exist. usually present. SYMPTOMS IN COMMON Both are associated with localized pain in the side. " " " " abnormal sounds on auscultation. " " " " diminished expansion of the chest. " " elevation of pulse and temperature. " " " " local ecchymosis. " " " " a history of an accident. FRACTURES. 197 FRACTURE OF THE RIBS. PNEUMO-THORAX, (of a traumatic origin). Appearance of Chest. The chest Avail is often locally de- The chest wall is distended, and pressed at the seat of fracture. the intercostal spaces widened from air within the pleural cavity. Outline of Ribs. The fractured rib can often be The outline of the ribs is seen and felt to be irregular in outline, or felt to be normal. the fragments can be felt to overlap each other. Dyspncea. The dyspncea present is due only The dyspnoea is intense and is to the pain, and is not excessive. due to compression of the affected lung by atmospheric pressure. Palpation. A vocal fremitus can be perceiA^ed No vocal fremitus, or crepitus is on palpation of the chest when the detected. patient speaks or counts, and crepi- tus may also be detected. Percussion. The percussion note is normal Pure " tympanitic" percussion over the affected side. resembling that of the abdomen, will be present. Inspection. The expansion of the affected side No expansion of the affected side is limited, but plainly perceptible. occurs on inspiration. Auscultation. Respiratory sounds are heard over No respiratory sounds are heard, the seat of fracture, though they provided the lung be not punctured, may be feeble. but if so, "amphoric breathing" may exist. SYMPTOMS IN COMMON. Both are associated writh pain. " " " " dyspnoea. " " " " history of traumatism. 198 SURGICAL DIAGNOSIS. FRACTURE OF THE RIBS. EMPHYSEMA OF TISSUES. Appearance of the Chest. The chest wall is often depressed The tissues over the chest are in- at the immediate seat of fracture. flated with air, and the chest has, therefore, a puffy or distended ap- pearance, which is often extensively diffused. Abnormal Sounds. A fine, grating crepitus maybe A peculiar "crackling" noise and perceived during inspiration or ex- sensation to the touch may be per- piration, both on palpation and ceived on pressure over the em- auscultation, physematous tissues, irrespective of respiratory efforts. Outline of Ribs. The outline of the fractured ribs The ribs are felt to be normal in is felt often to be irregular ; or the their outline and position, if their overriding of the fragments may be contour can be detected through the detected. inflated tissues. Effects on Respiration. Pain is present in the side, and Pain may not be present to any the breathing is often restricted in serious degree, nor need the breath- consequence, ing be, of necessity, restricted. Duration of the Syaiptoms. The symptoms are continued for The symptoms may, in some some days after the accident. cases, rapidly subside. SYMPTOMS IN COMMON Both arc associated with abnormal auscultation. " " " " " palpation of the chest. " " " " deformity. FRACTURES. 199 FRACTURE IN GENERAL, IN THE VICINITY OF JOINTS. DISLOCATION. Deformity. The deformity is not in the joint, but near it, as is shoAvn by com- parison Avith the opposite side. It varies in its seat and in its de- gree, and is easily removed. The abnormal projections are usually felt to be small and irregu- lar in shape. The axis of the limb is not uni- form, but varies with changes in the relation of the fragments to each other. The deformity is great, and is lo- cated in the joint itself. It is stationary, and disappears only after reduction of the disloca- tion. The abnormal tumor, when per- ceived, is felt to be large, smooth, and rounded at its edges. The axis of the limb is abnormal, but is constantly the same and is of uniform direction throughout the whole length of the bone. Mobility of the Liaib. The mobility of the limb is of an abnormal type. It is augmented in its degree. It is not ahvays located at the region of a joint. All attempted voluntary move- ments are abnormal. The movements of the joint are greatly restricted, both in degree and direction. The movements are located in the immediate locality of the nor- mal joint, but not Avithin it. All attempted voluntary move- ments are normal in direction, but restricted in amount. Crepitus. Appears at the time of the acci- dent, is easily obtained, and is of a grating character. If present, crepitus is a late symptom ; is obtained with diffi- culty, and is of a rubbing char- acter. Pain. Is seldom severe if the parts are at rest. It continues after reduction. Is usually severe even though the parts are at rest. Is always relieved by reduction. 200 SURGICAL DIAGNOSIS. FRACTURE IN GENERAL, IN DISLOCATION, THE VICINITY OF JOINTS, (continued). (continued). Length of Limb. Shortening is often present, but Shortening and lengthening may lengthening never. both, at times, exist. Position of Limbs. Fractured limbs usually lie close Dislocated limbs usually stand to the median line of the body. out from the body, and cannot be made to lie parallel to its median line. Appearance of Joints. The bony prominences in the The relations of the bony promi- vicinity of joints are unaltered in nences normal to the joint are un- their relations to each other. altered. Sensibility. Numbness of the injured limb is Numbness is often a prominent often absent, but if present, is slight symptom ; it is usually present to a in amount. greater or less degree. Ecchymosis. Is often extensive, and is located Is usually slight and superficial, in a dependent part. if present. Reducibility. The deformity is easily reduced, but shows a tendency to return. No sound is perceived at the moment of reduction. The deformity is reduced often with difficulty, but Avhen accom- plished, no tendency toAvards a re- turn is manifest. A distinct snap is often perceived at the moment of reduction. DISEASES OF the MALE GENITALS. DISEASES OF THE MALE GENITALS. The surgical diseases of the male genitals may be divided into A. Diseases of the Testicle. B. C. D. E. F. G. Tunica Vaginalis. Spermatic Cord. Scrotum. Bladder. Prostate Gland and Urethra. Penis. I shall consider the diseases of the male genitals in this order, enumerating under each of the separate divisions the various sur- gical conditions liable to exist, and the sources of error in diag- nosis Avhich pertain to the various organs under consideration. I shall endeavor in this chapter to elucidate as exhaustively as is compatible with conciseness, those diseases Avhich are most com- mon in a general surgical practice, and shall be content with the enumeration only of such as are infrequent, referring those desirous of more extended information to the various monographs upon the special subjects. DISEASES OF THE TESTICLE. The testicles may become enlarged from the following named con- ditions : 1. Simple Inflammatory Orchitis which is a frequent sequela of injury, mumps by metastasis, and exten- sion of inflammation down the spermatic cord. It is largely due to an cedematous infiltration of the testi- cle, but may result in suppuration, and is associated with all the symptoms characteristic of inflamma- tory processes in general. 203 204 SURGICAL DIAGNOSIS. 2. Specific Deposit withest the Testicle, or " Syphili- tic Orchitis." This type of disease is a sequela of the acquired variety of syphilis, as a rule. It con- sists of circumscribed, or infiltrated deposits of gum- mata. It is a rare affection before the age of pu- berty, and is most frequently located at the period of its commencement, in the body of the testicle. It may, however, subsequently involve the epidi- dymis. 3. Cheesy Degeneration of the Testicle, or "Tuber- cular Orchitis." This variety of degeneration oc- curs in a tubercular diathesis, and exists in connec- tion AAdth a similar condition of other organs in the large majority of cases. It is essentially a disease of early manhood, and is primarily located in the globus major of the epididymis. It is associated, as a rule, with impairment of the general health, and is frequently accompanied by suppuration in its ad- vanced stages, and in some cases by fungoid growth. 4. "Malignant Orchitis," or Cancerous Deposit in the Testicle. This variety of disease may occur in all ages. It is a frequent disease after the age of fifty. It is primarily a disease of the body of the testicle, but involves the epididymis and the cord in its ad- vanced stages. It is associated with impairment of the general health as the later cachexia is developed. It is chiefly of the encephaloid variety, although scirrhus may occur in this region, and occasionally melanoid cancer may be present. 5. Cysts of the Testicle, called also " Cystic Sar- coma." This is a rare affection, and consists of compound or proliferous cysts developed within the testicle. They vary usually in size from that of a millet seed to the dimensions of a pigeon's egg, and contain either a transparent, viscid, albumi- nous fluid, or a blood-stained fluid with coagula. The cysts are usually of an elongated form, and are primarily a disease of the body of the testis, although the epididymis may become involved. They are probably produced by an occlusion of the tubvli DISEASES OF THE MALE GENITALS. 205 seminiferi, or the ducts of the rete testis. They are sometimes associated with enchondroma. 6. Hematocele of the Testicle. This is frequently the result of a blow, as in riding on horseback, and being throAvn upon the pommel of the saddle; or of violent muscular efforts, as in attempts to raise heavy weights. It may also occur from direct wounds of the testicle, and during scurvy and pur- pura. It is due to the rupture of a blood-vessel, and the blood is usually effused into the cavity of the tunica vaginalis. The testicle under these circumstances immediately enlarges, and symptoms referable to the escape of blood become manifest. Haematocele may occur when hydrocele has pre- ceded the exciting cause of hemorrhage. In this way tapping not infrequently creates a complica- tion, although a lancet, if used, is more liable to produce haematocele than a trochar. The source of hemorrhage in haematocele of the testicle may be the spermatic artery, or some of the branches either of the spermatic, or of the artery of the vas deferens. The testicle, as a rule, lies at the posterior portion of the tumor, but as this rule has exceptions, pressure upon the back of the tumor in doubtful cases will yield the peculiar " sickening sensation," usually associated with com- pression of the testicle, and thus decide its exact location. 7. Lipoma of the Testicle. Fatty tumors of the tes- ticle occasionally occur. They are to be diagnosed by their slow and painless growth, by the absence of an exciting cause, by the general health being unimpaired, and by the general characteristics of fatty deposits. 8. Fibrous Tumors of the Testicle. This type of dis- ease is frequently associated with the condition of atrophy of the testicle. It consists of a marked increase in the connective tissue of the organ. SURGICAL DIAGNOSIS. It may also accompany cysts of the testicle, or it may occur as an independent process, resulting in a painless and marked enlargement of the organ, as is common in the so-called " chronic enlargement" of the testicle, which possesses no distinctive symp- toms. It is questionable if this state of chronic indura- tion is not, in the majority of cases, a direct sequela to a chronic orchitis, the products of the inflamma- tion having undergone organization into connective tissue, instead of becoming absorbed. 9. Enchondroma of the Testicle. Cartilaginous tumors of the testicle are seldom unassociated with other textural changes Avithin that organ. Still, in rare cases, the deposit has been localized to so marked a degree as to constitute a separate or principal lesion. While this type of tumor is often associated with cancer of the testicle, yet it can doubtless be re- garded as in itself, non-malignant. 10. Benign Fungus of the Testicle, or "Hernia Testis." This term is used to express a condition of the tes- ticle, where a fungus groAvth protrudes from the tes- ticle and scrotum. The term " granular swelling " has been sometimes used to express this condition, but the mode of origin has caused the term " hernia tes- tis" to be more universally applied. This fungus growth consists of a protrusion of the glandular structure of the testicle through the tu- nica albuginea, the tunica vaginalis, and the adhe- rent scrotum. It results frequently from suppuration of the tes- ticle and ulceration of its coverings, as a sequela of chronic orchitis. It may, however, occasionally fol- low an acute suppurative process within the testicle, but these cases are uncommon. The fungus, on microscopical examination, is found to consist of the tubules of the testicle with intertu- bular changes, and granulations springing up from those tubules which are nearest to the surface. The tunica albuginea is thickened around the margin of the opening, through which the fungus DISEASES OF THE MALE GENITALS. 207 protrudes, the edges of Avhich are everted. The scrotum around the margin of the opening is indu- rated and thickened, and in some cases is under- mined. 11. Chronic Inflammatory Induration of the Testicle. This variety of disease, to which the term " chronic orchitis " is applied, is of surgical importance from its tendency to destroy the glandular structure of the testicle. It usually folloAvs an attack of simple acute orchi- tis whose duration has been prolonged by repeated attacks, or by excess in alcohol and venery, or trau- matism. It results in a gradual enlargement of the testicle without any markedly acute symptoms, and is more closely allied in its history to that of tubercular de- posit. It differs however from that disease in its primary seat, which is usually Avithin the body of the organ, as Avell as in its general pathological characteristics. It is a frequent cause of benign fungus of the tes- ticle from ulceration of the tunica albuginea. It is to be diagnosed from cancer of the testicle, tubercular orchitis, and haematocele of the testis. The testicle may present also the following conditions which are not accompanied icith an enlargement of the organ, but which are of surgical interest: 1. Arrested Development of the Testicle. 2. Congenital Malformations of the Testicle ; includ- ing Inversion of the testicle. Union of the testicles. Supernumerary testicle. Impervious vas deferens. 3. Congenital Absence of the Testicles : " cryptorchid- ism" 4. Neuralgia of the Testicle. 208 SURGICAL DIAGNOSIS. 5. Atrophy of the Testicle. 6. Incomplete Descent of the Testicle : " monorchidism." 7. Calcareous Deposits in the Testicle. Many of these affections can with difficulty be mistaken in diag- nosis, and will therefore be simply enumerated. In the following pages Avill be found contrasted, however, those diseases which con- stitute the principal sources of error in diagnosis. DISEASES OF THE MALE GENITALS 209 ACUTE ORCHITIS. NEURALGIA OF THE TESTIS. History. Is usually either of traumatic Is a frequent affection in weak origin, or is associated Avith a his- and nervous young men, and in tory of venereal disease. masturbators. It also is often as- sociated Avith varicocele and mala- rial conditions. Testicle. The testicle is swollen, but is not The testicle is retracted during retracted. the attack, if severe, but is normal in its size. Pain. The pain is constant and not par- The pain is paroxysmal in char- oxysmal. acter, and intense. It comes on gradually with the It comes and goes suddenly, Avith- swelling and disappears slowly. out premonition. Gastric Symptoms. Nausea and vomiting are infre- Nausea and vomiting are often quent. present. Effect of Pressure. Great tenderness on pressure ex- The testicle is painless on pres- ists, until the SAvelling or the acute sure during the intervals between symptoms disappear. the attacks. SYMPTOMS IN COMMON Both are associated with marked pain in the testicle. " maybe" " nausea and Aromiting. " " " " tenderness on pressure. 14 210 SURGICAL DIAGNOSIS. SYPHILITIC ORCHITIS. TUBERCULAR ORCHITIS. Location of Origin. Begins in the body of the testicle Begins in the globus major of the as a primary disease. epididymis, and involves the testicle secondarily. Age Affected. May exist at any age ; but seldom Occurs in early manhood, as a before puberty. rule. Extent. Is usually a unilateral disease. Is frequently a bilateral disease. Testicle. The testicle is regular in contour, The testicle is marked with hard, uniform in its consistence, and knotty nodules, but is soft and elas- harder than normal. tic between them. Hydrocele. Hydrocele is occasionally present. Hydrocele is a frequent compli- cation. Termination. Tends toAvards calcareous or fi- Tends towards cheesy degeneration brous degeneration, or atrophy. and suppuration after an interval. Ulceration and Fungus. Ulceration and fungoid growths Ulceration and fungoid growths are absent. are frequent in the last stages. FlSTULiE. Fistulae are seldom formed. Fistulae are frequently formed which heal after the gland has been evacuated. History. A history of syphilis exists, or A tubercular history is present, evidences of it are discovered in the and other organs are usually af- skin or the glands. fected. Sexual Desire. Sexual desire is decreased, but the Sexual desire is increased, but power of coition is usually slowly the power of coition is usually im- affected. paired. DISEASES OF THE MALE GENITALS. 211 MALIGNANT ORCHITIS. SYPHILITIC ORCHITIS. Age Affected. Affects all ages, even children. Is very rare before puberty. Previous History. No previous history of causation A history of syphilis, or some exists, evidences of it, is usually present. Seat of Origin. Begins in the body of the testicle, Begins in the body of the testicle, but grows rapidly. but grows slowly and painlessly. Characteristics of the Tuaior. The tumor ulcerates, and tends The tumor never ulcerates, nor to form a fungoid growth. tends to form fungoid excrescences. The tumor often hiAades the cord. The tumor seldom invades the cord. The tumor is not of uniform con- The tumor is uniform in consis- sistence. fence. Pain. The pain is severe and lancinat- Pain is seldom present. A sense ing in character during the latter of Aveight only exists. stages. Integument. The skin is always involved in its The skin is seldom involved. advanced stages. Fluctuation. Fluctuation is often detected over Fluctuation is absent. localized spots in the testicle. Effect of Castration. The tumor returns, as a rule, The tumor, if removed, never ex- after castration. hibits a tendency to return. 212 SURGICAL DIAGNOSIS. CYSTS OF TESTIS. HYDROCELE. Frequency. Is a rare malady. Is an extremely frequent disease. Size of Testicle. The testicle may be either en- The size of the scrotum is always larged or diminished in size. increased ; but the testicle is un- affected as to its size. Tuaior. The tumor consists of a localized The tumor begins from below swelling which may be situated in and extends upwards. different parts of the testicle. Translucency. The tumor is not translucent. The tumor is translucent on placing a lighted candle behind it. Fluctuation. The fluctuation, if perceived, is Fluctuation is well marked, and very indistinct. It may often be is always detected. absent. Veins of Cord. The veins of the cord are enlarged The veins of the cord are normal and varicose. in their appearance. SYMPTOMS IN COMMON. Both are associated Avith slow development. " " " " absence of pain. " " " " oA'al or globular form. " " " " smoothness of the surface. " " " " elasticity. " " " " fluctuation. DISEASES OF THE MALE GENITALS. 213 BENIGN FUNGUS OF TES- CANCER OF TESTICLE, WITH TICLE (Hernia Testis). FUNGUS. Definition. Is a protrusion of the tubular Is a rapidly increasing growth, structure of the gland through the possessing no resemblance to the coverings of the testicle and scro- glandular structure of the testicle. tum. Appearance of Tuaior. The tumor has a neck Avhich is The constriction at the neck is markedly constricted. not well marked. Surface of Tumor. The surface is granular, but is The surface is friable in its tex- firm in its texture. ture. Effects of Pressure. The tumor is painless to the The testicle fails to yield the nor- touch, but the testicle is normally mal " sickening sensation " on pres- affected by pressure. sure. Pain. The pain is severe until protru- The pain is of a violent and lan- sion occurs, when it ceases. cinating character. Character of the Discharge. The discharge from the fungus Hemorrhage is frequent from its often contains spermatozoa. surface, especially when handled ; and the discharge is profuse and foetid. Location. The disease is always unilateral. The disease may be bilateral. COAIPLICATIONS. The skin, spermatic cord, and The integument, spermatic cord, neighboring glands are usually nor- and neighboring glands are usually mal. involved. General Health. The general health may be good. A marked cachexia exists. 214 SURGICAL DIAGNOSIS. ORCHITIS. EPIDIDYMITIS. Frequency. Is a very rare affection. Is extremely common. History. Is produced by mumps, cold, Is almost invariably associated gout, traumatism, etc., etc. with urethral disease or irritation. Pain. The pain is excruciatingly severe, Pain is usually of moderate se- even in cases of moderate enlarge- verity, except in extreme enlarge- ment, and is not relieved by position, ment, and is relieved by position. Shape of Tuaior. Is usually associated with an oval The shape is often modified by tumor. scrotal oedema. Effects upon Testicle. The testicle is extremely hard The body of the testicle is, as a and very sensitive to pressure. rule, normal. If complicated, it is less sensitive than orchitis. The epididymis is not distinguish- The epididymis always becomes able from the rest of the tumor. distinguishable Avhen the disease is in its decline, although often ob- scurely so at its height. Hydrocele. Hydrocele is rare as a complica- Hydrocele is ahvays present in tion. acute cases. Course of Disease. The disease is slow in its progress. The disease is usually rapid in its progress. Constitutional Syaiptoais. The constitutional symptoms are The constitutional symptoms are often marked. absent, or unimportant. DISEASES OF THE MALE GENITALS. 215 ORCHITIS EPIDIDYMITIS (continued). (continued). Methods of Termination. Resolution, abscess, gangrene, Resolution with chronic thick- atrophy, or chronic induration may ening of epididymis usually takes occur. place. Effects on Function. Impotence may result if both Temporary sterility may occur, sides have suffered destruction of but never impotence. tissue. (" Genito-Urinary Diseases and Syphilis," Van Beuren and Keys.) 216 SURGICAL DIAGNOSIS. TABLE FOR THE DIAGNOSIS OF DISEASES OF TESTICLE. SYPHILITIC TESTIS. Rare before pu- berty. Syphilitic. Begins in the tody of the testicle. Unaffected. Slow lent. and indo- Skin rarely in- volved. Suppuration rare. Hydrocele com- mon. No pain present; a sense of weight only is perceived. Irregular at first, but ultimately smooth. Hard and stony. Seldom affected. TUBERCULAR MALIGNANT TESTIS. TESTIS. Age Affected. Early manhood All ages are af- and youth. fected, but youth most frequently. History. Scrofidous. No cause or pre- vious history of dis- ease exists. Seat of Origin. Begins in the glo- Begins in the body bus major of the of the testicle. epididymis. General Health. Usually impaired. Impaired in the last stages. Progress of Development. Slow in growth. Rapid in its growth. Skin becomes in- volved before sup- puration. Suppuration pres- ent. Hydrocele infre- quent. Pain in Absent until sup- puration commen- ces. Surface of Nodular and knot- ty throughout. Skin involved in its late stages. Ulceration and fungus growth fre- quent. Hydrocele infre- quent. Testicle. A severe and lan- cinating pain is al- ways present in the last stages. the Tumor. Smooth but un- even. Consistence of Tumor. Hard and resist- Soft and fluctu- ant, ant in spots. Epididymis. Begins in it, and Extends to it in is affected through- the last stages. out the disease. SARCOMA OF TESTIS. Early manhood. No history; cause unknown. Begins in the body of testicle. Unimpaired till late in disease, if ever affected. Very slow, but often becoming sud- denly rapid. Skin unaffected. No suppuration or fungus growth. Hydrocele rare. No pain. Slightly uneven. Fluctuant in spots. Is seldom involved. DISEASES OF THE MALE GENITALS. 217 SYPHILITIC TUBERCULAR MALIGNANT SARCOMA OF. TESTIS. TESTIS. TESTIS. TESTIS. (Continued.) Scrotal Veins. Unchanged. Normal. Enlarged and va-ricose from pressure of inguinal glands. Normal. Size of Tumor. Comparatively Never very large. May be immense. May be very large. small. Effect of Pressure. No pain or any No pain ou pres- Pain aggravated No pain ; but sensation on pres- sure. by handling tumor. squeezing the testi- sure. cle produces faint-ness. Number of Testicles Affected. Both testicles of- Both testicles of- Only one testicle One testicle only ten consecutively at- ten attacked in suc- is, as a rule, affect- is involved. tacked. cession. ed. Fungus Growth. Is very rare. Is very common; Is constant in the No fungus ever and is pale, soft, and advanced stages. exists. bleeds easily. Pus Fungus bleeds thin. Sinuses exist profusely. leading into testicle. Fungus discharge is bad-smelling and ichorous. Fungus grows Fungus grows ra- slowly. pidly. Fungus is pain- Fungus is very less. painful. Duration. Several years. Several years. Average is about Indefinite dura- two years. tion. Prognosis. RecoATery, if well Radical cure rare. Bad prognosis. Good prognosis if treated. Kills by hemor- removed. If left, rhage, cachexia or may become cancer. return after castra- tion. Termination. Calcareous degen- Suppuration, for- Ulceration and Cancerous degen- eration, mation of fistulae, fungoid growth. eration, or station- Fibrous degenera- and evacuation of ary condition. tion. the testicle. Atrophy. 218 SURGICAL DIAGNOSIS. HEMATOCELE. HYDROCELE. Rapidity of Development. The tumor develops rapidly if of The tumor develops slowly. traumatic origin, but slowly if spon- taneous in character. History. A history of traumatism is fre- No history of injury exists. quently present. Fluctuation. Fluctuation is detected at first, Fluctuation is well marked at all but soon disappears, as coagulation times and over all portions of the of the blood renders the tumor hard tumor. and non-fluctuant. Shape of Tumor. The tumor is pyriform in shape. The tumor is usually ovoid in shape. Effect of Transmitted Light. The tumor is opaque, as shown The tumor is translucent, save at by a lighted candle placed behind the posterior portion, where the tes- it. tide is usually present. Appearance of Skin. The skin is usually discolored. The skin is normal in color. Constitutional Syaiptoais. Pallor, prostration, and general No symptoms referable to hemor- evidences of loss of blood exist. rhage are detected. Weight of Tuaior. The tumor is heavy in Aveight. The tumor is light in weight. Spermatic Cord. The cord is free and unaffected The spermatic cord is sometimes in the majority of cases. involved. DISEASES OF THE MALE GENITALS. 219 DISEASES OF THE TUNICA VAGINALIS AND OF THE SPERMATIC CORD. The tunica vaginalis, or the serous covering of the testicle, may contain within its normal cavity either effused blood, constituting haematocele, or an excess of its natural secretion, constituting the disease termed hydrocele. The first of these has already been considered under diseases of the testicle, although it may properly be also classified as a disease of the tunica vaginalis. The second condition, viz. : that of hydro- cele, may be of several distinct anatomical varieties. Hydrocele may be classified into 1. Simple Hydrocele. This condition is the direct re- sult of inflammatory processes occurring in the tu- nica vaginalis and the sub-serous cellular investment. The inflammatory process is, in the majority of cases, essentially of the chronic variety. The testi- cle is found enclosed, or rather displaced by the dis- tended sac, which contains an amber-colored fluid, and is usually located at the posterior portion of the scrotal tumor, rather beloAV its centre. This position of the testicle, although present in the large majority of cases, is not always insured. Old adhesions in the serous coverings of the testicle from previous inflammation often retain that organ in some particular locality, and the fluid is thus forced to accumulate in some special direction. It is thus probably that the so-called " Multi- locular Hydrocele " is produced, in which distinct cysts, having often no communication with each other, are detected. Hydrocele is without doubt the most common disease of the testicle or its coverings. It affects all ages and all ranks of life. It is most common, how- ever, in infancy and in middle life, and occurs in warm climates more frequently than in cold regions. It is generally unilateral, and the left side is most frequently affected. The exciting causes of the disease seem to include SURGICAL DIAGNOSIS. anything which will disturb the nicely adjusted balance betAveen the functions of secretion and ab- sorption. Thus, all causes exciting an abnormal determination of blood to the part, or impeding the free venous return, may result in this condition from interference with the circulation within the gland or its coverings. The dependent position of the left testicle, and the absence of a direct venous return on the left side, afford an explanation of its frequency on that side of the scrotum, although the pressure exerted by the sigmoid flexure of the colon upon the spermatic veins, is also advanced as a possible exciting cause. Hydrocele is usually developed after a violent strain, or great fatigue, or after a slight blow upon the gland Avhich was considered, at the time, as trivial. It may also accompany hydraemia, and may result from sympathetic connection with chronic diseases of the urethra or bladder. If hydrocele is accompanied by an enlargement of the testicle, the condition is often distinguished by the term " Hydro-Sarcocele." 2. Congenital Hydrocele. This condition occurs from an imperfect closure of the canal betAveen the cavity of the peritoneum and that of the tunica vaginalis after the testicle has descended. The opening re- maining is usually small in size, and the fluid which accumulates seems to be due to gravity of the peri- toneal effusion. A rare form of disease, resembling a congenital hydrocele, accompanies a late transition of the testicle when no hernial protrusion simultaneously occurs. Congenital hydrocele is to be confounded with a reducible intestinal hernia, and with ordinary hy- drocele. 3. Encysted Hydrocele of the Testicle. In this form of hydrocele, fluid is effused into an adventitious cyst, or cysts, distinct from the cavity of the tunica vaginalis. They may be developed in one of two situations: DISEASES OF THE MALE GENITALS. 221 either at the epididymis beneath the visceral layer of the tunica vaginalis, or beneath that portion of the tunica vaginalis covering the body of the testicle. The first is by far the more common, the latter being very rare. The cysts of the epididymis often become pedun- culated, but if so, seldom exceed the size of a pea. They usually contain a small amount of fluid, and are hard and semi-transparent. They are quite common after the age of forty. "When " encysted hydrocele of the epididymis " at- tains, however, a large size, without undergoing pe- dunculation, the testicle is usually displaced to the bottom of the sac; rarely, if ever,- to its posterior portion. The tumor is smaller than an ordinary hydrocele, and seldom exceeds four ounces in con- tents, although the size may, in rare instances, equal that of a large hydrocele. These cysts are fre- quently multiple, and their contents are either straw-colored and albuminous ; or they may be thick, turbid, and filled with coagula. When the body of the testicle becomes the seat of this disease, the term "encysted hydrocele of the tunica vaginalis" is applied, in contradistinction to simple multilocular cysts, due to adhesions within the cavity of the serous investment of the testis. They enclose a milky fluid, and often contain spermatozoa, probably introduced by a rupture of the tubules of the testicle from over-distension. Encysted hydrocele, in general, is characterized by an imperceptible origin, by a slow and painless growth, and by a stationary condition, after attain- ing a moderate size, which often remains for years producing no inconvenience or pain. It is to be confounded only with localized hydro- cele from adhesions, but the aspirator will usually decide this question by the character of the fluid contents of the tumor. 4. Diffuse Hydrocele of the Spermatic Cord. This af- fection is described by Pott, under the denomination of hydrocele of the cells of the tunica communis. SURGICAL DIAGNOSIS. The disease partakes largely of the character of an ordinary oedema diffused throughout the loose connective-tissue of the spermatic vessels, and of the cord, and is enclosed in a layer of compressed tissue, invested by the musculo-aponeurotic structure of the cremaster muscle. The base of the tumor corresponds to that point where the spermatic vessels join the testicle, and is cut off, at this point, by a dense septum from com- munication with the tunica vaginalis. It frequently extends along the cord, and may, in rare cases, enter the abdomen. The tumor is smooth, uniform, and nearly cylindrical in shape. It is a comparatively rare disease, and is produced by obstructed venous return, as exists in case of local pressure from enlarged inguinal glands etc., etc. It is to be diagnosed from omental hernia, and from encysted hydrocele of the cord. 5. Encysted Hydrocele of the Spermatic Cord. This condition is the result of the formation of a distinct cyst, or cysts, within the loose cellular or connec- tive tissue of the spermatic cord. It is usually oval in form, seldom if ever exceeds the size of a hen's egg, and is usually much smaller. It is situated in one of four locations : either just above the testicle, at the external ring, in the mid- dle portion of the cord, or in the inguinal canal. It is usually a solitary cyst, but in some cases multi- ple cysts are formed. It is due, probably, to a partial or imperfect oblite- rcdion of the peritoneal prolongation which accom- panies the testicle in its descent into the scrotum, resulting in an isolated sac, or a succession of pouches being left, which becomes distended with serous fluid. It is of gradual and slow development, and may possess obscure and indistinct fluctuation. It can be handled without pain, and is often more or less transparent. It is quite freely movable in the longitudinal direction of the spermatic cord. It is frequent in infants, but may exist at all stages in life. DISEASES OF THE MALE GENITALS. 223 It is to be diagnosed from encysted hydrocele of the testicle, if close to the gland, by its mobility and its separation from the testicle Avhen drawn upwards, and from the character of its fluid con- tents. When in the inguinal canal it may be mistaken for a hernia. 6. Varicocele of the Spermatic Cord and Testicle. The term " Varicocele " is used to designate a vari- cose condition of the spermatic veins within the scrotum, Avhile the term Cirsocele is used to denote a varicose condition of the veins of the cord and testicle. The two terms are, hoAveArer, often used synonymously to express any abnormally varicose condition of the spermatic veins independent of the location affected. In this disease, the venous coats are thickened so as to resemble arteries in their structure, and their course is rendered tortuous and irregular. The calibre of the veins is increased by dilatation of their coats, and the apparent number of the veins is largely increased by the distension of venous capil- laries. The disease is most frequent upon the left side, the proportion being nearly twenty to one. The causes of this excessive frequency upon the left side have been thus explained : 1st. The left testicle hangs lower in the scrotum, and thus the veins of the left side support a heavier column of blood. 2d. The spermatic veins of the left side are pressed upon by the sigmoid flexure of the colon when distended. 3d. The spermatic vein of the left side joins the renal vein at a right angle to the current of blood, thus impeding the rapid return of blood from the left testicle. 4th. The left spermatic vein is by some authorities stated to be poorly supplied with valves; but the 224 SURGICAL DIAGNOSIS. anatomical accuracy of the statement is question- able. Varicocele, as a disease, may result from A. Causes which impair the general vigor of the parts. Under this head may be included 1. Masturbation. 2. Abuse of venery. 3. Chronic orchitis, or repeated attacks of acute orchitis. 4. Lack of proper support from a relaxed scrotum. B. Causes producing varicocele from pressure. Under this head may be included 1. Abdominal tumors. 2. Enlarged lumbar or inguinal glands. 3. Hernia. 4. Trusses, or belts worn around the waist. 5. Accumulation of fat in the omentum and mesentery. C. Causes producing varicocele by muscular effort. This class of causes may include 1. Prolonged riding on horseback. 2. " rowing. 3. exercise, in running, waltzing, etc. 4. Excessive and violent muscular efforts. 5. Whooping-cough. Varicocele occurs most frequently at the time of puberty. If due to mechanical pressure, it is most frequent in those ad- vanced in life. It is a very common affection, and is indicated by a tumor possessing the appearance and feel of a "bag of worms," associated with a sense of weight and local distress, which increases as night approaches, from the relaxation of the scrotum. A sense of immediate relief is present after coition, but a severe exacerbation of the symptoms follows during the succeeding twenty- four hours. Varicocele is to be diagnosed from scrotal hernia, with which it has many points in common. 7. Lipoma of the Spermatic Cord. Fatty tumors usually DISEASES OF THE MALE GENITALS. 225 form in front of the spermatic vessels, as a loose and movable tumor, having a soft, doughy feel, and a lobular appearance. They may be mistaken for a hernia of omentum. They possess no distinctive symptoms, and are a source of little, if any, incon- venience. 8. Spasm of the Cremaster Muscle, causing Retraction of the Testicle. This occurs in some diseases of the kidney, in the passage of a renal calculus, and in affections of the prostate gland. In all cases it is the direct result of nervous irritation transmitted from other parts. It may be associated in some instances with a local injury to the groin, and may occur when the testicle or epididymis becomes sympathetically inflamed, from an existing ure- thral lesion. It is of diagnostic value as con- firmatory evidence only when the history of the exciting disease is obscure. 15 226 SURGICAL DIAGNOSIS. HYDROCELE. SCROTAL HERNIA. Development of Tumor. The tumor develops slowly. The tumor develops suddenly, in the majority of cases. History of Tumor. The tumor appeared first at the The tumor developed from above bottom of the scrotum, without doAvnwards, after a strain, injury, cause. etc. Density of Tuaior. The tumor is very hard and The tumor may be hard or elastic. doughy, but is ne\rer elastic. Effect of Light. The tumor is translucent. The tumor is opaque. Inguinal Canal. The inguinal canal is empty. The inguinal canal is filled. Spermatic Cord. The spermatic cord is easily felt. The spermatic cord is concealed. Percussion. The percussion note over the The percussion note over the tumor is fiat. tumor is usually resonant. Fluctuation. Fluctuation is apparent. Fluctuation is absent. Cough Impulse. No impulse, on coughing, is per- A cough impulse is perceptible, ceived in the tumor. as a rule, Avithin the tumor. Auscultation. No gurgling is heard within the Gurgling within the tumor is tumor. often detected. Constipation. The function of the alimentary Constipation may result from the canal is unimpaired. displacement of the intestine. Reducibility. The tumor cannot be reduced. Reduction is possible. DISEASES OF THE MALE GENITALS. 227 VARICOCELE. SCROTAL HERNIA. Palpation. The tumor is knotty and irregular The tumor is usually smooth on and feels like " a bag of worms." its surface and regular in its out- line. Color of Integument. A bluish tint is usually present. The integument is normal in color. Location. Is most frequent on the left side. May exist on either side. Effect of Heat. Tumor increases on the applica- The effects of heat upon the tion of heat. tumor are negative. Developaient. Gradual. Sudden. Percussion. A dull percussion note exists over Resonant percussion usually ex- the tumor. ists. Fluctuation. May exist if the vessels be very Never exists. large. Speraiatic Cord. Not affected. Concealed or displaced. Inguinal Canal. Uninvolved. Usually filled. Cough Impulse. Absent. Usually detected. Reduction. Reduces often spontaneously by Reduction is usually accomplished any position favoring increased ve- by taxis alone. nous return. 228 SURGICAL DIAGNOSIS. VARICOCELE SCROTAL HERNIA (continued). (continued). Return of Tumor. The tumor returns when the pa- The tumor, if once reduced, can tient stands up, in spite of pressure be prevented from a return by pres- at the ring. sure at the external ring. Sensation in Scrotuai. A sense of weight, and of constant There is a sense of distension only, dragging in the scrotum, exists. . unless inflammation or strangula- tion exist. DISEASES OF THE MALE GENITALS. 229 HYDROCELE, ENCYSTED. CYSTS OF TESTIS. Location. Are most commonly located at Are most commonly situated in the epididymis, but may rarely af- the body of the testicle. feet the body of the testicle. Pedicle. The cysts are of ten pedunculated. The tumor is rarely peduncu- lated. Number. The tumors are frequently mul- The tumor is usually single. tiple. Size of Tuaior. The tumors are usually quite The tumor is usually of the size small in size, but may, in rare cases, of a pigeon's egg when fully de- reach a fluid contents of four veloped, and seldom exceeds it. ounces. Development. The tumors grow slowly and pain- The tumor grows slowly, but is lessly, as a rule, and are often sta- often associated Avith enchondroma- tionary in size for years. tous deposits. Contents. The tumor, if located on the body The tumor seldom if ever con- of the testicle, usually contains tains spermatozoa. An albuminous spermatozoa, but if on the epidi- fluid and coagula are however fre- dymis an albuminous fluid and oc- quently present. casional coagula are withdraAvn on aspiration. Frequency. These tumors are not uncommon Is a rare affection. after the age of forty years. 230 SURGICAL DIAGNOSIS. HYDROCELE. CONGENITAL HERNIA. Age Affected. May affect any age; and, if in Is usually a disease of infant adults, is not necessarily associated life ; but if once present, subse- with a history of a previous attack. quent attacks in adult life may oc- cur. Fluctuation. The tumor is markedly fluctuant The tumor is usually fluctuant in all of its localities. at its upper portion since the peri- toneal effusion gravitates. Translucency. The tumor is always translu- The tumor may be translucent. cent. Pedicle. The tumor is not pediculated. The tumor has a marked pedicle. Shape of Tumor. The tumor is pyriform. The tumor is globular. Development. The tumor always develops slow- The tumor may be of sudden oc- ly and gradually. currence, or may show sudden and rapid increase in its size Avhen once developed. Inguinal Canal. The inguinal canal is empty. The inguinal canal is either dis- tended or involved. Reducibility. The tumor cannot be reduced. The fluid portion, when reduced by taxis or pressure, leaves a previ- ously concealed testicle, which also reduces with a marked gurgle and occasions a peculiar sichening sen- sation during its passage through the inguinal canal. DISEASES OF THE MALE GENITALS. 231 HYDROCELE OF THE CORD. INGUINAL HERNIA. Liaiits of Tuaior. The tumor is circumscribed. The tumor is frequently scrotal, and is generally diffused. Palpation. The tumor is tense. The tumor is soft, as a rule. Reducibility. The tumor is usually irreducible, The tumor reduces with a gur- but if not so no gurgle is present gle. on its reduction. Translucency. The tumor is often translucent. The tumor is opaque. Fluctuation. The tumor is fluctuant. The tumor does not fluctuate. Percussion. The percussion note is dull over The percussion note is resonant the tumor. over the tumor, as a rule. Bowel. No intestinal embarrassment ex- Intestinal embarrassment is often ists. present. Impulse from Testicle.. The testicle, if moved, transmits Movements of the testicle have an impulse to the tumor. no effect upon the tumor. Cough Iaipulse. Impulse on coughing is absent. An impulse on coughing is fre- quently felt in the tumor. Auscultation. No gurgling is detected. Gurgling is often heard in the tumor. Return after Reduction. The tumor returns after reduc- The tumor remains reduced if the tion irrespectiA^e of position. dorsal position is maintained. 232 SURGICAL DIAGNOSIS. HYDROCELE. HEMATOCELE. Rapidity of Development. The tumor develops sloAvly. The tumor develops rapidly if of traumatic origin, but slowly if spon- taneous in character. History. No history of injury exists. A history of traumatism is fre- quently present. Fluctuation. Fluctuation is well marked at all Fluctuation is detected at first, times and over all portions of the but soon disappears, as coagulation tumor. of the blood renders the tumor hard and non-fluctuant. Shape of Tuaior. The tumor is usually ovoid in The tumor is pyriform in shape. shape. Effect of Transaiitted Light. The tumor is translucent, save at The tumor is opaque, as shown the posterior portion, Avhere the tes- by a lighted candle placed behind tide is usually present. it. Appearance of Skin. The skin is normal in color. The skin is usually discolored. Constitutional Symptoms. No symptoms referable to hemor- Pallor, prostration, and general rhage are detected. evidences of loss of blood exist. Weight of Tuaior. The tumor is light in weight. The tumor is heavy in weight. Speraiatic Cord. The spermatic cord is sometimes The cord is free and unaffected involved. in the majority of cases. DISEASES OF THE MALE GENITALS. 233 DISEASES OF THE BLADDER. The diseases and the surgical conditions which may affect the bladder may be thus enumerated: A. Malformations of the Bladder, under which head may be included 1. Deficiency of the Bladder, in which the ureters open directly into the urethra, or, as in some re- ported cases, the ureters may enter the rectum, and thus discharge the renal excretion. In the female sex a few cases have been reported where the ureters communicated directly with the vagina. 2. Multiplicity of Bladders. Tavo well-known reported cases are on record illustrating this malformation. In one, that of Blasius, tAvo Avell-defined sacs existed, into each of which one ureter emptied; in the other, that of Molinetti, five bladders, five kid- neys, and six ureters, are said to have existed in one woman. It is probable that many cases of sacculated blad- der from long-standing disease may have been mis- taken for this deformity. 3. Extroversion of the Bladder. This condition is not one of extreme rarity. It is often associated with absence of the pubes, and is due to a congeni- tal absence of the anterior wall of the bladder. A protrusion of its posterior surface, which is red in appearance, is caused by the pressure of the ab- dominal viscera upon it, and appears as a small vascular flattened tumor. The extroverted portion usually reveals the open- ings of the ureters near its centre, and a small rudi- mentary penis in the male is apparent at its loAver margin. In many cases a small pouch, covered with hair, exists, either on the side of, or below the tumor, which, in the male, contains the testicles, 234 SURGICAL DIAGNOSIS. and, in both sexes, often a hernial protrusion of the bowel. The tumor is extremely sensitive to the touch, often bleeds on slight irritation, and is continually moistened Avith the urine, which escapes from the open ureters. This escape of urine not only produces a urinous odor to the patient, but also results in excoriation of the neighboring parts. B. Diseases associated with Structural Changes within the Bladder, under which head may be included 1. Inflammatory Conditions of the Bladder : Acute Cystitis. Chronic " Ulceration. Suppuration of the vesi- cal walls. Gangrene. 2. Hypertrophy of the Vesical Walls, associated often with sacculation of the bladder, and resulting from obstructed outlet. 3. Tumors of the Bladder Fibrous \ -^ , ., ( Polypoid. Villous. Epithelioma. Malignant. 4. Bar at the Neck of the Bladder. This occurs chiefly in elderly subjects, and may be due to pros- tatic enlargement, or may be independent of it. 5. Hernia of the Bladder: "Cystocele." Is a rare condition, and occurs as an inguinal hernia in the male, and as a femoral or vaginal hernia in the female. 6. Inversion of the Bladder. This condition occurs rarely, and usually affects children, especially those of the female sex. The bladder is seen to protrude through the urethra. 7. Rupture of the Bladder. This accident occurs from direct or indirect violence, from an obstructed ure- DISEASES OF THE MALE GENITALS. 235 thra, or from weakening of the vesical walls from disease. 8. Calculi in the Bladder. These are dependent upon some abnormal condition of urine or the organs containing it. They may be movable or encysted. 9. Foreign Bodies in the Bladder. These are usually introduced, per urethra, by the patient, either by accident or to elicit sympathy. 10. Tubercle of the Bladder. This occurs rarely and ahvays with similar changes in the prostate gland and the kidney. C. Conditions of the Bladder, not necessarily associated with Structural Changes in that Organ. This class of abnormal conditions of the bladder includes 1. Paralysis of the Bladder. This condition depends upon the existence of some cerebral or spinal lesion. It may follow injury, cerebral or spinal apoplexy, softenings or degenerative changes in the brain or the spinal cord, sexual excesses, shock, fevers, reflex irritation, or poisons. 2. Atony of the Bladder. This condition frequently accompanies any source of obstruction to the free evacuation of the bladder. It may also follow pro- longed voluntary retention of urine, cerebral and spinal affections, fevers, and temporary spasm. 3. Spasm of the Bladder. This condition is seldom un- associated with an exciting cause, as inflammation, calculi, foreign groAvths, etc. It is indicated by in- voluntary, uncontrollable, and exceedingly painful contractions of the bladder. 4. Neuralgia of the Bladder. This is a rare condition. It is associated with many symptoms indicative of stone in the bladder, and is to be diagnosed from it only by the exclusion of that disease. 5. Retention of Urine. This condition may exist in the young, middle-aged, or the old. It usually results from prostatic inflammation, urethral stricture, stone in the bladder, prostatic enlargement, foreign bodies in the urethra, urethral spasm, and urethral rupture. 236 SURGICAL DIAGNOSIS. It may also occur from pressure of pelvic tumors, fracture of the pelvic bones, shock and reflex irrita- tion. 6. Incontinence of Urine. This is a very frequent con- dition of childhood, but may also affect adults. In adults it occurs most frequently in females, as sloughing from pressure, use of instruments in labor, and over-distension of the urethra in removing cal- culi are frequently followed by it. In men it is seldom unassociated with retention of urine, and is therefore, properly speaking, an overflow rather than pure incontinence. 7. Overflow of Urine. This, condition results from an habitual engorgement of the bladder, resulting from a retention of its own secretion. It frequently results from, or accompanies chronic prostatic enlargement, or organic urethral stricture, and is usually first noticed during sleep, although subsequently any movements requiring the action of the abdominal muscles may produce it, by pressure upon the habitually distended bladder. Many of these conditions require no special guides to diagnosis, their simple enumeration being sufficient to prevent confusion; many may also co-exist, since they are often dependent upon each other not only for their origin, but also for their continuance, and thus variations in the symptoms may be produced, which it is diffi- cult to clearly elucidate. As examples of this, we seldom discover a calculus without inflammatory changes within the bladder, and often lesions of a more advanced character are present; again, re- tention of urine may result from structural disease within the bladder, or, if originally independent of disease within that organ, may excite the same by urinary decomposition or by simple dis- tension of the bladder itself. Inflammatory conditions also, or the presence of obstruction to the free drainage of urine, as from tumors, enlarged prostate, cancer, etc., may, in time, result in the formation of a calculus, the nucleus of which originated either as a plug of mucus, coagulated blood, or an aggregation of urinary salts, precipitated by the am- moniacal reaction of the urine. It is difficult therefore, as evidenced by these few examples, to DISEASES OF THE MALE GENITALS. 237 draw marked contrasts between diseases which are so often com- plicated, and Avhich present, in consequence, the combined symp- toms of two affections. Besides, many of the structural changes within the bladder, or its congenital deformities and malformations, cannot be positively diagnosed during life, although suspicion may be strongly directed towards the possibility of their existence. I have arranged therefore, in the form of differential tables, only such conditions of the bladder as seem to me most liable to be con- founded in a general surgical practice, or to be capable of accurate and positive diagnosis. 238 SURGICAL DIAGNOSIS. CANCER OF THE BLADDER. STONE IN THE BLADDER. Pain. The pain is lancinating in char- The pain is never lancinating in acter, and is felt in the pelvis, rec- character, and is felt chiefly in the tum, back, or hip. penis. The pain is increased by pressure The pain is often increased by and catheterism. motion or exercise, but is not affected by catheterism. Intestinal Symptoms. Intestinal obstruction is frequent. Intestinal embarrassment is rare. Hemorrhage. Hemorrhage is frequent and often Hemorrhage is less frequent and severe. profuse. Tumor. A tumor is felt per rectum which A tumor may be detected per rec- is immovable. tum, and, if so, it is movable. Urine. Blood, pus, cancer cells, organ- Pus, blood, and crystalline de- ized tissue, etc., are often mixed posits are found often in the urine. Avith the urine. Age. Occurs after the fiftieth year of age. Occurs at any age. History. Dyspeptic gastric derangements An attack of renal colic is fre- often precede its development. quently the apparent commence- ment. Cachexia. A marked cachexia exists. No cachexia is present. SYMPTOMS IN COMMON. Both are associated Avith pain in expelling the last drops of urine, " " " " frequent interruption of the stream. " " " " frequent hematuria. " " " (i pus in the urine. " " " " pain independent of micturition. DISEASES OF THE MALE GENITALS. 239 RUPTURE OF THE BLADDER. RETENTION OF URINE. Percussion. Dulness on percussion over the Dulness over the seat of the blad- bladder is either absent, or diffused der ahvays exists, and is markedly beyond its normal limits. circumscribed. Pain. The pain is not localized, but is The pain is severe, but is local- rather that of a general peritonitis, ized in the vicinity of the bladder. History. A history of traumatism, falls, or A history of urethral stricture, severe abdominal contraction upon calculus, or nervous causation is a distended bladder, exists. most frequent; but traumatism may produce it. Origin. A sense of tearing is often per- No sensation of rupture is pro- ceived by the patient. duced. Catheterisai. A catheter, if introduced, either A catheter, if introduced fully fails to reach the urine, or collects into the bladder, ahvays discloses abnormal quantities if the peritoneal urine and affords immediate relief. cavity is filled. Urine. The urine, drawn by the catheter, The urine is generally normal or is frequently albuminous from ad- ammoniacal, in case its decomposi- mixture of peritoneal effusion, but tion has occurred within the bladder no casts are detected unless a kidney from prolonged retention. complication exists. Injection of Fluid. If water or milk be injected into The bladder is found, on explora- the bladder through a catheter no tion, to be distended after injection distension of the bladder is produced of fluids through a catheter. as revealed by a searcher. Sequels. Peritonitis always follows unless No serious results follow, if relief the abdomen be opened, the peri- is not too long delayed. toneal ca\rity Avashed out, and the rent closed by suture. 240 SURGICAL DIAGNOSIS. RETENTION OF URINE. SUPPRESSION OF URINE. Pain. Great pain, in the region of the Pain in the bladder is absent. bladder, results from distension. Percussion. Dulness on percussion exists over No dulness, over the bladder, is the distended bladder. detected on percussion. Tenesmus. Great desire to micturate and No vesical tenesmus, or desire to vesical tenesmus are present. micturate, exists. History. A history of urethral stricture, A history of injury over the kid- direct injury to the urethra, impac- ney, surgical procedure, severe ex- tion of a calculus, or some local or posure, or some infectious disease, nervous cause, is present. etc., is usually present. Catheterism. A catheter, when introduced, No urine in the bladder is usually affords relief by a withdrawal of the detected by the introduction of a retained urine. catheter, nor is relief of symptoms produced in case a small amount of residual urine is discovered and withdrawn. Constitutional Effects. No constitutional effects are pro- A urinous odor of the skin exists, duced, provided the condition be and rapid symptoms of uraemia de- not complicated Avith urinal or local velop. changes. DISEASES OF THE MALE GENITALS. 241 RETENTION OF URINE. INCONTINENCE OF URINE. Urinal Escape. The urine is totally arrested, none There is a continual escape of escapes. urine. Bladder. The bladder is found to be dis- The bladder may be occasionally tended, by percussion over its seat, found empty, but is generally dis- tended, as revealed by percussion. Catheterism. Relief is always afforded by the The bladder, if distended with introduction of a catheter. urine, will be relieved by catheter- ism. Exploration of Bladder. No alteration in the neck of the In cases of true incontinence, the bladder nor change from its normal bladder will have a defective power poAver of retention of injected fluids, of retaining fluids, as revealed by will be discovered. artificial distension by means of in- jection into its cavity. Age Affected. Is frequent in middle life and in Is most frequent in youth and old age, but is infrequent in youth, old age. Urethral Exploration. Urethral stricture or prostatic en- The urethral canal is often of largement is frequently detected, on normal calibre, and free from dis- exploration of the urethra, as an ease. exciting cause of retention. 16 242 SURGICAL DIAGNOSIS. ACUTE CYSTITIS. STONE IN THE BLADDER. Invasion. The invasion of cystitis is often The approach of symptoms, due sudden and accompanied by acute to a calculus, is often insidious and symptoms as rigors, fever, vomit- dates from a previous attack of re- ing, anxiety of countenance, etc. nal colic, in the majority of cases. Pain. The pain may be located above The pain is most frequently lo- the pubes, in the perineum, neck of cated in the glans penis. bladder, loins, or thighs. The pain is of a burning charac- The pain is most increased by ter and is rendered acute by pres- exercise, horseback riding, etc., and sure. during micturition, in some cases. Bladder. The bladder is extremely irritable The bladder retains urine easily, and cannot retain urine. unless a complicating cystitis exist. Catheterism. The introduction of instruments The effects of catheterism are ne- into the bladder produces great gative, as a rule. pain. Urine. The urine contains mucus in The urine may contain pus, large quantities, often blood and blood, crystalline salts, or it may pus. It is frequently alkaline in be normal in its appearance and re- its reaction. action. SYMPTOMS IN COMMON. Both are associated with pain in region of bladder. " may be " " urinal changes. " " " " frequent and often painful micturition. DISEASES OF THE MALE GENITALS. 243 PARALYSIS OF THE BLADDER. ATONY OF THE BLADDER. Definition. Is a condition dependent upon a loss of, or impaired contractile power of the organ from imperfect ner- vous supply. Is a condition of temporary loss of contractile poAver, resulting from obstruction to the free evacuation of the organ, or impaired nutrition. Origin. Paralysis of the bladder is to be diagnosed chiefly by its origin. It may ensue from 1. Injuries to the brain. 2. " " spinal cord. 3. Softening of nerve centres. 4. Apoplexy of neiwe centres. 5. Functional derangements of nerve centres. Organic disease of nerve cen- tres. Reflex derangements of nerve centres. Spinal debility from excesses. Shock. Fevers. Poisons, etc., etc. 6. 7. 9. 10. 11. Atony of the bladder may also be chiefly diagnosed by its exciting causes. Among these may be men- tioned 1. Prostatic enlargement. 2. Urethral stricture. 3. Prolonged voluntary retention of urine. 4. Fevers. 5. Poisons. 6. Extreme debility. 7. Acute local inflammations. Improvement. The improvement is slow, and often the condition is incurable. The improvement is rapid if the cause be removed. Frequency. Is a comparatively rare disease. Is a frequent affection. 244 SURGICAL DIAGNOSIS. CHRONIC CYSTITIS. CHRONIC PROSTATITIS. Origin. Is a sequela to an attack of acute prostatitis, or may result from an extension of inflammations from neighboring parts. Is a common disease of the blad- der, and may occur from 1. Continuation of an acute cys- titis. 2. Decomposition of urine. 3. Abnormal condition of urine ; as extreme acidity, presence of irritating salts, extreme dilution, etc. 4. Foreign bodies in bladder. 5. Extension of inflammation from neighboring organs. Size of Stream. The stream may be of normal The stream is diminished in size size. from tumefaction of the prostate. Appearance of Urine. The urine contains pus, often in large quantities, Avhich assumes the character of a semi-transparent, te- nacious, ropy deposit, Avhich rapidly settles in the containing vessel. The urine is generally alkaline in reaction, and often ammoniacal in its odor. The urine is cloudy and may often contain pus and blood in small quantities. The urine is generally acid and is never ammoniacal, unless some bladder complication exists. The pain is not markedly con fined to the perineum. Pain. Pain exists in the perineum and rectum. Micturition and sexual in- tercourse are often painful. Urethral Discharge. No urethral discharge is produced if uncomplicated. A gleety discharge is often pres- ent. Rectal Exaaiination. The prostate gland is normal. The prostate is enlarged and sen- sitive. DISEASES OF THE MALE GENITALS. 245 DISEASES OF THE PROSTATE GLAND. The prostate gland may be the seat of the following varieties of disease : A. Inflammatory Diseases, under which head may be included 1. Acute Prostatitis. This disease is seldom a primary affection except when caused by injury. It usually results from an extension of disease from adjacent or associate organs. It is a rare disease in child- hood and in old age, but is frequently met with in middle life. It is frequently of gonorrhceal origin, and may, in rare cases, be of idiopathic occurrence. 2. Chronic Prostatitis. In this condition, prostatic en- largement is always present, provided a previous acute prostatitis existed, but otherwise it may be absent. It is indicated chiefly by a gleet, pus and blood in the urine, weight and dull pain in the perineum and near the anus, painful micturition, pain in sexual intercourse, and frequent nocturnal emissions. 3. Prostatic Abscess. This condition, when it exists, is almost invariably the result of an acute inflamma- tion of the prostate. It most frequently affects the lateral lobes of the gland. Abscesses may be solitary or multiple. The seat of rupture may be located in the urethra, bladder, rectum, perineum, or peritoneal ca\dty. This last-named method of termination, however, is rare, but, when present, is usually followed by fatal inflammation. B. Hypertrophy of the Gland—"Prostatic Enlargement." This condition is one of simple augmentation of the A-olume of the prostate, dependent upon the increased nutrition of its constitutional elements. It most frequently affects the Avhole gland, but not uniformly. The urethra is encroached upon in most cases, and the prostate is increased both in size and in 246 SURGICAL DIAGNOSIS. weight. When the middle lobe of the gland is hyper- trophied, a marked obstacle to catheterism is created. This disease is essentially one of advanced age, as it seldom appears, to any marked degree, before the age of fifty. From its mechanical effects it possesses great surgical importance. C. Atrophy of the Prostate. This condition usually occurs as a result of mechanical compression, or of structural disease within the gland. It accompanies abscess and tubercular deposit in the prostate, and frequently follows prolonged compression from a stone in the bladder. It may in rare cases be a congenital defect or result from simple senile decay. D. Cancer of the Prostate. Scirrhus of the prostate is very rare, encephaloid less rare, but by no means common. Both are present most often in advanced life, but no age is exempt from the development of encephaloid cancer. No absolute cause for the appearance of cancer in this region can always be detected, though it may follow the development of a Aresical calculus or the formation of a urethral stricture. The duration of the disease seldom, as a rule, exceeds twelve months. It is one of the causes of hsematuria. Melanotic deposit is said to be occasionally associated with encephaloid of the prostate. E. Tubercle of the Prostate. This is a condition of extreme rarity and is always associated with a similar condition of the adjacent organs. The volume of the prostate may be either natural, increased, or diminished, though the latter is, by far, the most frequent condition. No abso- lute diagnosis of this affection can be made during life, although the presence of tubercle may be suspected. The symptoms of abscess are occasionally developed by suppuration around the cheesy masses. F. Cystic Disease of the Prostate. Cysts of the prostate gland are rarely met with ; but, when present, they possess a pathological interest. They are usually multiple, several existing at a time, and they vary in size from a mere speck to that of an olive. Their contents are transparent and consist of either a thick, viscid, albuminous substance, or a thin DISEASES OF THE MALE GENITALS. 247 serous fluid. These cysts are due, in all probability, to closure of the prostatic ducts and retention of their secretion. Little is known as to their progress, symptoms, or termination. By some they are regarded as dependent only upon the previous existence of prostatic concretions. G. Prostatic Calculi. These little bodies are probably the result of a disordered follicular secretion, dependent upon sub-acute or chronic irritation. They are most common in old age, but may exist at any period of life. They consist almost entirely of phosphate of lime. When very abundant they may destroy the glandular structure of the prostate and become aggregated into one large cyst. They may often be positively detected during life by introducing the finger into the rectum, while a bulbous bougie is passed in and out of the prostate. By this means they may be felt as immovable bodies, or if encysted, as a bag of small nodules. Their immo- bility is a symptom of great diagnostic importance. H. Prostatic Hemorrhage. Hemorrhage from the prostate is rare, and present usually in the aged, when catheterism is forcibly employed. It may follow also falls upon the nates, riding upon horseback, blows in the perineum, or excessive venereal indulgence. The hemorrhage is occa- sionally spontaneous, and in these cases is dependent upon some ulceration or granular condition of the mucous membrane, or the presence of a fungous, erectile, or en- cephaloid tumor. The blood from the prostate is often unmixed with urine, and often precedes and also follows the act of micturition. I. Phlebolites. By this term is designated earthy concretions within the veins. In the female, the veins of the vagina and uterus, and, in the male, the prostatic plexus of veins, are most frequently affected. They usually follow chronic irritation. They consist chiefly of phosphate and carbonate of lime, cemented by a small quantity of ani- mal matter. J. Wounds of the Prostate Gland. These are the result either of accident or design. In the latter case they are 248 SURGICAL DIAGNOSIS. made by the surgeon for some useful purpose, as the ex- traction of stone, etc., etc. Wounds of the prostate gland may be, as respects their character, either incised, lace- rated, punctured, or gun-shot. Wounds, due to accident, may result from forcible catheterism, by inexperienced attempts at extraction of a stone, by fracture of the pelvic bones, by puncture through the perineum or rectum of some pointed stick or instrument, and by gun-shot wounds. The effects of wounds of the prostate gland may be manifested, either as hemorrhage, inflammation, infiltra- tion of urine and consequent sloughing, retention of urine from tumefaction of the surrounding parts, urethro- vesical or urethro-rectal fistulas, and abscess either with- in the substance of the gland or between the gland and the rectum. If unassociated with wounds of the skin, injuries to the prostate are obscure and often difficult of diagnosis. In old age wounds of the prostate are associated with serious hemorrhage. This is explained on the ground of the great increase in the size and the varicose condi- tion of the prostatic plexus of veins. I have in the preceding pages briefly sketched the general out- lines of diseases of the prostate gland. In some instances I have enumerated, in connection with the de- scription of the disease, the few points upon which our present means of diagnosis of these obscure diseases rest. Atrophy, cancer, tubercle, cystic disease, prostatic calculi, and phlebolites may often exist unsuspected during life, as the symptoms are frequently of a vague and imperfect character. I have, however, arranged in the form of tables the points of contrast between the inflammatory affections of the prostate and the distinctions to be drawn between hypertrophy of the prostate gland and organic urethral stricture. DISEASES OF THE MALE GENITALS. 249 ACUTE PROSTATITIS. CHRONIC PROSTATITIS. History. Is usually of traumatic origin, or Is secondary to the acute form, or follows an extension of inflamma- may folloAV a gonorrhoea by an ex- tion from other parts. tension of that disease backwards. Pain. The pain is violent and pulsatile, The pain, when present, is local situated deep in the perineum in and confined to the pelvis usually front of the anus, and is augmented in the rectal region. by pressure. Rectal Symptoms. Rectal tenesmus and marked pain Rectal tenesmus is often absent, during defecation are usually pres- and defecation is seldom painful. ent. Urine. The urine is high colored, and The condition of the urine is af- may contain pus or blood. fected by the weather, habits of the patient, and the amount of exercise taken. Retention of urine is frequent. Retention of urine is infrequent. Rigors. Rigors are frequent if suppura- Rigors are seldom present. tion occurs. Rectal Exaaiination. The prostate, Avhen examined per The prostate exhibits local sensi- rectum, is hot, enlarged and tender, tiveness to the touch and enlarge- In case suppuration occurs it often ment. It seldom, if ever, goes on to becomes fluctuant. suppuration, and is therefore not fluctuant. Abscess. Pus may form and escape through Abscess is of rare occurrence. the urethra, bladder, rectum, pelvic fascia, or perineum. SYMPTOMS IN COMMON. Both may be associated with, frequent micturition. " " (i " pain during micturition. " " " " elevation of pulse and temperature. 250 SURGICAL DIAGNOSIS. HYPERTROPHY OF THE ORGANIC URETHRAL PROSTATE. STRICTURE. Age Affected. Is most frequent after fifty. Occurs at any age, but usually after puberty. History. A venereal history is often ab- Is commonly associated with ve- sent. nereal history. Micturition. The length of the act of mictu- Micturition is prolonged, as a rition is often hastened by attitude, rule, but is unaffected by attitude. Bladder. A sense of incomplete evacuation No abnormal sensations are pres- is always present in the bladder. ent in the bladder if not diseased. Urine. The urine is frequently ammo- The urine is seldom ammoniacal, niacal from decomposition of the as the bladder can empty itself com- residual urine retained by the en- pletely. larged prostate. Pus, mucus and blood are com- No abnormal deposits exist, save mon ingredients. when complications are present. Rectal Exploration. The finger when introduced into The prostate is found to be of the rectum detects the enlarge- normal size, by rectal examination. ment of the prostate. Urethral Exploration. Bulbous bougies reveal a perfect- Bulbous bougies, or a urethro- ly normal urethra in front of the meter, reveal the seat, calibre and prostatic region, if uncomplicated, length of the urethral constriction. SYMPTOMS IN COMMON Both are associated with a prolongation of the act of micturition. " " " " impairment of the force and size of the urinal stream. " " " " frequent retention of urine. " hemorrhoids from straining. " " " " changes in bladder, kidneys and ureters. DISEASES OF THE MALE GENITALS. 251 DISEASES OF THE URETHRA. The surgical diseases of the urethral canal may be classified into A. Inflammatory Diseases. Under which head may be embraced 1. Gonorrheal Inflammation. This condition depends upon the contact of a specific poison Avith the ure- thral mucous membrane. It is characterized by all the symptoms of acute catarrhal inflammations, and when long continued, results in new connective- tissue formation outside of the urethral walls. It is the most frequent cause of organic stricture. It is evidenced by local engorgement, a purulent dis- charge, pain in micturition, and occasionally by con- stitutional disturbance. 2. "Urethritis," or, Non-specific Inflammation. This condition is produced by local irritation, and not by the contact of a specific gonorrhceal poison. It dif- fers from the former type of disease in the absence of its severe local symptoms and the amount of the discharge. It may result in the formation of stric- ture if of protracted duration. In very acute forms, urethritis is, clinically, closely allied to gonorrhceal inflammation. 3. Local Ulcers, of the Chancroidal or Syphilitic Variety. This type of disease will be considered, in all its bearings, in subsequent pages, arranged in the form of a diagnostic table. B. Diseases of the Urethra, affecting the Structure of its Coats. Under this head may be embraced 1. Urethral Stricture (organic). Under the term urethral stricture I include only abnormal organic contraction of the urethral canal. It may present the following types : 1. Annular, where a localized ring of contrac- tion exists, as if an external cord were tied around SURGICAL DIAGNOSIS. the urethra. 2. Linear, where an elevated ridge exists, parallel to the long axis of the urethra. 3. In- durated Annular, or " hour-glass " stricture, where the constricting ring is indurated or thickened at its base. 4. Tortuous, where the urethral canal is irregularly constricted. 5. "Bridle stricture," where bands extend transversely across the urethral canal. It may result from specific or non-specific inflam- mation, from cicatrizations or adhesions within the urethra, from abnormal urethral growths, and from congenital malformation. Its early symptoms are chiefly gleet, alterations in the size of the urinal stream, and interference with the act of micturition. Its later symptoms depend upon changes in neighboring parts, pro- duced by its mechanical interference with the free escape of urine, and may be localized within the bladder, rectum, kidney, perineum, or testicle. 2. Urethral Dilatation. Urethral dilatation occurs most frequently at the membranous portion of that canal. It is due to obstructed evacuation of urine. It results in the formation often of a perineal tumor, which appears only during micturition. It is a frequent cause of urethral rupture. 3. Urethral Rupture. This condition may be of trau- matic or spontaneous origin. It follows blows or lacerations in the vicinity of the perineum, or it may result from a previously existing local dilata- tion of the urethra. It may occur either within the membranous por- tion, immediately in front of the triangular ligament of the perineum, or anterior to the peno-scrotal junction. It seldom, if ever, affects the prostatic portion of the urethra, unless as the direct result of injury or abscess of the prostate. Rupture of the urethra is always followed by, or accompanied with extravasation of urine. The symptoms produced by this extravasation differ with the locality of the seat of rupture. In all cases, however, if the urine be retained outside of its normal channels, sloughing occurs from decom- DISEASES OF THE MALE GENITALS. 253 position of the retained urea into carbonate of am- monia and the excessive inflammation produced by it, though the symptoms accompanying this de- structive process may vary greatly with the locality affected. 4. Urethral Deformities. The deformities of the ure- thra may be congenital or acquired. In rare cases the meatus may be located at the side of the glans penis, the urethra may terminate in the groin, the ejaculatory ducts may open as a separate canal on the dorsum of the penis behind the glans, enor- mous congenital dilatations of the urethra may exist, congenital stricture, and valvules pointing backwards and obstructing the flow of urine but not the passage of instruments, have been reported. Imperforation, atresia, hypospadius, and epispa- dius, are, hoAvever, the deformities of the urethra most frequently encountered. 5. Urethral Tumors. The tumors of the urethra may be either polypi, vascular granulations, tubercle, or cancer. The first two are most frequently located in the prostatic portion of the canal. Tubercular or cancerous deposits in the urethra are rarely primary, but are secondary, as a rule, to similar conditions of the bladder, prostate gland, or kidney, which have reached an advanced stage in the disease. 6. Urethral Abscess. Urethral abscess is most fre- quently located at the fossa navicularis, the bulb of the corpus spongiosum, or in CoAvper's glands. The latter condition is denominated " CoAvperitis " by some authorities. When the fossa navicularis is affected, the tumor appears on one side of the frae- num, but if the bulb or CoAvper's glands are affected the tumor is situated in the perineum. In either case the symptoms are those of abscess, and the causation is usually gonorrhceal. 7. Urethral Fistula. These may exist in the perineum, scrotum, groin, nates, penis, or even above the sym- physis pubis in case of extravasation of urine. Uri- 254 SURGICAL DIAGNOSIS. nary fistulae may be classified as 1. Simple fistulae where the surrounding parts are normal. 2. Fistulae complicated by inflammatory induration and de- formity of tissues. 3. Fistulae dependent upon de- struction of the soft parts by sloughing. Fistulae of the urethra are generally associated with urethral stricture or abscess, but they may fol- Ioav impaction of calculi or foreign bodies. They also result from injury causing a rupture of the urethra, and, in rare cases, are congenital. C. Conditions impeding the Normal Exit of Urine and Inde- pendent of Structural Changes. This class of condi- tions embraces: 1. Urethral Spasm. This condition seldom, if ever, ex- ists to a degree sufficient in itself to prevent or im- pede the normal power of expulsion of urine, except Avhen complicated by organic stricture. It is de- veloped, when present, to the greatest degree in the membranous portion of the urethra, in which location the compressor urethrae muscle assists the involun- tary muscular fibres of the urethral walls. It may result from acid urine, cantharides, turpentine, alco- hol, repressed gonorrhceal discharge, organic stric- ture, and rectal diseases. It is associated with marked and intermitting variations in the size of the stream, and if uncompli- cated by organic stricture should disclose a normal degree of patency of the urethra after the attack has subsided. 2. Congestive Stricture. This variety of stricture is always dependent upon turgescence of the urethral mucous membrane, arising from an inflammatory condition of that part. It is always associated with more or less spasm of the urethra, and, like that disease, is to be diagnosed from organic contraction by the existence of a normal urethral calibre after the attack has been relieved. 3. Urethral Calculi. These bodies are usually derived from the kidney or the bladder, but, in rare in- stances, may form behind an urethral obstruction. DISEASES OF THE MALE GENITALS. 255 They may be single or multiple, and may be asso- ciated with retention of urine, or an absence of symptoms of obstruction. If not removed, dilatation of the urethra, ulceration, and frequently rupture, follow. 4. Foreign Bodies in the Urethra. Foreign bodies are frequently introduced into the urethra either through accident or during attempts to relieve retention of urine, or to induce sexual excitement by the friction of some extraneous substance upon the urethral walls. Thus pieces of slate pencil, heads of wheat, leather thongs, hair-pins, etc., etc., have, in numer- ous cases, been reported as present in the urethral canal. 256 SURGICAL DIAGNOSIS. RUPTURE OF THE URETHRA PERINEAL ABSCESS. WITHIN THE TRIANGULAR LIGAMENT. Origin. Appears as a sudden tumor in the Begins as a slowly increasing perineum, associated with an indis- tumor in the perineum. tinct sense of rupture and abnormal sense of warmth in the perineum. Previous History. A previous history of urethral A sense of heat, local pain and stricture is usually present, but no soreness have usually preceded the premonitory manifestations of rup- development of the tumor. ture may have existed. Fluctuation. Fluctuation is present from the Fluctuation appears late. onset. Tumor. Is elastic and tense from the onset, Is hard and oedematous in its until it burrows or escapes from the early stages, but becomes fluctuant perineum. and elastic later. Micturition. Retention of urine is frequent and Retention of urine is seldom pres- follows rapidly upon the appearance ent, but, if so, it occurs late in the of the tumor. disease. Extent of Inflammation. The scrotum, abdominal walls The inflammation and suppura- and thighs, may become rapidly im- tion are confined solely to the peri- plicated when the tumor leaves the neum. perineum. Results. Tends towards rapid sloughing. Tends towards pointing and the evacuation of pus. SYMPTOMS IN COMMON Both are associated with a,perineal tumor. " " " " possible retention of urine. 11 " " " suppuration. " " " " fluctuation. DISEASES OF THE MALE GENITALS. 257 RUPTURE OF THE URETHRA RUPTURE OF THE URETHRA IN THE MEMBRANOUS IN FRONT OF THE TRI- PORTION. ANGULAR LIGAMENT. Tuaior. The tumor is, at first, confined The tumor is never confined to to the perineum. the perineum. Scrotum. If the scrotum be distended by The scrotum is frequently dis- urine, it is only involved after tended from the onset of the attack sloughing of the triangular liga- and appears red, tense and cedema- ment has freed the imprisoned urine, tous. Abdomen. The abdominal walls often escape The abdominal walls frequently infiltration by urine, and subsequent become involved before the tension sloughing. of the scrotum is relieved by in- cision or by sloughing. Thighs. The thighs are involved late, if The thighs are often infiltrated at all. early. Pelvic Organs. The pelvic organs may undergo sloughing or a general peritonitis may ensue from extension of the urine into the pelvic fascia. 17 The pelvic organs are never in- volved. 258 SURGICAL DIAGNOSIS. RUPTURE OF THE URETHRA FRACTURE OF THE PENIS. IN FRONT OF THE SCRO- TUM. Origin. May be of spontaneous origin, or Is always due to injury. due to traumatism. It usually follows and is depen- Is not dependent upon urethral dent upon urethral stricture. stricture or any diseased condition. Penis. The penis is red, SAVollen, tense The penis is greatly swollen and and cedematous. ecchymosed, or, hemorrhage may exist through the urethra or in- tegument. Integument. The integument is always intact, The integument may be lace- but is distended. rated. History. A history of the appearance of The history of some accident to the tumor during attempt at mic- the genital organ Avhile in the state turition is usually present, pro- of erection, is usually present. vided the rupture was not trau- matic. SYMPTOMS IN COMMON Both are associated with great swelling and deformity. an tt it frequent retention of urine. " " " " frequent sloughing. " " " " frequent suppuration. << " " " possible permanent deformity after recovery. DISEASES OF THE MALE GENITALS. 259 ORGANIC STRICTURE OF ENLARGED PROSTATE. THE URETHRA. Age Affected. Occurs at any age, but usually Is most frequent after the age of after puberty. fifty years. History. Is commonly associated with a A venereal history is often absent. venereal history. Micturition. Micturition is prolonged, as a • The length of the act of mictu- rule, but is unaffected by attitude. rition is often hastened by attitude. Bladder. No abnormal sensations are pres- A sense of incomplete evacuation ent in the bladder if not diseased. is always present in the bladder. Urine. The urine is seldom ammoniacal The urine is frequently ammo- as the bladder can empty itself com- niacal from decomposition of the pletely. residual urine retained by the en- larged prostate. No abnormal deposits exist, save Pus, mucus and blood are com- when complications are present. mon ingredients. Rectal Exploration. The prostate is found to be of The finger, Avhen introduced into normal size, by rectal examination, the rectum, detects the enlargement of the prostate. Urethral Exploration. Bulbous bougies, or an urethro- Bulbous bougies reveal a perfectly meter reveal the seat, calibre and normal urethra in front of the pros- length of the urethral constriction, tatic region, if uncomplicated. SYMPTOMS IN COMMON. Both are associated Avith a, prolongation of the act of micturition. " " " " impairment of the force and size of the urinal stream. " " " " frequent retention of urine. " " " " hemorrhoids from straining. " « " " changes in bladder, kidneys and ureters. 260 SURGICAL DIAGNOSIS. ORGANIC URETHRAL URETHRAL TUMORS. STRICTURE. Sex Affected. Is principally a disease of males. Urethral tumors affect both sexes and may be of two great varieties, polypoid and vascular. In males the polypoid tumors are most common ; in females, the Avas- cular, or fleshy tumors are usually present. Location. Urethral stricture is never de- In males the tumors are most tected in the prostatic portion of the frequent just Avithin the meatus, urethra and seldom behind the bulb but they may affect the membra- of the corpus spongiosum. nous and prostatic portions of the urethra. Pain. Urethral strictures are sensitive, The vascular tumors are extreme- often, to the touch, but rarely give ly painful and sensitive, but the pain except during micturition. polypoid tumors are painless. Origin. Strictures are most frequently of The origin of these tumors is un- gonorrhoeal or traumatic origin. known. Hemorrhage. Strictures seldom cause sponta- The polypoid tumors seldom neous hemorrhage. bleed, but the vascular tumors often bleed profusely. Mobility. Strictures are constant in their Polypoid tumors may be movable situation and immovable. Avith the urethra. SYMPTOMS IN COMMON Both may produce a small stream. " " " prolonged and painful micturition. " t( il a gleety discharge. " " " subsequent diseases of adjacent organs. " i( " impaired general health. DISEASES OF THE MALE GENITALS. 261 DISEASES OF THE PENIS. The diseases to which the penis is subject may be divided into four groups as follows : A. Diseases of the Glans Penis : under Avhich head may be enumerated the following conditions : 1. Balanitis. This term is used to designate an inflam- mation of the surface of the glans penis. It occurs most frequently in persons of gouty habit, or those possessing an irritable skin. It results often in those not predisposed to its occurrence, from re- tention of the smegma preputii, from contact with gonorrhceal, menstrual, or leucorrhceal discharges, from lack of cleanliness, and from other sources of irritation. Its symptoms are similar to those of the following disease. 2. Posthitis. .By the term posthitis, is meant an in- flammation of the mucous membrane of the prepuce. Its causes and symptoms are identical with those of balanitis. The mucous membrane becomes red- dened, mottled and often ulcerated. A purulent discharge is present which arises from the surface of the glans, and not from the urethra. A sense of burning and itching at the penis exists, and scalding during micturition may often be present. Inflammatory phimosis often occurs from swelling of the prepuce, and warty vegetations are a common result of a prolonged balanitis or posthitis. 3. Herpes Progenitalis. This type of the herpes erup- tion appears either upon the glans, the mucous or cutaneous surface of the prepuce, or even upon the body of the penis. It is indicated by the formation of clusters of small vesicles, which often ulcerate when exposed to moisture, as when within the pre- putial covering, and assume, in rare cases, an angry and deep character. These ulcers more frequently tend, however, towards recovery, but in some in- 262 SURGICAL DIAGNOSIS. stances vegetations, balanitis or inflammatory phi- mosis result as sequelae. 4. Vegetations and Venereal Sores. " Venereal ivarts " may be located either upon the glands, prepuce, scrotum, anus, or, in some cases, within the urethral canal. Their common designation is a misnomer, as they are more often due to simple irritation than to a venereal origin. They are frequent in children and in pregnant women, who are troubled with irritating vaginal discharge. They are almost invariably multiple. True venereal ulcers however are frequently found in the same situations as are venereal warts. They are of two great types : canchroid and chancre; the former being a purely local disease, the latter being a local evidence only of an existing blood condition. These two diseases are due to the presence of a spe- cific poison, and will be considered in contrast in subsequent pages of this work. 5. Epithelioma. This form of cancer most frequently attacks the glans penis and prepuce, and occurs usually after the age of forty. It is characterized by all the general symptoms of epithelioma in other parts of the body. It will be more exhaustively considered under the head of tumors. B. Diseases of the Prepuce : under which head is embraced the conditions of phimosis and paraphimosis. 1. Phimosis. The prepuce may be incapable of retrac- tion over the glans from absence of the opening (atresia preputii), from inflammation, from adhe- sion, and from congenital defect. It is a normal condition in infancy, and, unless sufficient to cause inflation or "ballooning" of the prepuce during at- tempts at micturition, need cause no surgical inter- ference. Phimosis tends, if extensive, towards im- perfect development of the glans penis. It may also produce balanitis, cystitis, sperma- torrhoea, and reflex nervous diseases, if severe in extent and long continued. DISEASES OF THE MALE GENITALS. 263 2. Paraphimosis. Paraphimosis may be the result of an accidental retraction of a tight preputial orifice over the glans penis, or it may occur as a result of in- flammatory oedema, when the preputial orifice has always exhibited a normal condition. This latter condition often accompanies balanitis, gonorrhoea, chancroid, chancre, or even a severe attack of herpes. It occurs, as a rule, during at- tempts to apply local treatment to the existing con- dition of the glans penis. In all forms of paraphimosis the glans becomes rapidly swollen and livid in appearance, from the obstructed venous return, and thus increases the difficulty of reduction. If not rapidly relieved, sloughing occurs, and destruction of the gland or a urinary fistula is liable to be produced. C. Diseases of the Corpora Cavernosa : under which head are included the following conditions : 1. Inflammation. This condition is always one of serious import. It may arise spontaneously from a severe gonorrhoea, or in connection with the exanthematous fevers. It also follows contusions and fracture of the penis. As a rule, suppuration and gangrene result when the inflammatory process is severe. The local pain is very excessive. It is a rare disease. 2. Calcification of the Penis. This condition is ana- logous to atheroma of the blood-vessels. It is insidious in its approach, occurs in middle life or old age, and is first denoted by an imperfect and painful erection of the penis, the organ being bent where calcification has occurred, as the fibrous sheath loses its elasticity in consequence of the osseous deposit. In advanced cases osseous plates can be detected in the body of the organ. 3. Gummata. Gummy tumors may, in rare cases, affect the genitals in advanced stages of syphilis. They are to be diagnosed from fatty, fibrous, cystic and erectile tumors, Avhich may also affect the penis. This can be easily done by the previous history of the patient, and the tendency of gummata to sup- 264 SURGICAL DIAGNOSIS. purate and discharge. Gummata seldom reach a large size. 4. Chronic Circumscribed Inflammation. This affection is very rare. It consists of a local inflammatory induration, the cause of which is unknoAvn, pro- ducing a deformity of the penis during erection. The indurated mass has elasticity, and differs in this respect from the osseous plates produced by calcification. It is usually superficial, with well- defined edges, and is slowly progressive in develop- ment, or occasionally stationary for an indefinite period. 5. Fracture of the Penis. The fibrous sheath of the corpora cavernosa is occasionally ruptured and the adjacent erectile tissue is involved. This condition constitutes the so-called fracture of the penis. It is always accompanied by extensive extravasation of blood, and, in severe cases, may terminate in gan- grene. It is produced by injuries received Avhile the organ is in a state of erection. It terminates usually in recovery, when treated early, but may leave a deformity in erection or a nodular swelling at the seat of fracture, which may render subsequent sexual intercourse difficult and painful. By some authors the voluntary or spontaneous rupture of a chordee during a violent attack of gon- orrhoea or non-specific inflammation, is regarded as a variety of fracture of the penis. In this case, however, the corpus spongiosum only is involved, and, as the blood escapes through the urethra, little local deformity is the immediate result, although a severe form of organic stricture inevitably follows. D. Anomalies of the Penis. The penis may be rudimentary in size, or may in rare instances be enormously developed. It may also be double, as is reported by several authors; and in one case described by Nelaton was congenitally absent. These unnatural conditions, however, have little surgical importance, as nature, usually, provides a means of free urinal escape, and the general health is therefore unimpaired. DISEASES OF THE MALE GENITALS. 265 I have in the preceding pages briefly enumerated the principal surgical diseases of the genital organ. Many of them are infre- quent, and can be excluded as probable causes of confusion in diag- nosis on that ground ; while others are too clearly marked in their symptoms to need further elaboration. I have added, however, the distinctive points of diagnosis between chancroidal ulcers and the syphilitic sore, as they are frequently a source of doubt to the prac- titioner, and as a radical difference in the prognosis and treatment depends upon an early recognition of the disease existing. 266 SURGICAL DIAGNOSIS. CHANCROID. CHANCRE. Nature of Ulcer. Is a purely local affection. Is a local manifestation of an ex- isting blood disease. Incubation. The ulcer develops immediately The ulcer develops from 10 to after absorption of the poison :— 24 days after infection, as a rule. 24 hours to third day after infection. Shape of Ulcer. The ulcer is round, as a rule, but Is generally circular or oval. may be oval, or irregular from fu- sion of multiple sores. Edges of Ulcer. Are clean-cut, perpendicular, of- Are smooth, often elevated, ad- ten everted and undermined. herent, not undermined, and grad- ually melt into the floor of the ulcer. Floor of Ulcer. Uneven, honey-combed, warty or Smooth, often concave, and shin- irregular, without lustre. ing. Color of Ulcer. Yellowish ; often a reddish or vio- Grey in centre, darker at edges, let areola exists around the sore. sometimes scabbed ; areola is often absent. Situation. Rarely present except on, or near May exist on genitals, head, hands the genitals. or nipple. Causation. Contact with chancroidal ulcer or Contact with primary sore, a inoculation Avith its pus. secondary lesion of syphilis, vacci- nation, or inoculation upon an ab- rasion of the surface. Pain. Is usually painful. Is usually painless and indolent. Number. The ulcers are seldom single. A solitary sore is usually present. DISEASES OF THE MALE GENITALS. 267 CHANCROID CHANCRE (continued). (continued). Method of Origin. Begins as a pustule, or an ulcer Begins as a papule or an erosion, and remains an ulcer. and remains an erosion or ulcerates. Secretion. Ichorous and irritating pus in Scanty and serous in character, first stage ; but laudable when ulcer unless the sore be irritated when it is healing. becomes purulent. Induration. Is absent, unless the ulcer be ir- Often precedes the sore, and lasts ritated ; is not elastic or abrupt in long after its disappearance. It is its termination, subsides after the hard, elastic, cartilaginous, usually irritation is removed, is adherent to hemispherical in shape and abrupt the skin and sensith^e to pressure. in its outline. It is very movable and never sensitive to pressure. Inoculability. Is auto-inoculable, is transmissi- Is not auto-inoculable unless irri- ble and can be communicated to tated, and is transmissible only to animals. human species. Bubo. Suppuration of the lymphatics of The enlarged lymphatic glands in the groin is frequent. The bubo is the groin are usually painless, mul- usually painful and mono-glandu- tiple, and seldom suppurate, unless lar. injured or due to a mixed infection. Extent of Ulcer. Is often of large extent from an Is seldom phagadenic, and shows accompanying phagadaena, and se- little tendency to spread. vere in its local results. Duration. • Often lasts from one to two Is slow in development, but heals months. rapidly when once reparative pro- cesses commence. Cicatrix. Not distinctive. Pigmented, as a rule. Results. No constitutional symptoms are Secondary symptoms of syphilis developed. rapidly appear. 268 SURGICAL DIAGNOSIS. HERPES. BALANITIC ABRASION. Origin. It may occur from cold, fever, or It follows only friction, mechani- a nervous condition, as Avell as from cal irritation, or the contact of friction, irritation, or the chemical acrid discharges from the glans or action of acrid discharges. prepuce. Locality. May be a local disease only, or Is always a local affection. may exist as an evidence of an ab- normal nervous condition in other parts simultaneously. Development. It begins as a group of vesicles. Begins as an abrasion or a fissure. Pain. Is associated with a stinging and Is painful and sensitive. burning sensation as it develops. Tendency to Recur. A marked tendency to recur at No tendency to periodical relapses regular intervals is often exhibited, is present, but it may be reproduced It is often induced to return by by a return of the exciting cause. dissipation or excessive venery. Appearance of Ulcer. Is rounded in its shape, often Resembles a chancroidal ulcer slightly irregular, and its borders when fully developed. may disclose the remnants of pre- vious vesicles as segments of small circles. SURGICAL DISEASES ABDOMINAL CAVITY. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. Under this head will be considered, in this volume, the following named conditions, A. INJURIES OF THE ABDOMEN. The injuries to the abdo- men may be of three varieties, as folloAvs : 1. Contusion of the Abdomen. Contusions of the ab- domen may be present with or without rupture of the viscera. In either case such an accident is fre- quently accompanied with intense pain, faintness or syncope and vomiting. In some cases death has occurred by an impres- sion made upon the solar and cardiac plexuses, Avithout any internal lesion being discovered. Contusions of the abdomen may produce either rupture of muscles, extravasation of blood, rupture of the peritoneum, rupture of the diaphragm, rup- ture of the stomach or intestine, lacerations of the liver and spleen, rupture of the gall-bladder, or lacerations of the kidney and the ureter. Contusions of the abdomen usually occur from fly- ing objects, as cricket-balls, etc., etc., from blows received during altercations, from falls upon the abdomen, cart-wheels passing over the body, or from some other similar misfortune. If uncomplicated by injury to viscera, contusions of the abdomen may result in abscess or recovery. 2. Wounds of the Abdomen. Wounds of the abdominal parietes may be either superficial or deep, and may be associated with the absence of complications, or the protrusion, and possible injury of adjacent viscera. They may occur from sharp and pointed instru- ments, from being impaled upon iron spikes, caught 271 SURGICAL DIAGNOSIS. upon iron hooks, tossed by horned cattle, injured by glass, china, or missiles, or by the bites of carnivor- ous animals. Wounds of the abdomen may vary therefore greatly in appearance, variety, extent and location. They may be complicated with serious hemorrhage and with the introduction of foreign substances into the abdominal cavity through the wound, even in case the viscera escape injury. The intestines, stomach, liver, spleen, bladder, omentum, and mesentery may protrude, in case the location and character of the wound favor such a displacement. Artificial anus may result in cases of wounds of the abdominal parietes, although it is a more fre- quent sequela of diseased conditions of the intestine associated with sloughing. 3. Foreign Bodies in the Intestinal Canal. Foreign bodies which are proof against the action of the gastric or intestinal juices are often introduced into the stomach either by accident or with design. The foreign bodies often detected include coins, bullets, fruit-stones, pebbles, marbles, hair, string, oat-husk, pins, fish-bones, false teeth, etc., etc. The results of the introduction of foreign bodies into the stomach differ with the size and shape of the body introduced. Small, flat, or oval bodies may be voided with- out delay, pain, or other symptoms of disturbance. If hair, string, or similar substances, be present in the stomach, they often attain immense size, and, by remaining within that organ, frequently produce symptoms of severe dyspepsia, and subsequently those of ulceration and perforation of its coats. Irregular-shaped or globular bodies frequently be- come arrested at the ileo-caecal valve, if allowed to pass the pyloric orifice of the stomach. Sharp or pointed bodies are best voided by plenti- ful eating and the avoidance of cathartics, as, by so doing, the foreign body is more liable to be inclosed in the abundance of faecal material. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 273 Needles when swallowed often penetrate the walls of the alimentary canal and are transported to dis- tant points often before their removal. B. DISEASES OF THE INTESTINE: 1. F^cal Abscess. Abscess of the abdominal region is often dependent upon an artificial aperture in some portion of the alimentary canal. It may arise from perforation of the bowel as a sequel to simple ulceration, the lodgement of a foreign body in the intestine, ulceration of the gall-bladder from a gall- stone, stricture of the intestine, cancerous disease of the bowel, or faecal impaction as a result of mus- cular atony or paralysis, dependent upon previous catarrhal inflammation of the intestine. The most frequent seat of faecal abscess is in the region of the ilio-caecal valve—the right iliac fossa; but abscess may be present in any portion of the abdominal cavity. Faecal abscesses follow no definite rule as to symptoms, rate of progress, or termination. They may develop slowly and insidiously, or rapidly with severe local pain and marked consti- tutional disturbance folloAved by symptoms of a general peritonitis. In the diagnostic table be- tween typhlitis and perityphlitis will be found embodied the principal features of abdominal ab- scess. 2. Intestinal Obstruction. Intestinal obstruction may develop suddenly or slowly. When the attack is of sudden advent, and the symptoms markedly acute, the result is usually fatal to life ; but when slowly developed frequent relief can be afforded or recovery take place, without assistance, even when all hope of life may have vanished. The causes of sudden intestinal obstruction in- clude, 1. Foreign bodies, either artificially intro- duced or formed within the intestine. 2. Con- genital stricture or malformations of the intestine. 3. Twisting of the intestine or volvulus. 4. Obstruc- tions from peritoneal adhesions. 5. Invagination of 18 SURGICAL DIAGNOSIS. the bowel or intussusception, resulting from in- testinal tumors, worms, or unexplained causes. 6. Thickened peritoneal coverings and mesenteric attachments from an old hernial protrusion, and 7, strangulated hernia. The causes of gradual intestinal obstruction may be 1. Tumors pressing upon the bowel. 2. Simple stricture of the bowel from ulceration, injury, etc. 3. Cancer of the bowel occluding its normal calibre. 4. Tubercular peritonitis. 5. Abscess from trau- matism of abdominal walls. 6. Constipation or im- paction of faeces. 7. Inflamed and thickened intes- tine as the result of injury. The prominent symptoms of intestinal obstruction are 1. Local and severe pain. 2. Obstinate consti- pation. 3. Presence often of a tumor. 4. Localized dulness if the tumor cannot be felt. 5. Vomit- ing which becomes stercoraceous. 6. Tympanitis. 7. Symptoms of general peritonitis or collapse. C. DISEASES OF THE RECTUM. The rectum may present the following surgical conditions : 1. Hemorrhoids. These are of two varieties, external and internal, the former being located at the anus, the latter higher up within the rectum. They are both due to a varicose condition of the hemor- rhoidal veins. They are largely dependent upon portal obstruction. 2. Prolapse of the Rectum. This is a frequent disease of children. It is due in children to lack of tone in the muscular structure of the rectum, or to general debility. If present in adults, a relaxed condition of the sphincter exists. It may occasionally be produced by hemorrhoids and by urethral stricture as a result of straining. 3. Fistula of the Rectum. This condition may arise primarily by either ulceration of the rectum, or the formation of an abscess in the cellular tissue ex- ternal to the rectum. Rectal fistulae may be 1. Complete, where the rec- tal canal and the external opening communicate ; 2. Incomplete or blind fistulae, where one of these SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 275 openings is absent. Fistulae may vary in their number, situation, length and calibre. They are frequently associated with inflammatory induration of the neighboring tissues. 4. Ulcer or Fissure of the Anus. This condition may be either a true fissure, or a small, oval-shaped ulcer, located just within the anus. It produces the most intense suffering and can be detected only by a care- ful scrutiny of the parts, as it may be overlooked or concealed by the rugae round the anal margin. 5. Stricture of the Rectum. Stricture of the rectum may involve the whole circumference of the gut, or only a portion of it. The extent of the bowel affected may vary from two lines to two inches, or even more. The seat of stricture may Arary from one inch, to four or five inches above the anus. Stricture of the rectum may arise from cicatrices of formerly existing ulcers, from injuries, from sur- gical operations on the rectum, or from the pressure of tumors or organs. It is almost always associated with abscess and fistulae, if of long duration. 6. Cancer of the Rectum. Scirrhus, epithelioma, and colloid cancer, are met with in the rectum. They usually are first recognized as a hardened or indu- rated mass in the walls of the bowel causing dimi- nution in its calibre. Cancer in this locality usually results in death within four years from the date of its commencement. A marked cachexia becomes apparent as the dis- ease develops. 7. Rectal Polypus. Polypi of the rectum may be of three types: 1, vascular polypi; 2, warty polypi; and 3, fibro-cellular polypi. Of these, the first is most frequent among chil- dren, and is usually associated with hemorrhage; while the other two are comparatiATely non-vascu- lar. They are all markedly pediculated, and are much less painful than hemorrhoids. 8. Pruritus Anl This distressing affection may result 276 SURGICAL DIAGNOSIS. from constipation, abnormal intestinal secretion, ascarides in the rectum, prolonged sitting posture,^ and uterine diseases. It is usually associated with morbid textural changes around the anus, if long continued, from the irritation of scratching. 9. Neuralgia of the Rectum. This condition is diag- nosed by a severe and continuous pain within the rectum, not markedly affected by the condition of the bowel or attempts at defecation, and associated with no appreciable rectal disease. It occurs most frequently in females who have been in a state of depressed vitality. The following conditions of the rectum, viz., hemorrhoids, fistulae, fissure of the anus, cancer, rectal polypi and rectal prolapse, will be found contrasted in diagnostic tables at the close of this chapter on surgical diseases of the abdomen. D. HERNIA. By the term hernia is meant " a protrusion of any viscus from its natural or containing cavity." Hernia may be classified, first, on a basis of the anatomical loca- tion of the protruding viscus, as follows : Hernia : Classified on a basis of" location. 'In the cranial region. In the thoracic region. ;he ep: trium. In the mesogas- trium. In the hypogas- trium. Hernia Cerebri. } y Hernia of the Lung. ( Epigastric Hernia. r Ventral Hernia. < Umbilical Hernia. I Lumbar Hernia. Above Poupart's ligament. Below Poupart's ligament. \ Through pelvic apertures or in pelvic region. Omphalocele—Exom- phalos. Inguinal Hernia. Inguino-Scrotal Hernia. Inguino-Lablal Hernia. Femoral Hernia. Mero- cele. Obturator Hernia. Perineal " Pudendal " Vaginal " Ischiatic " SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 277 Hernia may be classified, secondly, on a basis of the contents of the sac: of Intestines. Hernia : Classified on a basis - of contents: of Omentum. of Intestines and Omentum. of Bladder. of Rectum. of other organs. Enterocele. Epiplocele. Entero-Epiplocele. Cystocele. Rectocele. Hernia Cerebri. " of Lung. " " Liver. " " Spleen. " " Kidney. " " Stomach. " " Testis. Hernia may be classified, thirdly, on a basis of the condition of the sac, as follows : Hernia : Classified on a basis of the ' condition of the sac : Reducible Hernia. \ Where the protruded viscus and its cov- erings can be replaced in their nor- mal situation. Strangulated Hernia. Incarcerated Hernia. Incomplete Hernia. Congenital Hernia. Infantile Hernia. f "Where the protruded viscus is retained Irreducible Hernia. \ in its abno™al position by adhesions, thickening of its coverings, or a de- posit of fat. Where the circulation of the displaced viscus is impaired by muscular spasm, oedema, or a sudden forcing of addi- tional contents into the sac. Where a hernial protrusion of intestine is rendered temporarily irreducible by gas or faeces. Where the hernial protrusion has not attained the development common to the region in which it exists. Where a hernial protrusion follows the descended testicle before the cavity of the tunica vaginalis is closed, thus giving it one layer only of peritoneal covering. Where a hernial protrusion into the scrotum occurs outside of, but parallel to the serous coats of the tunica vagi- nalis. This condition is not always one of infancy, although so named. 278 SURGICAL DIAGNOSIS. Nomenclature of Inguinal Hernia Certain special types of hernia are also subdivided on grounds of the surgical relations of the neck of the sac, the direction of the means of exit, or the location of the tumor. Thus inguinal hernia in its different forms may be spoken of or described under the fol- lowing names : 1. Indirect Hernia ; by which term is meant that form of inguinal hernia which passes through both the internal and external abdominal rings. 2. Direct Hernia ; by which term is in- cluded all forms of inguinal hernia which pass through the external ring but es- cape the internal ring. 3. External Hernia. This is a synonym for indirect inguinal hernia, the name being applied from the external relation of the neck of the sac to the deep epigas- tric artery. 4. Internal Hernia. This also is a synonym for direct inguinal hernia, since in both the neck of the sac lies internally to the epigastric artery. 5. Bubonocele. By this term is meant an in- complete indirect inguinal hernia. Its name is applied from its resemblance to an inflamed lymphatic gland in the groin (bubo). Causes of Hernia of the Abdominal Viscera. The conditions which may tend towards a protrusion of any of the abdominal viscera may be either predisposing or exciting. Under the first may be enumerated A. Wounds or Lacerations of the Abdomi- nal Walls. Hernial tumors of the liver, stomach, intestines, spleen and kidney, have been known to exist as a result of wounds of the abdominal parietes. The extent of the wound, its depth and loca- tion, tend greatly to modify its effect upon displacement of viscera. Predisposing causes of Hernia : SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 279 Predisposing causes of Hernia: (continued.) B. Weakening or Destruction of the Ab- dominal Walls by inflammation, ulcera- tion, suppuration, or disease. Hernial protrusions often follow abscess, severe types of ulceration and contusions of the abdominal walls, or when they are sub- jected to excessive strain, as in violent muscular efforts, prolonged attacks of coughing or sneezing, or in cases of straining duiing defecation. C. The Existence at Berth and Persist- ence AFTERWARDS OF A CANAL COMMUNI- CATING with the Peritoneal Cavity. The prolongation of the peritoneal cavi- ty, produced by the descent of the tes- ticle, becomes in the majority of cases a separate sac, called the tunica vagi- nalis, by adhesion of its surfaces Avith- in the inguinal canal during the first month of life and often before birth. In rare cases however this union fails to occur. D. A Gradual Protrusion of the Abdomi- nal Walls into an Abnormal Recepta- cle for Viscera. This condition we see manifested in cases of enormous double scrotal hernia. It occurs where a condition of relaxation of the abdomi- nal muscles or a redundance of tissues exists to a marked degree. E. Sex. Hernia as a disease affects males to a far greater extent than females. Still in the femoral and umbilical types of hernia the contrary holds good. F. Age. Hernia is most frequent in infancy, and is a common affection in youth. It is comparatively rare between the ages of 13 and 21; but as age advances the tendency to this affection steadily in- creases. In women hernia occurs most frequently from the ages of 20 to 50. 280 SURGICAL DIAGNOSIS. Predisposing causes of Hernia: (continued.) G. Height. Hernia occurs more often in tall than in short people, especially so if the general state of health is not ro- bust. H. Occupation. Occupations demanding great muscular effort or intermitting strain upon endurance, tend greatly to- wards the formation of hernia, espe- cially when aggravated by belts worn around the waist, Avhich, by compress- ing the viscera of the abdomen, tend to assist in the production of their dis- placement. The exciting causes of hernia usually consist of some violent mus- cular effort, under which head may be mentioned A. Lifting of Heavy Weights. B. Violent Efforts in Jumping, Running, or Climbing. C. Severe Attacks of Coughing or Sneez- ing. D. Straining during Attempts at Micturi- tion, when urethral stricture is present. E. Falls associated with Efforts to Re- cover Balance. Exciting causes of Hernia: Differential Diagnosis of Hernia. Hernia of the Inguinal Region may be confounded, as a disease, with the folloAving named conditions : 1. Hydrocele of the Testicle. 2. Sarcocele " " 3. Varicocele. 4. hematocele. 5. Bubo. 6. Undescended Testicle. 7. Impacted Faeces. 8. Hydrocele of the Cord. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. It is often difficult also to discriminate between the inguinal and femoral varieties of hernia, or to detect the various special forms of inguinal hernia from each other. In the diagnostic tables appended, I have endeavored, therefore, not only to exhibit the points of con- trast betAveen inguinal hernia and other surgical diseases confined to that locality of the body, but also to make clear the points of distinction between those various conditions of inguinal hernial pro- trusions, which are liable to be encountered in a surgical practice. Femoral Hernia may be confounded, in diagnosis, with many sur- gical conditions of the thigh, which often bear symptoms in com- mon with that disease. Among these conditions leading towards error, may be enumerated as important 1. Enlarged Glands. 2. Psoas Abscess. 3. Varix of the Saphenous Vein. 4. Lipoma of the Femoral Canal. I have added also, in the following pages, diagnostic tables be- tween ventral and umbilical hernia, thyroid and perineal hernia, diaphragmatic hernia and mediastinal tumors, congenital and infan- tile hernia, and congenital hernia and hydrocele. In connection with diseases of the rectum, will be shown in con- trast the symptoms of external and internal hemorrhoids, external hemorrhoids and condylomata of anus, internal hemorrhoids and rectal polypi, rectal prolapse and rectal polypi, cancer and stricture of the rectum, fissure of anus and fistulae of rectum. I have dwelt but slightly upon the symptoms of diseases of the abdomen, as they will be found in full in the following pages. I have left unmentioned in these tables, also, contusion of the ab- domen and its results, abscess and ecchymosis, as they have no special features over similar changes in other parts, and properly belong to the following chapter on diseases of tissues, in which they will be considered. I have introduced, however, a table of diagnosis between Typhli- tis and Perityphlitis, as it seems properly to belong to this chapter; and I have added, in connection with it, a table of the causes and symptoms of intestinal obstruction. 282 SURGICAL DIAGNOSIS. TYPHLITIS. PERITYPHLITIS. Definition. Is an inflammation of the vermi- Is an inflammation of the con- form appendix of the caecum. nective tissue about the caecum. History. The appearance of a tumor in the No early diagnostic symptoms right iliac fossa is preceded by co- precede the attack. It occurs from lichy pains and distension of the traumatism, ulceration of the ver- abdomen from tympanitis. miform appendix, pyaemia, etc. Pain. The pain is superficial and is con- The pain is deep-seated in the fined to the right iliac fossa and right iliac fossa. right hip. Numbness. No numbness is felt in the right A sense of numbness is present thigh and leg. often in the right lower extremity. Effect of Motion. Motion of the thigh produces Motion of the thigh produces pain only in the later stages. pain early in the disease. Tumor. The tumor is sausage-shaped and The tumor is deeply located and superficial. fluctuates in the advanced stages. Percussion. Flatness is present OA'er the tumor. Tympanitic percussion, from the inflated caecum, exists over the tu- mor, if uncomplicated. Control of Thigh. The patient can raise the right The patient cannot raise the right thigh. thigh, as a rule. Abscess. Suppuration and pointing are Suppuration, and pointing, as a rarely, if ever, present. rule exist, if the abscess is to open externally. SURGICAL DISEASES OF THE ABDOMINAL CA VITY. INTESTINAL OBSTRUCTION. Intestinal Obstruction. (2 varieties.) If of sudden origin it may be due to If of slow develop- ment, may result from 1. Foreign bodies. 2. Twisting of the intes- tine. 3. Intussusception of the bowel. 4. Congenital stricture of the bowel. 5. Congenital malforma- tion of the bowel. 6. Strangulation of the bowel by bands of lymph. 7. Strangulated hernia. 8. Entanglement of bowel with mesentery or omentum. 1. Malignant disease. 2. Impaction of faeces. 3. Abnormal concretions. 4. Pressure of tumors, ab- scess, etc. 5. Tubercular peritonitis. SYMPTOMS IN COMMON. A tumor is usually detected in the abdomen. When due to impaction of faeces, this tumor indents on firm pressure. Pain is usually a marked symptom; it is local, as a rule, and deep- seated. Dulness on percussion exists often over the seat of pain, in case a tumor cannot be detected. Obstinate constipation exists, which Avithstands all attempts at removal. Vomiting is a marked symptom. When stercoraceous in character, it is a pathognomonic symptom. If occurring late in the attack it often indicates an obstruction low down in the boAvel. Distension of the abdomen from tympanitis. This condition is very marked Avhen the large intestine is obstructed, but much less so if the small intestine be the seat of disease. 284 SURGICAL DIAGNOSIS. EXTERNAL HEMORRHOIDS. INTERNAL HEMORRHOIDS. Appearance of Tuaior. The tumor is smooth on its sur- The tumor has often a granular face.s surface. The tumor is partially covered The tumor is entirely covered with integument. with mucous membrane. The tumor is seldom pediculated. The tumor is usually pediculated. Situation. The tumor is always situated at The tumor is attached to the the margin of the anus. walls of the rectum. Reducibility. The tumor always presents ex- The tumor can be replaced within ternally, but may often be evacu- the rectum and may remain replaced ated by pressure or position. for days, weeks, or months. Density. The tumor is firm in its texture. The tumor is soft and often fri- able. Hemorrhage. Hemorrhage is infrequent and Hemorrhage often becomes ex- seldom severe in amount. cessive and is of frequent occurrence. Pain. The pain is usually local and The pain is often conveyed to confined to the tumor. neighboring regions. The pain is usually of moderate The pain is severe, as a rule, in severity and is often absent. case the tumor becomes externally apparent. SURGICAL DISEASES OF THE ABDOMINAL CA V1TY. 285 EXTERNAL HEMORRHOIDS. CONDYLOMATA OF THE ANUS. Surface of Tumor. The surface of the tumor is The surface of the excrescences smooth. is of a Avarty appearance, resem- bling that of a straAvberry. Number. A solitary tumor is not uncom- The tumors are multiple, as a mon. rule, with deep clefts between them. Shape. The tumors are round or oval. The tumors are flat and broad. Development. The development of the tumors The development of condylomata is often very rapid. is usually slow. Discharge. No discharge is present. A profuse and irritating discharge exists. History. No venereal history is detected as A venereal history often exists as a cause. a cause. Effects of the Condition of the Bowel. The tumor is often affected in The tumors are independent of its size and appearance by the con- changes in the circulation of the dition of the bowel or causes affect- rectum or liver. ing the portal circulation. 286 SURGICAL DIAGNOSIS. INTERNAL HEMORRHOIDS. RECTAL POLYPUS. Nuaiber of Tumors. The tumors are usually multiple. A solitary tumor is most com- monly present. Size of Tumors. The tumor is generally small. The tumor is usually large. Pediculation. The pedicle is indistinct or absent. The pedicle is marked. Rapidity of Growth. Hemorrhoids often form with Polypus is usually of slow growth. great rapidity. Color. Hemorrhoids are usually of a The tumor is pale in color. violet color. Surface. The tumors are granular on their The surface of the tumor is surface. smooth. Age Affected. The young are rarely, if ever, af- The young are frequently af- fected, fected. Effects of Constipation. The condition of the boAvels ex- The size of rectal polypi is not erts a marked influence upon the affected by the condition of the size of the tumors. boAvels. Heaiorrhage. Hemorrhage is frequent and often Hemorrhage is infrequent, save severe. when the vascular form of polypus is present. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. RECTAL PROLAPSE. RECTAL POLYPUS. Tumor. The tumor is continuous all The tumor is located upon one around the circumference of the side of the rectum. rectum. Pedicle. No pedicle to the protrusion can A pedicle is always easily de- be detected. tected. State of Health. This condition is most common Occurs generally in healthy sub- in children with enfeebled con- jects. stitutions. Hemorrhage. Hemorrhage is frequent but is Hemorrhage is infrequent, save moderate in its severity. when the polypus is of the vascular variety. SYMPTOMS IN COMMON. Both occur chiefly in the young. " are reducible within the bowel. " are not severely painful unless retained after protrusion. " are pale in color. " painless to direct touch. " sensitive to traction upon them. 288 SURGICAL DIAGNOSIS. CANCER OF THE RECTUM. STRICTURE OF THE RECTUM. Age Affected. Is rare in the young, but is com- May affect any age. mon in advanced life. Location and Character. It may be detected as a uniform The constriction is usually an- infiltration around the rectum, or nular in character, and is seldom as nodular masses in its walls. It unilateral. It is most frequently is common near the anus, and its detected about two inches from the surface is often friable. anus, and it presents no abnormal condition of surface. Defecation. Defecation becomes difficult ear- Defecation becomes difficult late ly, even before marked constric- in the disease, as the rectal walls tion exists, from loss of contractile are normal in power. power in the rectum. Pain. A violent burning, or boring pain Pain is often absent. is present on defecation and often long after its completion. Abnoraial Sensations. A sensation of a foreign body in No abnormal sensations exist in the rectum is present. many typical cases. Health. The general health is rapidly The general health is slowly af- undermined. fected—if much altered. Discharge. A slimy, foetid, and often sanious No discharge is usually present. discharge from the bowel exists. SYMPTOMS IN COMMON. Both are associated with interference with defecation. " '■' " " diminished rectal calibre. " tympanitic distension of abdomen in advanced stages. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 289 FISSURE OF THE ANUS. FISTULA OF THE RECTUM. History. Occurs most often in females, debilitated subjects, or in syphilis. Occurs most often in men, and is preceded by a history of abscess. Pain. Pain is often absent and, if present, is not severe in type. A sense of moisture and itching is however present from the excoria- tion due to the discharge. The pain is burning in character. " " exacerbates often dur- ing menstruation. " " is augmented by defeca- tion. " " is often constant. " " is frequently not local but radiates to pel- vis, back, thighs, etc., etc. Sphincter of Anus. The sphincter is spasmodically The sphincter ani muscle is not contracted. The finger, if intro- affected. The bowel can be easily duced into the rectum, causes great and painlessly explored. pain. Urinary Symptoms. Retention of urine, painful mic- turition and other urinary symp- toms of a reflex character are com- Reflex urinary symptoms are sel- dom produced. mon. Inspection. A fissure or a small ulcer can be detected at the margin of the anus, if carefully looked for, as it is often concealed by the rugae. Inspection of the perineum re- veals either a papilla at the seat of the external opening of the fistula, or an orifice, Avhich is often con- cealed by folds of the skin. Discharge. No abnormal discharge from the fissure or ulcer occurs, sufficient to cause annoyance or notice. 19 A purulent or faecal discharge exists, causing irritation of the parts, staining the clothing, and generally having an offensive odor. 290 SURGICAL DIAGNOSIS. INDIRECT INGUINAL DIRECT INGUINAL HERNIA. HERNIA. Size of Tuaior. The tumor is often very large. The tumor is usually small in size. Shape of Tuaior. The tumor is usually flask-shaped. The tumor is usually globular. Location. The tumor is frequently scrotal. The tumor is seldom scrotal. Palpation. The tumor is usually an entero- The tumor is usually omental, cele, and is therefore soft and doughy and is therefore hard. to the touch. Per'cussion. Resonant percussion usually ex- Flatness on percussion over the ists over the tumor. tumor is frequent. Inguinal Canal. The inguinal canal is filled. The inguinal canal is empty. Speraiatic Cord. The spermatic cord usually lies The spermatic cord can be de- concealed behind the neck of the sac. tected at the outside of the neck, as a rule. Epigastric Artery. The pulsation of the deep epigas- The epigastric artery can be often trie artery is concealed. felt to pulsate outside of the neck of the tumor. Reduction. The tumor is reduced by pressure The tumor is reduced by pressure outwards and bachwards. directly bachwards. SYMPTOMS IN COMMON. Both are associated with a sudden advent. " an impulse on coughing. " reducibility, as a rule. " possible intestinal embarrassment. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 291 SCROTAL HERNIA. SARCOCELE. Palpation. The tumor is soft and doughy to The tumor is usually hard and the touch. resistant. Weight. The tumor is light. The tumor is heavy. Surface. The tumor is smooth and regular. The tumor is often nodular and irregular in outline. Pain. The tumor is seldom painful, un- The tumor is frequently painful. less inflamed or strangulated. Developaient. The tumor is of sudden advent. The tumor grows slowly, as a rule. Percussion. The percussion note OA'er the The percussion note over the tumor is usually resonant. tumor is usually dull or flat. Inguinal Canal. The inguinal canal is usually The inguinal canal is empty. filled. Cough Iaipulse. An impulse on coughing is pres- No impulse on coughing can be ent in the majority of cases. detected. Bowel. The bowel is occasionally embar- The bowel is never affected. rassed. Reduction. Reduction is accomplished by The tumor is irreducible. pressure bachwards and outwards, unless the hernia is strangulated, incarcerated, or irreducible. Auscultation. Gurgling may be detected. No auscultatory sounds are pres- ent. 292 SURGICAL DIAGNOSIS. SCROTAL HERNIA. HYDROCELE OF TESTICLE. Shape of Tumor. The tumor is usually flask-shaped. The tumor is pyriform or ovoid. Development. The tumor is usually of sudden Develops slowly from below up- advent; and develops from above wards. downwards. Palpation. The tumor is soft and doughy to The tumor is hard, tense and the touch, as a rule. elastic. Fluctuation. Fluctuation is absent. Fluctuation is well marked. Translucency. The tumor is opaque. The tumor is translucent. Percussion. Resonant percussion is usually The percussion note over the tu- present over the tumor. mor is dull or flat. Reducibility. The tumor is usually reducible. The tumor is never reducible. Speraiatic Cord. The spermatic cord is usually The spermatic cord is neither concealed by the neck of tumor. concealed nor displaced. Inguinal Canal. The inguinal canal is filled, save The inguinal canal is empty. when direct hernia enters the scro- tum. Aspirator. The effects of aspiration are nega- Fluid is withdrawn by aspiration tiA'e. or tapping. Bowel. The action of the bowel may be The action of the boAvel is un- embarrassed, affected. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. SCROTAL HERNIA. VARICOCELE. Palpation. The tumor is usually smooth on The tumor is knotty and irregu- its surface and regular in its outline, lar and feels like " a bag of worms." Color of Tuaior. The tumor is of normal color. The tumor is bluish. Location. May exist on either side. Most frequent on the left side. Effect of Heat. Negative. Tumor increases on the applica- tion of heat. Developaient. The tumor develops suddenly. The development of the tumor is gradual. Percussion. The percussion note is usually The percussion note is dull. resonant.. Fluctuation. Fluctuation never exists. Fluctuation may exist if the ves- sels be very large. Spermatic Cord. The spermatic cord is concealed The spermatic cord is not af- or displaced. fected. Inguinal Canal. The inguinal canal is usually The inguinal canal is uninvolved. filled. Cough Iaipulse. A cough impulse is usually de- No impulse on coughing exists. tected. Reduction. Reduction is accomplished usually Reduces often spontaneously by by taxis only. any position favoring increased venous return. Return of Tuaior. The tumor, if once reduced, can The tumor returns when the be prevented from a return by pres- patient stands up, in spite of pres- sure at the external ring. sure at the ring. Sensation in Scrotuai. There is a sense of distension only, A sense of weight, and of con- unless inflammation or strangula- stant dragging in the scrotum, ex- tion exist. ists. 294 SURGICAL DIAGNOSIS. SCROTAL HERNIA. HEMATOCELE OF TESTIS. Advent. The ad\-ent of the tumor is sud- The advent is sudden, if of trau- den, and it grows from above, doAvn- matic origin ; but if of spontane- wards. ous origin, the tumor may develop sloAvly. It grows from below, up- wards. Fluctuation. Fluctuation is never present. Fluctuation is always present un- til coagulation occurs. Palpation. The tumor is soft and doughy. The tumor is soft at first, but hard after coagulation occurs. Shape. The tumor is flask-shaped, unless The tumor is pyriformin its shape. due to direct hernia. Integument. Normal in color. Ecchymotic. Reducibility. The tumor is usually reducible. The tumor is irreducible. Percussion and Auscultation. Percussion is usually resonant; Percussion is dull or flat. Aus- gurgling may be also heard. cultation negative. Weight of Tuaior. The tumor is light in weight. The tumor is heavy. Speraiatic Cord. The spermatic cord is concealed The spermatic cord is unaffected. or displaced. Inguinal Canal. The inguinal canal is usually filled. The inguinal canal is empty. Constitutional Symptoais. None, save when strangulation, Pallor and great prostration are or severe inflammation of the sac often present from the loss of blood. exists. Bowels. The action of the bowel may be The bowels are unaffected. embarrassed. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 295 INCOMPLETE INGUINAL BUBO. HERNIA. Pain. The tumor is generally painless. The tumor is usually painful. Palpation. The tumor is usually soft. The tumor is hard, at the onset. Fluctuation. Fluctuation is absent. Fluctuation is present if suppura- tion occurs. Locality. The tumor is confined to limits of The tumor is often diffused beyond inguinal canal. the limits of the inguinal canal. Reducibility. Reduction is possible and often Reduction is impossible. easy. Outline of Tuaior. The outline of the tumor is often The outline of the tumor is usual- indistinct, ly clearly defined. CEDEArA. CEdema is absent, as a rule. CEdema is present, as a rule. Percussion. Frequently resonant percussion Dull percussion exists over the exists. tumor. Cough Iaipulse. A cough impulse is often detected. A cough impulse is usually absent. History. A history of muscular strain is A venereal origin is often de- usually present. tected. Bowel. The boAvel may be embarrassed in The bowel is unaffected. its action. Constitutional Syaiptoms. Absent, unless strangulation, or Frequent constitutional symp- inflammation of the sac, occurs. toms occur. Auscultation. Gurgling may be detected. No gurgle will be heard. 296 SURGICAL DIAGNOSIS. BUBONOCELE. UNDESCENDED TESTICLE. Pain. The tumor is usually painless. The tumor is very painful, and on pressure over it yields the pecu- liar sickening sensation Avhich is characteristic of compression of the testicle. Scrotum. Both testicles are present. The testicle is found wanting upon the side corresponding to the tumor. The scrotum is normal in develop- The scrotum is imperfectly de- ment, veloped on the same side. Reduction. Reduction of the tumor is asso- Reduction may be impossible, but ciated with a gurgle. if not so, no gurgle accompanies its return to the abdomen. Boavel. The action of the bowel may be The bowel is unaffected. embarrassed. SYMPTOMS IN COMMON. Both are associated Avith a small tumor. " " " " frequent reducibility. " maybe" " sudden advent. " impulse on coughing. " " " " vomiting. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 297 INGUINAL HERNIA. IMPACTION OF F2ECES. Location of Tumor. The tumor is felt only in the in- The tumor may be felt at the side, guinal region. as well as in the inguinal region. Developaient. The tumor develops suddenly The tumor develops slowly with after some strain or injury. previous colicky pains and from no apparent causation. Percussion. The percussion note is usually The percussion note over the tu- resonant. m0r is flat. Effects .of Pressure. Pressure causes no permanent Firm localized pressure over the change in the tumor unless it effects tumor causes indentation. reduction. Sensitiveness. The tumor is not sensitive unless The tumor is always tender on inflamed or strangulated. pressure in its advanced stages. Pain. The tumor is usually painless. The tumor is painful. Boavel. The bowel may be unaffected. Obstinate constipation always ex- ists. Voaiiting. Vomiting is absent if the hernia Vomiting is usually present. be not inflamed or strangulated. SYMPTOMS IN COMMON. Both are associated Avith a tumor. " may be associated with obstinate constipation. 298 SURGICAL DIAGNOSIS INGUINAL HERNIA. HYDROCELE OF THE CORD. Limits of Tumor. The tumor is frequently scrotal, The tumor is circumscribed. and is generally diffused. Palpation. The tumor is soft, as a rule. The tumor is tense. Reducibility. The tumor reduces with a gurgle. The tumor is usually irreduci- ble, but if not so no gurgle is pres- ent on its reduction. Translucency. The tumor is opaque. The tumor is often translucent. Fluctuation. The tumor does not fluctuate. The tumor is fluctuant. Percussion. The percussion note is resonant The percussion note is dull over over the tumor, as a rule. the tumor. Boavel. Intestinal embarrassment is often No intestinal embarrassment ex- present, ists. Iaipulse froai Testicle. Movements of the testicle have The testicle, if moved, transmits no effect upon the tumor. an impulse to the tumor. Cough Iaipulse. An impulse on coughing is fre- Impulse on coughing is absent. quently felt in the tumor. Auscultation. Gurgling is often heard in the No gurgling is detected. tumor. Return of the Reduction. The tumor remains reduced if The tumor returns after reduc- the dorsal position is maintained. tion irrespective of position. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 299 FEMORAL HERNIA. ENLARGED GLANDS. Depth of Tumor. The tumor is often felt deep in The tumor is always superficial. the groin. Mobility of Tumor. The movements of the tumor are The tumor exhibits great mo- restricted, bility. Reducibility. The tumor is reducible by pres- The tumor is not reducible. sure dowmvards, backwards and upwards. Nuaiber of Tumors. The tumor is always solitary. The tumor is seldom solitary. Fluctuation. Fluctuation is never present. Fluctuation is often detected Avithin the tumor. Bowel. Intestinal embarrassment is often No intestinal embarrassment is present. produced. Cough Impulse. An impulse on coughing may No impulse on coughing is de- often be detected on flexion and ad- tected. duction of the thigh, Avith the body bent forwards. Auscultation. Gurgling within the tumor is No gurgling is ever perceived in sometimes heard. the tumor. History. Is usually due to some severe A scrofulous diathesis is often muscular effort. present. Percussion. Resonant percussion may exist The percussion note over the tu- over the tumor, in some cases. mor is flat. Sex. Is rare in the male sex. Is equally frequent in both sexes. 300 SURGICAL DIAGNOSIS. FEMORAL HERNIA. PSOAS ABSCESS. Fluctuation. The tumor never fluctuates. The tumor often fluctuates, if superficial. Percussion. The percussion note over the The tumor ahvays yields a dull, tumor may be resonant. or flat percussion note. Relation of Feaioral Vessels. The neck of the sac lies internal The neck of the sac lies external to the femoral artery. to the femoral artery. Pain. Pain is frequently absent. A pain in the back or loins has always preceded the development of the tumor. General Health. The general health is often nor- The health is impaired. mal. History. A severe muscular effort usually A history of spinal disease or of precedes the advent of the tumor. pelvic affection exists. Bowel. Intestinal derangement is often The boAvel acts normally. produced. Reducibility. Reduction occurs with a distinct The tumor disappears gradually and sudden disappearance of the under direct pressure, but no gurgle tumor, usually with a gurgle. is perceived. The reduction requires pressure No absolute direction of pressure downwards, bachwards and up- is required. wards. Return of Tuaior. The hernia remains reduced if The tumor returns as soon as the the dorsal position is maintained. pressure is removed. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. FEMORAL HERNIA. VARIX OF SAPHENOUS VEIN. Size and Direction of Tuaior. The tumor is usually small, and The tumor is variable in size, and is directed obliquely across thigh. lies in the longitudinal axis of the limb. Palpation. The tumor is usually hard and The tumor is soft and often in- tense, but may be doughy. distinctly fluctuant. Effect of Heat. The tumor is not affected by heat. The tumor is increased in size by heat. Sex. The tumor is most frequent in Is equally common in both sexes. females. Percussion. Resonant percussion often exists. Flatness on percussion is present over tumor. Reducibility. Reduces with a sudden slip and a Reduces gradually without any gurgle. gurgle. Is reduced by pressure directed Is reduced by direct pressure and downwards, bachwards and up- a recumbent position. wards. Return after Reduction. The return is prevented when the The tumor returns when the patient is allowed to stand up, by patient stands, in spite of pressure pressure over the femoral ring. on the femoral ring. Boavel. Intestinal embarrassment is not No embarrassment of the func- infrequent. tion of the bowel is ever produced. Skin. The skin is normal in color. The skin is often discolored over tumor. Cough Impulse. May be detected by fiexion and Is often absent but may exist. adduction of the thigh, with the body bent forwards. 302 SURGICAL DIAGNOSIS. FEMORAL HERNIA. INGUINAL HERNIA. Sex Affected. Is most common in females. Is most frequent in males. Size of Tumor. Is usually a small tumor. Is often very large. Shape of Tumor. Is usually round, or, if elongated, Is flask-shaped and, if elongated, lies obliquely across the thigh. is often scrotal in its situation. Percussion. The tumor gives frequently a dull Resonant percussion is usually note on percussion. present. Location of Neck of Sac. The neck is felt below Poupart's The neck lies above Poupart's ligament. ligament. Relation of Spermatic Cord. The cord is felt internal and in The cord is felt external to, and front of the neck of the sac. behind the neck of the sac. Scrotum and Labia. The tumor never enters the The tumor often enters the scro- scrotum or the labia. tum and the labia. Femoral Pulsation. Femoral pulsation can be felt ex- The finger when pushed into the ternal to the neck of the tumor canal of the tumor fails to detect when the finger is introduced into any pulsation. the canal. Spine of the Pubes. The spine of the pubes can be The spine of the pubes can be felt to lie internal to the neck of detected externally to the neck of the sac. the sac. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 303 FEMORAL HERNIA. LIPOMA OF FEMORAL CANAL. Density of Tuaior. The tumor is often hard. The tumor is always doughy to the touch. Outline of Tumor. The tumor is small and well de- The tumor is not well defined in fined in its outline. its outline. Percussion. Resonant percussion may exist The tumor yields a dull percus- over the tumor. sion note. Advent. The tumor usually appears sud- The tumor develops slowly. denly. Reducibility. The tumor is usually reducible. The tumor is irreducible. Cough Iaipulse. An impulse on coughing can An impulse is never present often be detected by flexion and ad- within the tumor, on coughing. duction of the thigh, with the body bent forwards. Bowel. Intestinal embarrassment is not The bowel is not affected. infrequent. SYMPTOMS IN COMMON. Both are associated with a tumor in the upper part of the thigh. ft ft ft ft a inside of the femoral vessels. " " " " " external to the pubic spine. t< t( a tt tt below the spine of the pubes. 304 SURGICAL DIAGNOSIS. VENTRAL HERNIA. UMBILICAL HERNIA (Oaiphalocele ; Exomphalos). Advent. The tumor is never congenital. The tumor is often congenital. Age. The tumor may occur at any age. The tumor is frequent in infants. Appearance of Tuaior. The tumor has a well - defined The tumor usually has no appa- nech. rent neck, but consists of a simple bulging at the navel, Avhich is usu- ally spherical in its outline. Navel. The navel is present and in its The navel is absent, as the tumor normal situation. supplies its place. Palpation. The edges of an opening or fis- No unnatural opening can be de- sure in the abdominal walls can tected. often be detected. Reducibility. Reduction of the protrusion is Reduction is effected by mere often someAvhat difficult. pressure upon the protrusion. History. A previous history of traumatism, The history of traumatism or ab- abscess, or Aveakening of the abdo- scess is seldom present. minal walls, is present. SURGICAL DISEASES OF THE ABDOMINAL CA VITY. 305 THYROID HERNIA. PERINEAL HERNIA. Sex Affected. The tumor seldom occurs in the Is a rare disease ; but it affects male sex ; when small it may often both sexes equally, and is easily de- be impossible to detect its presence, tected Avhen present. Location. A tumor appears in the thigh near A tumor appears in the perineum the inferior commissure of the vulva, above the rectum. Neck of Tumor. The neck of the tumor can be felt A neck to the tumor is not dis- from the outside of the body, in the cernible, unless the protrusion is old and the emaciated. In obscure very extensive and involves the pe- cases a vaginal or rectal exploration rineum. The question of origin is, is often required to detect the situa- however, easily decided if the tu- tion of the neck of the tumor. mor be pronounced. SYMPTOMS IN COMMON. Both are associated with a tumor of sudden advent. " " " " resonant percussion. " " " " reducibility. " '' " " impulse on coughing, as a rule. " " " " ■ possible intestinal embarrassment. 20 306 SURGICAL DIAGNOSIS. DIAPHRAGMATIC HERNIA. MEDIASTINAL TUMORS. Percussion. Tympanitic percussion, or a lo- Mediastinal tumors are usually calized dulness low down in the situated high up in the thorax, as mediastinum or thorax is present, shoAvn by a localized dulness on if a hernial protrusion occurs percussion. through the diaphragm and is superficial. Auscultation. A gurgling sound is often heard No auscultatory signs exist, ex- over the seat of the tumor. cept in case of aneurism, Avhen a bruit will be detected. Advent. . The patient is conscious of the The tumor de\-elops without any sudden ad\Tent of the protrusion ■ marked or sudden symptoms till its into the thorax. size creates pressure. Bowel. Intestinal embarrassment is liable The bowel is unaffected. to exist. Thirst. Extreme thirst is liable to be Extreme thirst is absent. present. Peritonitis. Symptoms of peritonitis occur rapidly after the appearance of the tumor, if it be strangulated. No peritoneal symptoms are ever produced. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 307 CONGENITAL HERNIA. HYDROCELE. Age Affected. Is usually a disease of infant life ; May affect any age ; and, if in but, if once present, subsequent at- adults, is not necessarily associated tacks in adult life may occur. Avith a history of a previous attack. Fluctuation. The tumor is usually fluctuant at The tumor is markedly fluctuant its upper portion as the peritoneal in all of its localities. effusion gravitates into the sac. Translucency. The tumor may be translucent. The tumor is always translucent. Pedicle. The tumor has a marked pedicle. The tumor is not pediculated. Shape of Tumor. The tumor is globular. The tumor is pyriform. Development. The tumor may be of sudden oc- The tumor always develops slowly currence, or may show sudden and and gradually. rapid increase in its size when once developed. Inguinal Canal. The inguinal canal is either dis- The inguinal canal is empty. tended or involved. Reducibility. The fluid portion, when reduced The tumor cannot be reduced. by taxis or pressure, leaves a previ- ously concealed testicle which also reduces Avith a marked gurgle and occasions a peculiar sichening sen- sation during its passage through the inguinal canal. 308 SURGICAL DIAGNOSIS. CONGENITAL HERNIA. INFANTILE HERNIA. Advent. Occurs before the cavity of the Occurs after the closure of the tunica vaginalis has closed after the tunica vaginalis. descent of the testicle. Fluctuation. Fluctuation exists at the upper Fluctuation is absent. portion of the tumor from gravita- tion of the peritoneal fluid into the sac. Translucency. The tumor is frequently translu- The tumor is not translucent. cent at the upper portion of the sac. Reduction of Tumor. The reduction of the fluid con- The reduction of the tumor leaves tents and the intestinal portion of the testicle irreducible. the tumor leaves the testicle appa- rent, Avhich also reduces with a gur- gle and marked pain. Age Affected. Never affects adults unless a pre- Is most common in infancy, but vious attack has existed in infancy, may occur at any age from an ab- normal condition of the parts. DISEASES OF TISSUES. DISEASES OF TISSUES. I shall consider diseases of tissues in the following order: A. INFLAMMATORY CONDITIONS OF TISSUE. Under Avhich head may be enumerated 1. Tumefaction. Tumefaction of tissue always accom- panies severe forms of inflammatory processes. It is due to the excessive supply of blood furnished by the dilated capillary vessels, and frequently to an accompanying oedema of the inflamed tissues. It is associated Avith local pain and tenderness to the touch, as a rule, and is characterized also by a local and, possibly, a general rise in temperature. 2. Induration. Induration of tissue depends upon an abnormal connective-tissue cell-growth and its or- ganization and development into new tissue. It is the associate of chronic or sub-acute inflam- matory processes, as a rule, since, in the acute form, the new cell-growth is often too rapid to undergo organization, and suppuration follows. Inflammatory indurations of tissue are usually unassociated with pain or local symptoms after the cause has disappeared, and are slowly removed by nature, in the majority of instances, through a pro- cess of fatty degeneration and absorption. A diag- nosis is therefore made from its mode of origin and gradual disappearance. 3. Suppuration of Tissue. Suppuration of tissues may accompany superficial ulcerative or granulative pro- cesses, or may be, in itself, a circumscribed process of destruction of tissue. In the former conditions pus is an unimportant element, but in the latter it occasions marked and peculiar symptoms, and has received a special nomenclature. 311 SURGICAL DIAGNOSIS. Circumscribed pus may exist as acute or chronic abscess, furuncle, anthrax, suppurative inflammation of glands and organs, and as a symptom oipyaimia. It frequently results in the formation of sinuses and fistulce, when the source of irritation remains, as in caries, necrosis, foreign bodies, etc., etc. The character of pus is liable to variations, and separate names have been given the most common varieties. Thus healthy or laudable, ichorous, sani- ous, curdy, muco-pus, and sero-pus are terms most fre- quently used to express the existing condition and appearance of the discharge. Suppuration, if circumscribed and retained within tissue, yields both local and constitutional symptoms. The local symptoms are the development of a tumor, which is at first hard, but afterwards soft or fluctuant, and a change in the skin, which often' be- comes red, shiny and cedematous if the suppuration be near the surface. The constitutional symptoms are chills, fever, and elevation of the pulse, followed by hectic and exhaus- tion, if the suppuration be extensive. 4. Ulceration of Tissue. By an ulcer is meant a super- ficial solution of continuity of soft tissues, dependent upon molecular death. The process of ulceration can never occur within the substance of any tissue; it is essentially a condition of the surface. Ulcera- tion may affect the cutaneous and mucous surfaces of the body, the lining coat of the blood-vessels and serous membranes. Ulceration may be the result of, 1. Enfeebled cir- culation or defective nutrition from lack of blood, as exists in newly formed cicatrices, the lower limbs in the aged, the alae of the nose, and the cornea of the poorly nourished. 2. In specific diseases, as in scurvy, scrofula, some forms of syphilis, lupus, etc., etc. 3. In direct inflammation of an intense charac- ter, as in severe mechanical injury, the application of a chemical irritant or long-continued pressure upon a circumscribed locality producing injury to the surface. 4. Abnormal blood conditions, indepen- dent of congenital or acquired diathesis, may tend DISEASES OF TISSUES. 313 to excite ulceration of the serous lining of the blood-vessels and other serous structures. Ulcers may be classified as healthy, weak, indolent, irritable, hemorrhagic, inflamed, varicose, and phage- denic. The appearance of the edges of the ulcer and of the granulations upon its surface will character- ize the first six of these, while the history of origin and rapidity of development by sloughing will ren- der the other two obvious. B. GANGRENE OF TISSUE. A condition dependent upon an absolute and permanent arrest of nutrition to some local part of the body, provided that part retains to a greater or less degree its external form and anatomical characters, is termed " gangrene." The appearance of the affected part depends upon its previous vascularity, its solidity of structure, the cause and rapidity of the gangrenous process, and the presence or absence of exposure to the air. Gangrene may be divided into moist, dry, and hospital gangrene, on the basis of its appearance and origin. Of these, the first depends upon obstructed venous return; the second upon impaired arterial supply ; the third upon some epidemic poison causing a tendency to phagedena. Gangrene may result from local violence, excessive heat or cold, escharotics, inflammatory congestion and oedema, embolism, thrombosis, ligature of vessels, pres- sure of tumors, abnormal blood conditions, as in uraemia, fevers, etc., etc., old age, atheroma, and in severe malarial affections in children. Gangrene also follows excessive doses of ergot and phosphorus, and the inoculation of farcy, or glanders poison. Its symptoms depend upon its variety. In the dry form of gangrene, a simple withering and mummifying process occurs. In the moist variety, the part becomes dark, soft and infiltrated with gases from decomposition, causing an emphysematous crackling if pressure be made upon the part affected. It is characterized by blebs upon its surface, is offensive in odor, and finally separa- tion of the sphacelus or slough occurs. In hospital gangrene, a phagedenic process commences within a wound and symptoms of pyaemia often rapidly follow. It is markedly contagious and usually fatal. 314 SURGICAL DIAGNOSIS. C. ERYSIPELAS. Erysipelas is a diffuse inflammation of the skin, mucous, or serous membranes, which rapidly spreads over large surfaces, and is accompanied Avith febrile movement. It is, clinically, of three varieties: 1. Cutaneous erysipe- las, where only the superficial portions of the skin are involved. 2. Phlegmonous erysipelas, where the subcuta- neous cellular tissue is affected as well as the derma. 3. Internal erysipelas, where serous or mucous mem- branes are involved. The face is the most frequent seat of the cutaneous form. It commences usually Avith a chill, rise in tem- perature to 103°-104°, nausea or vomiting, and frequent stupor or delirium. The face becomes reddened and cedematous, the fea- tures distorted by swelling, and the eyes closed from oedema when the lids are implicated. The constitutional symptoms increase with the advance of the disease and terminate with its abatement, in from eight to twelve days. As the skin grows pale, it becomes scaly, abscesses or boils frequently occur, and the beard falls out but subsequently returns. Erysipelas occurs most in the spring and fall of the year. It may follow absorption of poisonous matter by the lymphatics, and frequently accompanies suppuration, when occurring Avithin the body. It occurs in the debili- tated, and in those addicted to alcohol, especially when subjected to injury. It is claimed that diabetes and Bright's disease predispose to it, and it has by no means been proven to be non-contagious. It is a frequent com- plication of wounds, especially those of the head and hands. The phlegmonous form occurs most often in the legs. It is associated Avith great tension of the affected part, subsequent sloughing of the skin, and exhaustive sup- puration. Its duration depends on its severity. D. ELEPHANTIASIS ARABUM—"Barbadoes Leg;" "Pa- chydermia" Elephantiasis consists of a hypertrophy of all the structures of which the integumentary cover- ing of the body is composed. The epidermis becomes thickened, roughened as in ichthyosis, and intersected with DISEASES OF TISSUES. 315 fissures. The chorion is increased in thickness, and the subcutaneous connective tissue is infiltrated with a gela- tinous material, which oozes out on section of the skin, and quickly coagulates. This disease is due largely to an engorgement of the lymphatic vessels. It begins as an erysipelas Avith an cedematous swelling of the lymphatic glands, or as an eczema, phlebitis, or lymphangitis. Elephantiasis may affect the feet, legs, scrotum, penis, labia and clitoris. The size of the affected part often be- comes immense. This disease is essentially one of hot climates. It is endemic in the East Indies, Syria, Japan, Egypt, the Barbadoes, and occasionally on the continents of Europe and America. It seldom begins before pu- berty, and is most frequent in males. It is sometimes hereditary. The absence of luxuriant vegetation seems to favor its development. When the scrotum becomes affected, as it frequently does, either independently, or when a similar condition of the leg exists, the penis is usually drawn into the tumor, as it enlarges, and becomes lost to vieAv. The disease exerts little, if any, influence upon the general health. Patients live for years, burdened with the weight of the groAving tumor, without impairment of any vital function. In advanced stages of the disease, obstinate ulcers often form upon the affected parts, or abscesses and even gangrene occur. An acute attack of erysipelas occasionally acts as a cause of death in these cases. E. LUPUS.—"Lupoid Ulceration;" "Lupus Vulgaris." This disease attacks the face, nose, cheeks, ears, buttocks and extremities. The trunk is rarely affected. It is also frequently found in the mucous membrane of the lips, hard palate, and throat. It begins as a brownish- red spot, which, varies in size from that of a pin's head, to a pea, and which subsequently becomes papular, or elevated, with a frequent increase in its size. This papule next undergoes cell infiltration and becomes nodular in appearance, and in a more advanced stage leads to the formation of an ulcer, through fatty degenera- tion or molecular destruction of tissue. The ravages of this ulcerative stage are often terribly severe and associated with marked deformity. 316 SURGICAL DIAGNOSIS. This disease occurs often in children, even as early as three years of age, but it requires at this early age several years to develop. It makes the most rapid strides dur- ing puberty. As it occurs most often upon the face, especially about the nose and mouth, ectropion, or eversion of the eyelid, not infrequently occurs from contraction of the tissues of the cheek. Epithelial cancer is sometimes developed from lupus after that disease has lasted for years. The cause of lupus is unknown. It does not develop as rapidly as syphilides, and is often present where the parents are not diseased. It fails also to respond to specific treatment. It is sometimes associated with scrofulous glandular enlargements. In the preceding pages I have hastily enumerated those changes in tissues, exclusive of tumors, which are most liable to be of sur- gical interest and value. I have avoided lengthy explanations of pathological processes, but have been forced to enter somewhat into their etiology, as it has a direct bearing upon the subject, which seems, to my mind, sufficient to demand it. I have arranged in the form of diagnostic tables the various forms of abscess, which are frequently encountered, and the diseases Avith which they are most liable to be confounded. I have also added as a guide to memory differential tables between dry gangrene and moist gangrene, and cutaneous and phlegmonous erysipelas. DISEASES OF TISSUES. 317 ANTHRAX (Carbuncle). FURUNCLE (Boil). Age Affected. Occurs during or after middle life. Occurs at any age. Location. Occurs in cellular tissue which is May occur in any locality. largely supplied Avith vessels. It is chiefly developed on the posterior surface of the trunk, and is seldom present upon the extremities. Shape of Tuaior. The tumor is elevated, but has a The tumor is usually conical in flat surface. shape. Pointing. The tumor never points. The tumor points rapidly. Method of Evacuation. The tumor opens at several places The tumor bursts at one spot and becomes honey-combed in ap- only, as a rule. pearance. Contents Evacuated. The discharge of pus occurs, and The contents of the tumor are long glistening shreds of dead con- chiefly pus. nective tissue subsequently pro- trude. Base of Tumor. The base is deeply indurated. The base is little indurated and the outline of the tumor is indis- tinctly circumscribed. Constitutional Effects. The effects upon the constitution The constitutional effects are are severe and often alarming. slight in degree, or absent. Results. Is not infrequently fatal. Is seldom, if ever, fatal. 318 SURGICAL DIAGNOSIS. ABSCESS. LOCAL 03DEMA, if circumscribed. Pain. The pain is markedly increased Pain on pressure is slight or ab- by pressure. sent. Palpation. The tumor is hard at its circum- The tumor is of uniform consis- ference, but is soft or elastic in its tence throughout. centre. Fluctuation. The tumor fluctuates as suppura- The tumor never fluctuates. tion advances. Chills. Rigors are often present if the Chills are absent, unless some suppuration be extensive. complication exists. SYMPTOMS IN COMMON. pain. redness of the skin. marked local swelling. elevation of local temperature. constitutional disturbance. Both may be associated with a a a it ti a tt a ft a a tt tt it a tt DISEASES OF TISSUES. 319 ACUTE ABSCESS. CHRONIC OR COLD ABSCESS. Age Affected. May occur at any age. Is most common in the young. Health. Often affects the healthy. Occurs in the debilitated, espe- cially in those of scrofulous or lym- phatic temperaments. Pointing. The tumor points rapidly. The tumor points very slowly. Temperature. The temperature of the body is The general temperature is near- often markedly elevated. ly normal. Pulse. The pulse is usually increased. The pulse is usually normal. Skin. The integument over the tumor The skin is usually pale and sel- is usually red, cedematous and ad- dom cedematous or adherent. herent to the surrounding parts. Size of Tumor. The tumor is seldom very large. The tumor is often immense in size. SYMPTOMS IN COMMON. Both are associated Avith an abnormal tumor. " tt a a fluctuation. tt a t-. a a detection of pus by the aspirator or exploring needle. tt a tt it pointing. 320 SURGICAL DIAGNOSIS. ILIAC ABSCESS. ABSCESS OF ABDOMINAL WALL. Origin. Follows parturition, instrumental Is usually independent of partu- delivery, or puerperal fever. rition. Pain. The pain is often very severe and Pain is often not markedly severe is accompanied, frequently, with nor are constitutional symptoms so rigors. frequently present. Situation of Tuaior. The tumor lies deep in the iliac The tumor is superficially lo- fossa. cated. Integuaient. The skin is involved late, if ever. The skin is involved early in the disease. Mobility of Tuaior. The tumor is immovable and hard The tumor allows of slight move- at its commencement. ment with the abdominal Avails. Rectal and Vaginal Examination. The tumor is definitely located by The tumor cannot be detected a rectal and vaginal examination, through the vagina or rectum. or by conjoined manipulation. Bladder and Rectum. The bladder, and often the rectum The bladder and rectum are not is affected by pressure of the tu- affected. mor. Direction of Escape of Pus. The pus may be evacuated The pus is usually evacuated di- through the vagina, uterus, bowel, rectly through the integument over bladder, skin of the thigh, through the seat of the tumor. the sciatic notch appearing upon the buttock, or into the peritoneal cavity. DISEASES OF TISSUES. 321 PSOAS ABSCESS. FEMORAL HERNIA. Situation of the Tuaior. The tumor, if in the thigh, lies The tumor lies inside of the fe- outside of the femoral vessels. moral vessels. Percussion. The percussion note over the tu- Resonant percussion over the tu- mor is dull. mor may exist. Pain. A pain in the back or loins has The tumor may be unassociated always preceded the deAdopment of with pain. the tumor. Fluctuation. The tumor is fluctuant, if super- The tumor never fluctuates. ficial. History. The tumor is preceded by a his- The tumor follows some severe tory of spinal disease, or of a peh'ic muscular strain, as a rule. affection. Bowel. No intestinal embarrassment is The intestinal function is often present. interfered Avith. General Health. The general health is impaired. The general health may be nor- mal. Reducibility. The tumor reduces under direct The tumor is reduced by pressure pressure, but no gurgle on reduction downwards, bachwards and up- is perceived. wards, and a gurgle is detected as the tumor disappears. Tendency to Return. The tumor returns when pressure The tumor will not return, as a is removed. rule, as long as a recumbent position is maintained. 21 322 SURGICAL DIAGNOSIS. ABSCESS OF ABDOMINAL ENLARGED SPLEEN. WALLS. Situation. The tumor is superficial. The tumor is deeply situated. Mobility. The tumor is only slightly mov- The tumor is freely movable. able. Pressure. The tumor is sensitive to pressure. The tumor is not sensitive to pressure. Fluctuation. Fluctuation appears as the dis- Fluctuation is always absent. ease advances. Pain. The pain is local and constant. No pain exists, as a rule. Teaiperature and Pulse. The temperature and the pulse The temperature and pulse may are usually increased. be affected if malarial enlargement exists. Rigors. Chills may be present. Chills are absent, save in malaria. History*. A history of contusion, or of some The tumor develops Avithout any exciting cause exists. apparent causation. Integument. The skin is usually involved and The integument is normal in its becomes red and cedematous, as appearance. pointing takes place. DISEASES OF TISSUES. 323 MOIST GANGRENE. DRY GANGRENE. Etiology. A condition of obstructed venous A condition of impaired arterial return is present, as a rule, although supply exists, Avhich is dependent abnormal blood conditions as pro- upon atheroma, embolism, pressure duced by fevers, uraemia, farcy, etc., upon the vessels, ligature, old age, etc., may excite this form of gan- ergot poisoning, etc. grene. Appearance of Affected Part. The diseased part is dark in co- The affected part undergoes a lor, soft, often emphysematous from process of desiccation, becoming, in gases due to decomposition, dotted time, shrivelled and mummified Avith blebs upon its surface and of without odor or decomposition. offensive odor. Constitutional Effect. Septicaemia is often produced by Blood poisoning, as evidenced by absorption of the decomposing ani- pyaemic or septicaemic symptoms, is mal material by the lymphatic ves- infrequent. sels. Progress. The disease progresses rapidly, as The disease is frequently of long a rule. duration. SYMPTOMS IN COMMON Both are associated with diminished temperature in the affected part. k tt tt a diminished sensibility " " tt a a altered color " " a a ti n spontaneous separation of the 324 SURGICAL DIAGNOSIS. CUTANEOUS ERYSIPELAS. PHLEGMONOUS ERYSIPELAS. Origin. Is usually of idiopathic origin. Is generally the result of injuries penetrating to the cellulaj tissue. Skin. The skin is uniform in its redness The color of the skin is not uni- when the erythema is fully devel- form at the onset, but is usually oped. darker at the centre. Swelling. Swelling may often be absent or A swelling is marked from the slight in amount, but when exten- onset Avhich at first pits on pressure, sive pitting on pressure exists. but the skin soon becomes too tense to admit of pitting. Pain. A tingling and itching pain is A burning and often a severe pul- at first experienced, which subse- sating pain is present at the onset quently becomes of a smarting char- Avhich lasts till the tension is re- acter. lieA'ed. Suppuration. Suppuration is seldom produced, Suppuration forms on the seA'enth the attack subsiding Avith desqua- or eighth day, and is preceded by mation of the cuticle. softening of the affected part, re- turn of pitting on pressure and a sense of fluctuation. Sloughing. Sloughing is rarely, if ever, pro- Sloughing of the skin rapidly f ol- duced. lows unless the tension is relieved and the pus evacuated. The Avound being aftenvards characterized by the protrusion of dead connective tissue in the form of white glisten- ing shreds. Termination. Is usually associated with a good Frequently kills by exhaustion, if prognosis unless the meninges be- extensive, or by blood poisoning. come affected. DISEASES OF TISSUES. 325 TUMORS. Tumors may be of two great classes, >« and solid: the former are called cysts or cystic tumors; the latter are usually named and classified on a basis of their anatomical construction, as revealed by microscopical examination. Solid tumors comprise both inflam- matory and non-inflammatory growths, although that term is more properly applied to new formations independent of a purely in- flammatory origin. The qualities which chiefly tend to characterize true tumors from other growths, are 1. A decided tendency to continuously increase. 2. An inherent nutritive activity, independent of the surrounding tissues. In attempting to classify tumors, I am led to follow the arrange- ment of T. Henry Green, of London, as it seems to me more clearly to elucidate this obscure subject than any other classification with which I am acquainted, and combines both simplicity of language with clearness of expression. Solid tumors maybe divided then into three great types : 1. Those of the type of connective tissue, in which the stroma of the tumor is usually in excess of the cell element, and the cells are those of the type of normal connective tissue. 2. Those of the type of higher tissues, as muscle, nerves, and blood-vessels; and 3. Those of the type of epithelial structures, as represented by glandular tu- mors, cancer, and papillomata. The following table will clearly ex- plain this classification: 326 SURGICAL DIAGNOSIS. ( Tumors of the connective tissue -< type: SOLID TUMORS. Tumors of the higher tissue type: Tumors of the epithelial type : Fully developed connective tissue. h Fibroma. Embryonic connectiAre tissue J (Saecoma). Fibro-Plastic. " Recurrent. " Nucleated. Myeloid. Glioma. Granulation tissue. Mucous tissue. Adipose tissue. Cartilage tissue. Lymphatic tissue. Bone tissue. Psammoma. Gummata. Lupus. Glanders. Myxoma. Lipoma. Enchondroma. Lymphoma. LeuTcczmia. Tubercle. Osteoma. Type of muscle. Myoma. " " nerve. Neuroma " " blood-vessels. Angioma. Cutaneous surface. Papillomata ; growing from -j Mucous " Sercms '' Adenoma. Carcinoma. Glandular tumors. Scirrhus. Encephaloid. Epithelioma. Colloid. Cystic tumors may also be divided into two great classes with their subdivisions, as shown in the following table, in which not only the varieties of cysts are enumerated, but the mechanism of their formation is also clearly explained. DISEASES OF TISSUES. 327 CYSTIC TUMORS. A. Cysts formed in preexisting cavities. B. Cysts formed in sacs of inde- pendent ori- gin. Retention Cysts ; (due to obstructed escape of secretion). Sebaceous cysts. Mucous cysts. Cysts in or- gans or glands. True sebaceous tumors. Comedones. Atheromatous tumors. [■ Occur only in mucous follicles. ' Ranula, due to occlusion of salivary ducts. Encysted hydrocele, due to occlusion of tubuli testis. Mammary cysts, due to occlusion of lacteal ducts. Simple cysts of the ovary, due to di- latation of Graafian follicle. Compound cysts of the ovary, due to dilatation of Graafian follicle. Cysts of the liver, due to occlusion of ducts. Cysts of the kidney, due to occlusion of tubes. Exudative Cysts ; (due to excessive secre- tion). Extravasation Cysts ; (due to hemorrhage into closed cavi- ties). Cysts due to softening of tis- sues in the cen- tre of tumors, as in Cysts due to ex- ' pansion and fu- sion of the spaces in connective tissue. Bursse. Ganglia. Hydrocele. Cysts of broad ligament. Haematocele. Sanguineous tumors. Lipoma. > Enchondroma. Sarcoma. New bursse. ► Serous cysts of the neck. Compound ovarian cysts. Cysts formed ( Parasites. around foreign -] Extravasated blood. bodies. ( Bullets, etc., etc. Congenital ( Frequently resulting from a blighted ovum. Cysts. ( often contain hair, bones, teeth, etc., etc. They 328 SURGICAL DIAGNOSIS. Tumors may be again classified on the basis of location as follows Brain. TUMORS OF THE HEAD. Scalp. Orbit. Antrum. Gums. Lips. Tongue. Jaws. ' Cysts. Glioma. Myxoma. Lipoma. Carcinoma. Psammoma. Gummata. Cholesteatoma. Tubercle. Hydatids. Lipoma. Sebaceous. Vascular. Glioma. Myxoma. Cystic. Osteoma. Medullary Cancer. Cystic. Erectile. Osseous. Fibroid. Enchondroma. Lipoma. Encephaloid. Cystic. Fibrous. Carcinoma. Myeloid. ( Cystic. < Epithelioma. ( Lupus. Cystic. Fibroid. Gummata. Epithelioma. . Encephaloid. Cystic. Fibroid. Myeloid. . Osteoma. DISEASES OF TISSUES. 329 B. TUMORS OF THE -| NECK. Vessels. Muscles. Parotid Gland. Thyroid Gland. Lymphatic Glands. - Integument. Mucus Membranes of pharynx oeso- phagus and La- rynx. Encysted Aneurism. Diffuse Cystic. Lipoma. Myoma. Cystic. Fibrous. Enchondroma. Hypertrophy. Abscess. Cancer. ( Cystic. ■< Hypertrophy. ' Encephaloid. Lipoma. Hypertrophy. Abscess. Syphilitic Induration. Tuberculous " Cancer. Fibroid. Serous Cysts. Moles. Warts. Keloid. Eloid : (coil-like tu- mor). Cystic. Myxoma. Fibroma. Adenoma. Sarcoma. Papillomata. Carcinoma. SURGICAL DIAGNOSIS. Mammal. Cysts. Fibroma. Adenoma. Enchondroma. Lipoma. Scirrhus. Encephaloid. Labia. Cysts. Abscess. Haematocele. Epithelioma. Uterus. C. TUMORS OF TRUNK. THE Cystic. Fibroid. Myoma. Enchondroma. Pulsatile. Carcinoma. Rectum. Fibrous. Fatty. Carcinoma. Prostate. Hypertrophy. Abscess. Scirrhus. Encephaloid. Testicle. Cysts. Tubercular deposits. Gumma. Enchondroma. Benign fungus. Carcinoma. DISEASES OF TISSUES. 331 Special surgical regions may also present an abnormal appearance, either from a local increase in size, or from the presence of some abnormal and well-defined tumor, which may demand extreme care in diagnosis, and which, for that reason, I have concluded also to tabulate. Of these special surgical regions, the axilla and the groin are the two most frequently affected with abnormal tumors, whose diagnosis is rendered difficult from their situation and depth. Tumors of the axilla may be thus enumerated: AXILLARY TUMORS. Dependent on blood-vessels. Of lymphatic type. Dependent on bone. Axillary ab- scess. Aneurism. Haematocele. Cancer of lymphatic glands. Tubercular infiltration of glands. Inflammatory enlargement of glands. Enlargement of glands from hyper- plasia. Dislocation of the head of humerus. Displaced head in fracture. Fragments of bone. Separation of the great tubercle. Osseous tumors. Due to suppuration of glands. " " " connective tissue. " diseases of ribs. " " " cervical verte- bra. " " " shoulder joint. " " " scapula. " empyema. Dependent on ) TT . £ ,, -. organs. } Hernia of the lung. 332 SURGICAL DIAGNOSIS. Abscess of lo- cal origin. TUMORS OF THE GROIN. In In the fossae. iliac In region of in- guinal canal. the region of femoral canal. ' Due to perityphlitis. " empyema, the pus burroAV- ing through diaphragm. " disease of hip joint. " pelvic suppuration. " suppuration about kidneys. " caries of vertebral column, (psoas abscess). Lymphatic glands. Lipoma of canal. Hydrocele of spermatic cord. Haematocele " Hernial protrusion. Arrested testicle. Cysts. Enlarged lymphatic glands. Varix of the saphenous vein. Dislocated head of femur. Enlarged bursa underneath the psoas tendon. Psoas abscess. Femoral aneurism. Ovarian tumors. Fibrous " Impacted faeces. Aneurism of iliac arteries. Abscess of abdominal walls. CANCER. In the preceding pages, I have classified tumors in general, and I noAv proceed to the consideration of those special forms of tumor, termed by some authors malignant, and included under the general head of carcinoma. Cancer is properly an anatomical term used to include all forms DISEASES OF TISSUES. 333 of new growth consisting of cells of an epithelial type, embedded in the alveoli of a fibrous stroma, and destitute of intercellular substance. It has been defined by "Waldeyer as an atypical epithelial neoplasm. It includes four distinct varieties : 1. Scirrhus. 2. En- cephaloid. 3. Colloid, and 4. Epithelioma. The colloid variety, termed also gelatiniform and alveolar cancer, is, in reality, but a degenerative stage of one of the other three varieties, and by some authors is con- sidered under the head of " colloid degeneration," since this change may likewise occur in tumors not possessing the microscopical char- acteristics of carcinoma. Cancerous tumors are always malignant, but all malignant tumors are not cancerous, since they fail to present the microscopical ap- pearance of cancer. They are however, clinically, of equal impor- tance, and I have, therefore, arranged in contrast the points in diag- nosis between malignant and benign tumors, for the purpose of aiding in their clinical discrimination. I shall defer the description of the symptoms of each of the four varieties of cancer, as they are to be found enumerated in the diag- nostic tables pertaining to each. I have inserted in this chapter among special forms of cancer, only malignant disease of the axilla and omentum, as similar disease in other localities will be found described in other chapters of this work. 334 SURGICAL DIAGNOSIS. BENIGN TUMORS. MALIGNANT TUMORS. Relation to Surrounding Parts. Are not intimately attached to Are infiltrated into the tissues the surrounding tissues. and often embody the surrounding structures in their OAvn substance. Multiplicity. Are frequently solitary. If mul- Tend to reproduce themselves, tiple they start simultaneously and and multiple tumors appear in advance with the same degree of succession. They often involve rapidity. They also affect, when many distinct localities and also multiple, the same type of tissue. affect different types of tissue. Rapidity of Growth. The tumors grow slowly, as a The tumors grow Avith great ra- rule, and, Avhen developed, are pidity, when once fully developed. often stationary for years. Ulceration. No tendency to ulcerate is A marked and uncontrollable marked, but ulceration may exist, tendency to ulceration exists. Tissues about Ulcer. The tissues near the ulcer are The tissues near the edges of the either healthy or simply indurated ulcer are altered in their structure from inflammation. from the normal type. Duration of Ulcer. The ulcer heals easily when irri- No tendency towards spontaneous tation is removed, or, if extensive repair is manifested, but the disease ulceration exists, the disease is in develops in direct proportion to the time destroyed. rapidity and the extent of the ul- cerative process. Structure of Growth. The tumors are homologous and Are heterologous and heteromor- homomorphous. They are similar phous. They differ in their struc- to some natural tissue of the body. ture and arrangement from natural tissues. Constitutional Effects. No constitutional effects are de- Constitutional effects are present veloped. and Avell marked in the later stages of the disease. DISEASES OF TISSUES. 335 SCIRRHUS ENCEPHALOID CANCER (Fibrous or Chronic Cancer). (Acute or Medullary Cancer). Origin. Is usually a primary disease. Occurs, most often, as a second- ary affection. Rapidity of Groavth. The tumor develops slowly. The tumor develops rapidly. Palpation. The tumor is hard and stony. The tumor is soft, lobulated and often elastic. Integument. The skin is usually puckered and The skin is neither depressed nor depressed before ulceration com- puckered. mences. Ulceration. The tumor ulcerates late and The tumor ulcerates early in the slowly, as a rule. disease and progresses rapidly. Hemorrhage. Hemorrhage from the tumor Hemorrhage occurs early in the occurs late in the disease. disease. Seat. Is usually present in the breast; The tumor is very malignant and it seldom reproduces itself in organs tends to rapidly invade organs and as scirrhus. It may be frequently glandular structures. found also in the alimentary canal. Stroma. • The stroma, as seen by the micro- The stroma is small in quantity. scope, is large in quantity. The tumor resembles brain tissue, on section. 336 SURGICAL DIAGNOSIS. EPITHELIOMA SCIRRHUS (Epithelial Cancer ; Clay-pipe (Fibrous or Chronic Cancer). Cancer ; Chiainey - saveep's Cancer). Location. Is usually a primary disease of Occurs in the mammary gland mucous or cutaneous surfaces. It and alimentary canal, in the ma- is rarely found in internal organs. jority of cases. The stomach, oeso- phagus and rectum are its most fre- quent locations internally. Mode of Origin. Begins as a small ulcer, or as a It seldom, if ever, commences as nodule Avhich subsequently ulcer- an ulcer. ates. Cut Surface of Tumor. If pressure be made upon the A juice is extracted from the cut scraped or cut surface of the tumor, surface, or by scraping the central a thick, crumbling, curdy material or softer portions. This juice con- is exuded, often in a ivorm-lihe sists of cells, nuclei and granules. form. This exudation consists of epithelial- scales. Effect of Dilution. This expressed material does not The juice of scirrhus, when mixed become diffused in Avater, but re- with water, becomes diffused and mains as minute visible particles. often lost. Microscope. A small section of the tumor, un- A section of the tumor reveals der a microscope, reveals epithelial excessive development of a fibrous nests and epithelial spheres. stroma and epithelial cells in a state, often, of atrophy. DISEASES OF TISSUES. 337 COLLOID CANCER SCIRRHUS OF ORGANS. (Alveolar or Gelatinous Cancer). Location. Is most frequent in the stomach, Is a rare disease of organs, save intestines and peritoneum. in the oesophagus, at the pylorus, and in the rectum. Development. The tumor develops rapidly. The tumor is slow in develop- ment. Malignancy. It frequently spreads, to glands It is the least malignant of car- and adjacent tissues. cinomatous tumors. Appearance of Cut Surface. Has a glistening, jelly-like, trans- It is a hard, nodular mass, whose lucent appearance. Its constituents cut surface is dense and compact. resemble mucin, save that they con- tain sulphur and do not precipitate on the addition of acetic acid. Microscope. A markedly developed alveolar A fibrous stroma is detected, structure exists, with large spheri- Avhich is excessively developed, and cal cells, which are often laminated the cell element is often detected in and which contain colloid material a stage of atrophy after the tumor in the form of drops. has reached advanced stages. Origin. Is not a distinct variety of cancer, It is a distinct type of cancer, and but is a degenerative process of other is often dependent on hereditary growths, as scirrhus, encephaloid, predisposition. sarcoma, etc., etc. 22 338 SURGICAL DIAGNOSIS. CANCER OF AXILLARY TUBERCULAR DISEASE OF GLANDS. AXILLARY GLANDS. Age Affected. Is seldom present in children. Is most frequent in children. History. . No scrofulous history is present. A scrofulous history exists. Growth. The tumor grows rapidly, in many The tumor is of slow growth. cases. Mobility. The tumor is often restricted in The tumor is very movable. its mobility. Number. The tumor may be solitary. The tumors are usually multiple. Neighboring Parts. The neighboring parts are often The surrounding parts are not af- affected, especially the mammae. fected. Teraiination. Ulceration rapidly develops after Suppuration occurs in the majori- the tumor has become superficial. ty of cases, and its evacuation is preceded by a sense of fluctuation Avithin the tumor. Effects of Removal. A return of the disease, after re- The disease shows no tendency moval of the tumor, within tAvo toAvards a return after removal. years is frequently present. DISEASES OF TISSUES. 339 CANCER OF OMENTUM. ENLARGED SPLEEN. Percussion. The area of dulness extends across The area of dulness seldom crosses the abdomen, but is not conveyed to the right of the median line, and backwards. is ahvays conveyed bachwards. Location of Tuaior. It never ascends behind the ribs. It frequently ascends behind the ribs. Surface of Tuaior. Palpation detects a rough and un- The surface of the tumor is even surface. smooth and regular. Density of Tumor. The tumor is hard as a rule. The tumor is soft to the touch. ' Ascites. Ascites is a frequent complica- Ascites is seldom present. tion. History. A cancerous hereditary taint is A malarial history is most fre- often found. quent. Cachexia. A cancerous cachexia is devel- A cachexia is not developed. oped as the disease advances. Pain. Pain is a prominent symptom in Pain is usually absent. the advanced stages. Age Affected. Occurs chiefly after forty. May occur at any age. Effects of Pressure. Tenderness on pressure is com- The tumor is not usually sensi- mon. tive to pressure. 340 SURGICAL DIAGNOSIS. TUMORS OF THE HEAD. The various tumors of the cranium which are met with in a surgi- cal practice are 1. Sebaceous Tumors of the Scalp. 2. Fatty 3. Exostoses of the Skull. 4. Abscess. 5. Cephalhematoma. 6. Encephalocele. 7. Dropsy of the Meninges of the Brain. 8. Hernia Cerebri. The tumors of the face include 1. Cysts of the Antrum. 2. Solid Tumors of the Antrum. 3. Abscess " " 4. Tumors of the Orbit and Eyelids. 5. Cancerous Tumors. 6. Lupus. 7. Fatty Tumors. The tumors of the mouth include 1. Ranula, a cystic tumor from obstruction of sublingual ducts. 2. Epulis, a fibrous tumor of the periosteum of the gum. 3. Parulis, a local suppuration of the gum. 4. Enlargement of the Tonsils. 5. Tumors of the Tongue, encysted, fatty, gumma, erectile, and cancer. 6. Polypi. 7. Hypertrophy of the Palate. In the following pages will be found diagnostic tables between such of these conditions as are most liable to be confounded. Some of these, however, have been previously recorded under special types of bone diseases, but are intentionally duplicated as they properly belong to each division. DISEASES OF TISSUES. 341 SEBACEOUS TUMORS.OF THE FATTY TUMORS OF THE ^ALP. S0ALR COAIPARATIVE FREQUENCY. These tumors are most frequent Fatty tumors are most frequent in this locality. upon the back and shoulders, but may exist in any locality, and not infrequently upon the scalp. Mobility. The tumor is freely movable un- The tumor frequently involves der the skin. the skin. Palpation. The tumor is tense, smooth and The tumor is soft and doughy. elastic. Outline of Tumor. The tumor is distinct and regu- Outline irregular and indistinct. lar in its outline. Orifice of Ducts. A black speck on the tumor in- The sebaceous ducts are normal dicates the obstructed duct of the and unobstructed. sac. Effect of Pressure. The tumor can often be evacu- The tumor cannot be evacuated ated by firm pressure. by pressure. Size of Tuaior. The tumor is of moderate size. The tumor may become very large. Suppuration. The tumor frequently suppurates The tumor seldom suppurates or and occasionally ulcerates. ulcerates spontaneously. Odor. The tumor is often associated The tumor is without odor. Avith an offensive odor, from an es- cape of its contents. 342 SURGICAL DIAGNOSIS. SEBACEOUS TUMORS. EXOSTOSES OF CRANIUM. Palpation. The tumor is tense, smooth and The tumor is of bony hardness. elastic to the touch. Mobility. The tumor is freely movable The tumor is immovable. under the skin. Appearance on Inspection. On careful inspection of the The tumor exhibits no unnatural tumor, the obstructed duct will be condition of the integument or its perceived as a blach speck upon its glands. surface. Effect of Pressure. On firm pressure the contents of Pressure upon the tumor causes the sac of the tumor may often be no evacuation of contents. evacuated as a cheesy mass. Odor. An offensiA-e odor is occasionally The tumor is odorless. associated Avith the tumor from a slight escape of its contents. SYMPTOMS IN COMMON. Both are frequently multiple. " " of slow growth. " " distinctly circumscribed in their outline. DISEASES OF TISSUES. 343 EXTRA-CRANIAL TUMORS. INTRA-CRANIAL TUMORS. Respiratory Moveaients. The tumor exhibits no move- The tumor rises with expiration ments during respiration. from obstructed venous return to the chest, and falls during inspiration. Size of Tuaior. The size of the tumor never ex- The tumor frequently enlarges on hibits sudden and temporary varia- severe attacks of coughing or cry- tions. ing. Effect of Pressure. The tumor cannot be made to The tumor can often be reduced, disappear within the cranium by either entirely or in part, by direct pressure. pressure upon it. No cerebral symptoms are pro- Symptoms of cerebral compression duced by pressure. are often produced in case the pres- sure be severe or long continued, but they usually cease when the pressure is removed, as the tumor returns to its former position. Condition of Craniuai. The bony Avails of the cranium An aperture can often be detected are intact. in the cranial bones on reduction of the tumor. SYMPTOMS IN COMMON. Both may be associated Avith an absence of cerebral disturbance. tt a tt a similarity in feel and consistence. a a a ti rapid or sIoav formation. it a ti tt an absence of apparent causation or a knowl- edge on the part of patient or friends of a congenital defect or deformity. 344 SURGICAL DIAGNOSIS. ENCEPHALOCELE. DROPSY OF THE BRAIN. Situation. Occurs at the occiput, sutures, Is most frequent at the anterior anterior fontanelle, and occasionally and posterior fontanelles, but may at the root of the nose betAveen the also be apparent at any of the two halves of the frontal bone. cranial sutures. Contents of Tuaior. The protrusion consists chiefly of The tumor is due to an excessive brain substance. amount of fluid Avithin the mem- branes of the cerebrum, and the pro- trusion of the membranes. Appearance of Tuaior. The tumor is usually pediculated. The tumor seldom, if ever, is pediculated. Translucency. The tumor is opaque. The tumor is usually translucent. Rapidity of Growth. The tumor seldom enlarges after The tumor frequently enlarges birth, but if so, its development is rapidly and results in marked de- very slow. formity. SYMPTOMS IN COMMON Both are usually congenital tumors. " painless. " soft and possibly elastic. " " " bluish in color. " covered by thinned and altered integument. " reducible Avithin the cranium. " often associated with respiratory movements. " " " " " pulsation. DISEASES OF TISSUES. 345 ENCEPHALOCELE. CEPHALHEMATOMA. History of Tuaior. Is usually congenital. Occurs, after birth, in infants. Situation. Is frequent at the fontanelles and Is never confined to sutures and cranial sutures. seldom involves them. Is usually located upon some individual bone of the cranium. Effect of Pressure. Pressure upon the tumor causes Pressure upon the tumor causes reduction within the cranium and no cerebral symptoms nor a reduc- possible cerebral symptoms. tion of the tumor. Fluctuation. Fluctuation is absent. Fluctuation is present in the tumor before coagulation occurs. Pulsation. Pulsation is sometimes present Pulsation Avithin the tumor is Avithin the tumor. rare. Respiratory Moveaients. Respiratory movements within Respiratory movements are ab- the tumor are generally present. sent. Size of Tumor. The tumor is generally of mode- The tumor may often be diffused rate dimensions. over a large area. Integuaient. The skin over the tumor is usually The integument over the tumor very thin and altered in its struc- is usually normal. ture and appearance. 346 SURGICAL DIAGNOSIS. ABSCESS OF ANTRUM. SOLID TUMORS OF ANTRUM. Deformity, The antrum is equally distended. The antrum is unequally dis- tended. Inflaaiaiatory Syaiptoms. No acute inflammatory symp- toms are present, (such as pain, oedema, great sensitiveness, and con- stitutional disturbance). Acute inflammatory symptoms are present, such as Chills, Great pain, " sensitiAreness to touch, QEdema of face, Increased pulse, and " temperature. Fluctuation. Fluctuation often appears in ad- Fluctuation is absent, as a rule. vanced stages. Discharge into Mouth or Nose. A tendency to the discharge of pus through the teeth sockets, or through the nostril during forced expiration, or in certain positions of the body. Exploring Needle. No tendency towards a sponta- neous discharge of the contents of the cavity of the antrum is appa- rent. The exploring needle in cases of The exploring needle gives nega- doubt decides the diagnosis. tive results. SYMPTOMS IN COMMON. Both are often associated Avith projection of the eyeball. effacement of the nostril. depression of roof of month. bulging of the cheek. closure of the lachrymal duct. interference with mastication. " " deglutition. parchment-like crepitus when the bone be- comes thin. DISEASES OF TISSUES. 347 EPITHELIOMA. LUPUS. Locations Affected. Affects the face, nose, ears, cheeks, buttocks, and extremities. It also affects the mucous mem- brane of the lips, hard palate, and throat. Affects principally the lips, cheeks, nose, forehead, and scro- tum. It is also found frequently on the mucous membranes of the tongue, prepuce, labia, uterus, and bladder. Development. Begins either as a subcutaneous Begins as a brownish-red spot, movable nodule, Avhich undergoes which subsequently becomes a pa- ulceration, or as a small, foul ulcer pule and then ulcerates. Avith indurated edges. Age Affected. Occurs rarely, if ever, in the Occurs before middle life. It young, and is usually due to local may often affect young children. irritation. Is not dependent upon local irrita- tion. Extent. Is gradual in its development, and is often unassociated with any very marked deformity. Its ravages are often terribly se- vere, and the part affected under- goes, in some cases, marked and rapid deformity. Surface of Ulcer. The surface of the ulcer is fre- quently papillated and villous, from an irregular growth of the corium. The surface is often friable, and on pressure frequently exudes a thick, crumbling and curdy material in a worm-lihe form. In some cases the ulcer is scabbed. The ulcer may often be " serpigi- nous" in character. It may be scabbed, and, on removal of the scab, the surface may present irreg- ular elevations and depressions on its surface. The skin, hair, seba- ceous follicles and sweat glands, are often destroyed. Repair. Seldom, if eArer, tends towards spontaneous recovery. The ulcer frequently heals with a depressed and puckered cicatrix. 348 SURGICAL DIAGNOSIS. TUMORS OF THE BREAST. The mammary gland may be affected with the following condi- tions which result in its enlargement: 1. Acute Abscess. 2. Chronic Abscess. 3. Simple Cysts. 4. Compound Cysts. 5. Glandular Tumors. 6. Hypertrophy of the Mamme. 7. Scirrhus. 8. Encephaloid Cancer. Of these diseases, scirrhus and encephaloid have already been considered together under the head of cancerous tumors, and as they have no special distinctive features when confined to the mam- mary gland, that table will not be here duplicated. I have arranged the remainder in the form of diagnostic tables, with the exception of compound cysts, which cannot readily be distinguished from simple cysts of the breast, by the rational or physical signs per- taining to either. I have added also a diagnostic table between scirrhus, as the most frequent type of cancer in this locality, and innocent mammary tumors, since the importance of the discrimina- tion can hardly be over-estimated. DISEASES OF TISSUES. 349 ACUTE MAMMARY ABSCESS. CHRONIC MAMMARY ABSCESS. Condition of Breast. The breast is red, hot and cede- Breast normal, or slightly cede- matous- matous at its loAver margin. Origin. FoIIoavs traumatism or lactation. Occurs after a period of uterine activity as in menstrual derange- ment, miscarriage, abortion, or normal confinement. Tuaior. Is usually situated near the nip- The tumor is deep seated in the pie and is fixed and often im- substance of the gland and is mova- movable. Me, as a rule. The tumor develops rapidly and The tumor develops slowly and is is very painful and sensitive to the nearly painless, and not sensitive. touch. The nipple is usually affected. The nipple is seldom invoked. Integument. The skin becomes involved early. The skin becomes involved late. Number of Tuaiors. The tumor is solitary. The tumor may begin as a num- ber of small nodules which subse- quently coalesce. Fluctuation. Fluctuation is distinct when the Fluctuation is often indistinct tumor is grasped and made promi- from the depth of the tumor and nent. thickening of its wall, but elasticity is present. Constitutional Symptoms. The pulse and general tempera- The constitutional disturbance is ture are markedly elevated. slight and may be absent. Exploring Needle. Pus mixed with milh is often de- Pus is withdrawn by the needle, tected by the exploring needle. but no evidences of milh are present. 350 SURGICAL DIAGNOSIS. CYSTS OF THE BREAST. GLANDULAR TUMOR OF BREAST. Origin. May be due to obstruction of the Occurs most frequently in maid- milk ducts or to cysts of indepen- ens between twenty and forty years dent origin, (as per table on cystic of age, and is often associated with tumors). Hydatid cysts are some- menstrual derangements or trauma- times present. tism. Development. The tumor usually develops slow- The tumors are most frequently ly, but may form rapidly after ces- de\-eloped at the upper and inner sation of the menses or if due to hy- portion of the breast, and, as a datids. rule, grow slowly. Palpation. The tumor is smooth, circum- The tumor is round, oval or lobu- scribed and movable. If due to lar, firm and incompressible, and is hydatids, a peculiar fremitus on very movable. In rare cases it may percussion is obtained. protrude through the skin, but does not ulcerate or bleed, as a rule. Fluctuation. The tumor usually fluctuates. The tumor never fluctuates. Translucency. The tumor may be translucent if The tumor is opaque. very superficial. Neighboring Glands. The neighboring glands are sel- The neighboring glands may be dom involved. involved, but are usually not so. Exploring Needle. Milk, serum, or hydatid cysts The results of the exploring may be obtained by an exploring needle are negative. needle from these tumors. DISEASES OF TISSUES. 351 GLANDULAR TUMOR OF HYPERTROPHY OF MAMM.E. THE BREAST. Origin. Occurs most frequently in maid- ens betAveen twenty and forty years of age, and is often associated Avith menstrual derangements or trauma- tism. Is most frequent in the married during the term of pregnancy or menstrual derangement. It is never of traumatic origin. Location. The inner and upper portion of one breast is usually affected. Both breasts are simultaneously enlarged, as a rule, and become very heavy. Mobility. The tumor is usually very mov- able. The breasts are usually less mova- ble than normal. SYMPTOMS IN COMMON. Both are usually firm and incompressible. painless. of slow growth. unassociated Avith tegumentary changes. associated with normal health. free from enlargement of neighboring glands. characterized by a normal position and appearance of the nipple. 352 SURGICAL DIAGNOSIS. SCIRRHUS OF THE BREAST. INNOCENT TUMORS OF THE BREAST. Outline of Tuaior. The tumor is irregular in shape, The tumor may be irregular, nodular and indistinct at its cir- round or oval, and is usually dis- cumference. tinctly circumscribed. Mobility. The tumor is deeply attached to The tumor moves freely within the gland, and, if movable, simply the breast itself. slides on the pectoral muscle. Palpation. The tumor is hard and stony. The tumor is softer and more elastic. Weight of Tumor. The tumor is heavy. The tumor is light. Breast. The breast is shrunken. The breast is normal or increased in size. Pain. Lancinating, severe and paroxys- Pain is often absent. If present mal pain exists in latter stages. it is continuous and of moderate severity. Nipple. The nipple is retracted. The nipple is normal, as a rule. Axillary Glands. The axillary glands are enlarged The axillary glands may be en- and hardened. larged, but are never hardened or fixed. Growth of Tumor. The tumor grows rapidly. The tumor grows sloAvly -and is often stationary for years. DISEASES OF TISSUES. 353 SCIRRHUS OF THE BREAST INNOCENT TUMORS OF THE {continued). BREAST (continued'). Ulceration. Ulceration is frequent, progressive Ulceration is infrequent and easily and obstinate. treated. Superficial Veins. The superficial veins are promi- The veins are little affected. nent and enlarged. Health. A cachexia is developed. The general health remains good. COAIPLICATIONS. Cancerous tumors develop in other Complications are infrequent. organs and tissues. 23 354 SURGICAL DIAGNOSIS. TUMORS OF THE UTERUS. The uterus may become enlarged from the following named con- ditions : 1. Congestive Uterine Hyperemia. 2. Fibroid Tumor. 3. Hydatids. 4. Retained Menstrual Blood. 5. Uterine Fibro-Cyst. 6. Uterine Polypus. 7. Uterine Moles. 8. Pregnancy. 9. Cancer of the Uterus. I have treated of cancer in previous pages of this book, and shall not again consider it as a special uterine tumor, as it presents no special or distinctive characters in this region other than those per- ceived in all locations. It may primarily affect the body of the uterus or the cervix. I have added in the folloAving pages, how- ever, the symptoms of the various other conditions, resulting in uterine enlargement, in the form of diagnostic tables, as they are liable to be easily confounded with each other in diagnosis. DISEASES OF TISSUES. 355 CONGESTIVE UTERINE EARLY PREGNANCY HYPEREMIA. Development. The uterus ceases to develop in The uterus steadily increases in size after reaching moderate dimen- size till large dimensions are reach- sions. ecj# Sensitiveness. The tumor is tender and sensitive The uterus is not usually sensi- to pressure. tive. Pain. A severe pain in the back and Pain in the back and loins is loins exists. often absent, but, if present, is not severe. Walking. Walking becomes difficult from Walking is not interfered with. the existing pain. Fostal Manifestations. After the fourth month all symp- Evidences of foetal presence exist toms of pregnancy in its advanced after the fourth month, viz. : foetal stages are absent. movements, quickening, foetal heart, placental bruit, ballottement, etc. SYMPTOMS IN COMMON. Both are often associated Avith absence of the menses. a a a a a YOmitmg. " " " " " local uterine disturbance. " " " " " vesical and rectal irritability. 356 SURGICAL DIAGNOSIS. FIBROID TUMOR OF UTERUS. PREGNANCY. Menstruation. Menorrhagia or metrorrhagia is Amenorrhoea is usually present, present, as a rule. but may be absent. Tumor. Nodules can be detected on palpa- The uterus is uniformly increased tion of the uterus. in size. Consistence. The tumor is hard and resistant. The tumor is more elastic. Cervix. The cervix is normal. The cervix is often altered in its condition and appearance. Auscultation. The auscultatory signs are nega- Foetal heart and the placental tive. bruit are heard after the fifth month. Fcetal Manifestations. Quickening, foetal movements Foetal manifestations develop, and other manifestations are ab- unless the foetus be dead. sent. Duration of Tuaior. The duration of the tumor is in- The duration is limited. definite. Location of Tuaior. The tumor may not always be The tumor usually lies in the median in location. median line. DISEASES OF TISSUES. 357 RETAINED MENSTRUAL PREGNANCY BLOOD. Condition of Sexual Organs. The sexual organs are abnormal. The sexual organs exhibit no un- An examination may detect : Im- natural acquired condition, or ab- perforate hymen; adhesion of va- normal development. ginal walls ; adhesion of lips of cervix ; congenital defects ; trau- matic conditions. Menstrual Epochs. At each return of the normal The dates of ovarian irritation date for menstruation the patient are not usually perceived during suffers intense pain, but does not pregnancy, but, in rare cases, men- menstruate, struation continues without any ab- normal symptoms. Constitutional Symptoais. The retention and decomposition No constitutional disturbance, of menstrual products create con- save from exhaustive vomiting, is stitutional disturbances, Avhich are perceived if the foetus be alive, and often severely marked. no maternal disease exists. Foetal Manifestations. No evidences of foetal life are de- Fcetal life is clearly indicated af- tected. ter the fifth month. SYMPTOMS IN COMMON Both are usually associated with amenorrhoea. " " " ' " " a uterine tumor. " " " ". " frequent local pains. " " " " " vesical irritation. " " " " " rectal " 358 SURGICAL DIAGNOSIS. UTERINE HYDATIDS. PREGNANCY. Developaient. The tumor develops Avith great The tumor develops with a mode- rapidity, rate rapidity. Uterine Discharge. Watery and bloody discharges Uterine discharge is usually ab- from the uterus are frequently sent, but a leucorrhoea may often present. exist. Cysts are often spontaneously Cysts are never evacuated. evacuated from the uterus. Uterine Tenesmus. Uterine tenesmus is usually pres- Uterine tenesmus is usually ab- ent. sent. Constitutional Disturbance. The evidences of constitutional The constitutional disturbance is disturbance are often well marked. slight or absent, as a rule. Auscultation. The auscultatory signs are nega- Foetal heart and placental bruit tive. are heard after the fifth month. Fcetal Manifestations. Fcetal manifestations are absent. Fcetal moA'ements and quickening are apparent, if the child be alive. DISEASES OF TISSUES. 359 UTERINE FIBROID. SOLID OVARIAN TUMOR. Menstruation. The tumor is usually accompanied The menstrual function is often by monorrhagia. unaffected. Movements of Tumor. The uterus always participates in The uterus is usually independent movements communicated to the of motions of the tumor. tumor. Moveaients of Uterus. The uterus, if moved by a uterine The uterus, if moved, exerts no sound, affects the tumor. influence upon the tumor, as a rule. Multiplicity of Tumors. The tumors are often multiple. The tumor is usually solitary. Palpation. The tumor is hard, incompressi- The tumor is less dense, and ble and heavy. lighter in weight. . Uterine Cavity. The cavity of the uterus is often The cavity of the uterus is nor- increased, as revealed by measure- mal in length. ment with the uterine sound. Cervix of Uterus. The cervix is in the median line, The cervix is often laterally dis- as a rule. placed. Fluctuation. Fluctuation is absent. Fluctuation may be detected in localized spots on the tumor, if the tumor is compound in its character. 360 SURGICAL DIAGNOSIS. UTERINE FIBRO-CYST. OVARIAN CYST. Development. The tumor grows slowly. The tumor grows rapidly. Age Affected. The tumor occurs after thirty The tumor may affect any age years of age. after puberty. Cavity of Uterus. The uterine cavity is enlarged. The uterine cavity is normal. Moveaient of Tumor. The tumor, if moA'ed, affects the The tumor is independent of the uterus, and vice versa. uterus in many cases. Position of Uterus. The uterus is often lifted out of The uterus is usually displaced the pelvis and can be detected above laterally Avithin the pelvis. the pubes. The uterus is often in front of The uterus is generally behind the tumor. the tumor. Health of Patient. The health is little affected. The health is undermined in two or three years. Fluid of Tuaiors. The fluid, if withdrawn, coagu- The fluid, if AvithdraAvn, never lates quickly and spontaneously. coagulates. Microscope. A peculiar "fibre cell, "mentioned Granular cells, epithelial cells by Drysdale, is often detected. and cholesterine are often detected. DISEASES OF TISSUES. 361 UTERINE POLYPUS. UTERINE FIBROID. Mobility of Tuaior. After the cervix has been dilated The tumor may often be felt ex- a movable tumor is perceived Avithin ternally, and in some cases only the uterine cavity. after dilatation of the cervix, but it is always immovable. Palpation. The uterus is smooth upon palpa- The uterus is nodular on its ex- tion of its external surface. ternal surface, as a rule. Pedicle. The tumor is usually pediculated. The tumor is seldom pediculated. SYMPTOMS IN COMMON. Both are often associated with menorrhagia. " " " " " metrorrhagia. " " " " " leucorrhoea. tt tt a a ti pam jn ^]ie i3ack and in the loins. " " " " " dysmenorrhoea. 362 SURGICAL DIAGNOSIS. TUMORS OF THE OVARY. The various tumors which affect the ovary and its appendages, may be enumerated as follows : 1. Fibrous Tumors. 2. Fibro-cystic Tumors. 3. Carcinoma. 4. Cysto-carcinoma. 5. Dermoid Cysts. 6. Colloid Degeneration. 7. Hydatid Cysts. 8. Cysts of the Broad Ligament. Ovarian tumors may be confounded in diagnosis with, 1. Ascites. 2. Pelvic abscess. 3. Cysts of the kidney. 4. Pregnant uterus. 5. Fibro-cyst of the uterus. 6. Uterine Fibroid. Two of these diagnoses have already been considered in contrast, under the head of tumors of the uterus ; the others will be found arranged in the form of diagnostic tables in the ensuing pages. DISEASES OF TISSUES. OVARIAN DROPSY. ASCITES. Situation of Tuaior. The tumor is most prominent The tumor is uniform and sym- upon one side, save in advanced metrical. stages. Effect of Attitude. The tumor remains prominent The tumor flattens and increases and globular in all positions of the in its breadth on lying down. body. Fluctuation. The tumor is locally fluctuant. The tumor fluctuates through the entire abdomen. Origin. The tumor begins in one iliac The tumor begins symmetrically fossa. from below. Percussion Note. The percussion is dull in front The percussion is resonant in when the patient lies upon her front of abdomen, when patient lies back, but is tympanitic, from dis- on the back, as the boAvel floats; placed intestine, at the sides. but is flat at the sides of the ab- domen. Line of Dulness. Is constant and not affected by Is variable, and is affected by at- attitude. titude of patient and by amount of fluid present. Palpation. Palpation detects an oval outline No circumscribed outline to tu- and an irregular surface to the tu- mor or irregularity of surface is mor. discovered. Cervix of Uterus. The cervix is normal in position. The cervix is frequently displaced. General Health. The health is usually good until The health is usually impaired the tumor becomes large. from the commencement. 364 SURGICAL DIAGNOSIS. OVARIAN DROPSY ASCITES (continued). (continued). (Edema of Liaibs. If present, oedema of the limbs It often precedes the ascites. folloivs the advent of tumor. Aortic Pulsation. Aortic pulsation may be trans- Aortic pulsation is never present. mitted. History. No apparent cause exists. Hepatic, cardiac, or renal disease often co-exists. Skin. Normal color and moisture of the The skin is often jaundiced, and skin exist. is frequently dry like parchment. Fluid Contents. The fluid, if draAvn by aspirator, The fluid, if drawn by aspirator, may reveal the following character- may reveal the folloAving character- istics : istics : 1. Amber or brown in color. 1. Light straw-colored. 2. Not spontaneously coagulable. 2. Spontaneously coagulable, if fibrinous. 3. Specific gravity, 1018 to 1024. 3. Specific gravity, 1010 to 1015. 4. Paralbumen and metalbumen. Microscope reveals: Microscope reveals : 1. Granular cells, Avhich become 1. Pus cells. clear by action of acetic acid, but not increased in size. 2. Oil globules. 2. Oil globules. 3. Cholesterine and albuminoid 3. Amoeboid bodies. matters. 4. Epithelium (cylindrical). 4. Squamous epithelium. DISEASES OF TISSUES. 365 FLUID TUMORS OF THE PELVIC ABSCESS. OVARY. Origin. The tumor is preceded by no in- The tumor is preceded by symp- flammatory symptoms. toms of pelvic cellulitis. Extent of Tuaior. The tumor rises gradually above The tumor rarely extends to the the umbilicus. umbilicus. Mobility of Tuaior. The tumor is movable, when of The tumor is fixed and immov- moderate size. able. Pain. The tumor is usually painless, The tumor is exceedingly painful, and not sensitive to pressure. and is sensitive to the touch. Outline of Tuaior. The tumor is distinct in outline. The outline of the tumor is ob- scure. Developaient. The tumor deA'elops slowly. The tumor develops rapidly. Suppuration. The tumor does not point or sup- The tumor tends towards point- purate. ing and the evacuation of pus. . Constitutional Syaiptoais. Inflammatory symptoms are ab- Chills and often an elevation of sent during the development of the pulse and temperature accompany tumor. the development of the tumor. Exploring Needle. The characteristic fluid of ovarian Pus is withdrawn after the tu- tumors, as described on preceding mor softens and becomes fluctuant. page, is AvithdraAvn when the ex- ploring needle or aspirator is used. 366 SURGICAL DIAGNOSIS. UNILOCULAR OVARIAN RENAL CYST, (Dropsy or CYST. Hydatids). Intestinal Displacement. The tumor displaces the intes- The tumor displaces the intes- tine backAvards, as revealed by per- tine forwards. cussion. Urinary Changes. The urine is normal. The urine may contain pus, blood, or albumen. It may also occasionally be evacuated in sudden and large quantity, and the tumor then simultaneously subsides. Developaient. The tumor grows from below up- The tumor grows from above wards. dowmvards. Frequency. Is common, and affects all ages. Is a rare disease. Mobility. The tumor cannot be displaced The tumor may possibly be capa- upwards. ble of an upward displacement, so as to allow of resonant percussion above the pelvis. Origin. The tumor is never due to echi- The tumor may be of hydatid nococci. origin, or may be due to obstructed escape of urine. Colon. The tumor is neArer crossed by The tumor is often crossed by the the colon, as shoAvn by percussion. descending colon if on the left side. The tumor lies internally to the The tumor, if on right side, often ascending colon. lies externally to the ascending colon. Menstruation. Menstrual derangements are fre- Menstrual derangements are usu- quent. ally absent. Location of Tuaior. The tumor involves both sides, if The tumor is unilateral. of large dimensions. DISEASES OF TISSUES. 367 OVARIAN TUMOR. PREGNANCY. Situation of Tumor. The tumor is not median in po- The tumor is median in its po- sition till far advanced. si tion. Fluctuation. The tumor is often fluctuant. The tumor is seldom, if ever, fluctuant. Origin. The tumor begins in one iliac The tumor begins in the median fossa. line. Groavth. The tumor grows slowly. The growth of the tumor is rapid. Uterus and Cervix. The uterus and cervix are normal. The uterus and cervix are altered. Menstruation. Menstruation is often unaffected. Amenorrhoea is the rule. Auscultation. No abnormal auscultatory sounds Placental bruit and foetal heart are detected. are heard after the fourth month, unless the child be dead. Fostal Manifestations. No quickening or fcetal move- Foetal manifestations are a promi- ments are detected. nent symptom. Duration. Indefinite. Limited. SYMPTOMS IN COMMON. Both may produce enlargement of the breasts. tt ft a pam in the breasts. tt tt a areola " " a ti a morning sickness. 368 SURGICAL DIAGNOSIS. TUMORS OF THE PELVIS. The various types of tumor found within the pelvis may be enu- merated as follows: 1. Pelvic Cellulitis. 2. Pelvic Peritonitis. 3. Pelvic Haematocele. 4. Extra-uterine Pregnancy. 5. Utertne Cancer. 6. Inversion of Uterus. 7. Uterine Fibroid. 8. Uterine Polypus. 9. Rectal Cancer. 10. Ovarian Tumor in Early Stage. 11. Osseous Tumors of the Pelvic Bones. 12. Vaginal Thrombus. 13. Vesical Calculus, (if large). 14. Hernia of Bladder or Rectum. 15. Prostatic Enlargement: (cancer, tubercle, abscess). Many of these conditions have been treated of in preceding chapters of this work, and will be found included under the diseases of organs, or of special localities of the body. I shall present, therefore, in the following pages only diagnostic tables, in which are contrasted the symptoms of pelvic cellulitis, pelvic peritonitis, pelvic haematocele, extra-uterine pregnancy, vaginal polypus, and inversion of the uterus. DISEASES OF TISSUES. 369 PELVIC CELLULITIS. PELVIC PERITONITIS. Tumor. The tumor will be felt loiu down The tumor, if detected, will be in the pelvis, and will be most felt high up in the pelvis, and will marked on one side, as a rule. be located in the median line, as a rule. A hardening of the whole pelvic roof is more common than a tumor. Mobility of Uterus. The uterus will be slightly mova- The uterus will be immovable. ble. Suppuration. Suppuration is usually produced. Suppuration seldom occurs. Tyaipanitis. Tympanitis is absent. Tympanitis is usually present. Appearance of Face. The expression of the face is nor- The face has an anxious expres- mal. sion. Constitutional Effects. The constitutional effects are Elevation of pulse and tempera- slight or absent. ture, vomiting, tenderness of abdo- men, etc., etc., are liable to exist. Relapses. No tendency to relapses, during Relapses are frequent at the menstruation, is present. monthly periods. Position of Uterus. The uterus is not necessarily dis- The uterus is usually displaced placed. by subsequent adhesions and con- traction of new connective-tissue development. History. Cellulitis most frequently follows Peritonitis most frequently fol- parturition, abortion, or operations lows exposure during menstruation, upon the pelvic viscera. disease of the ovaries, gonorrhoea and escape of fluids into the peri- toneal cavity. 24 370 SURGICAL DIAGNOSIS. PELVIC HEMATOCELE. EXTRA-UTERINE PREG- NANCY. Development. A tumor deAelops suddenly, with A tumor develops slowly. constitutional symptoms of hemor- rhage, if due to traumatism ; but slowly, if due to spontaneous, effu- sion of blood. Menstruation. Menstruation may be normal. Amenorrhoea is usually present. Hemorrhage. Symptoms of hemorrhage, if pres- Hemorrhage is liable to occur ent, precede or accompany the de- only after the tumor has developed. velopment of the tumor. Uterine Syaiptoms. The early symptoms of pregnancy The early symptoms of pregnancy, are usually absent. viz. : morning sickness, suppression of menses, areola in breasts, kiestein in the urine, etc., etc., are often present. Fluctuation. The tumor fluctuates at its com- The tumor is often fluctuant mencement, but grows hard as co- throughout its entire development. agulation of the blood advances. Teraiination. The tumor tends to decrease in The tumor tends to develop or size and disappear after the hemor- to rupture. In the latter case, death rhage is arrested. from hemorrhage or peritonitis is common. DISEASES OF TISSUES. 371 VAGINAL POLYPUS. INVERSION OF THE UTERUS. Uterine Probe. The uterine probe, if passed The uterine probe will be arrested through the vagina by the side of at the vaginal attachment to the the tumor, will enter the body of uterus. the uterus. Rectal Examination. The uterine body can be detected The finger in the rectum detects in its normal position by the finger, the absence of the uterus from its when introduced into the rectum. normal position. Conjoined Manipulation. By pressing the abdominal walls The uterus is not detected, save firmly downwards to wards the pelvis as the cause of the vaginal tumor, while the finger of the other hand by the same means of examination. is crowded by the side of the tumor into the \*agina, the uterus can often be detected by one of the two hands. Recto-vesical Exploration. A sound introduced into the blad- No intervening tumor will be der will often reveal to a finger in thus detected, save that in the ATa- the rectum an intervening tumor, gina, and thus the diagnosis of inver- which is the body of the uterus in sion of the uterus may be verified. its normal position. Acupuncture. Acupuncture will give no pain. Acupuncture will give pain. 372 SURGICAL DIAGNOSIS. TUMORS OF THE SPINE. The tumors of the spine comprise those of a congenital variety and the condition called spina-bifida. Among the different forms of congenital tumors of the spine which have been reported may be enumerated 1. Parasitic growths (containing the remnants of an obliterated foetus). 2. Cystic Tumors (simple and compound). 3. Fibroid Tumors. 4. Fatty Tumors. Congenital tumors of the spine are most frequently located in the vicinity of the sacral or the lower lumbar regions. They are often connected directly with the spinal membranes, in which case the bony encasement of the spinal cord is locally deficient. They may be present upon the anterior or posterior aspect of the spine and are not infrequently intra-pelvic for that reason. If situated so as to press upon the pelvic viscera they may create a displacement of the coccyx, and a protrusion of the anus and perineum may be also produced. If the tumor have a direct connection with the spinal membranes, it will, with few if any exceptions, lie in or spring from the median line. If cystic in its variety it will usually reveal a contents similar to the cerebro-spinal fluid in its chemical composition provided any communication with the cavity of the arachnoid is present, and differs little, therefore, in its actual construction from that of spina-bifida. Congenital tumors in the spinal region communicate in rare cases with the cavity of some viscus, as the intestine, rectum, bladder, etc. In this event a possible escape of the contents of the tumor into these various organs will be the only means of determining such an abnormal condition. Spina-Bifida. This condition is in reality a congenital hernia of the spinal mem- branes through an abnormal opening in the vertebral column. It is a frequent deformity and is either distinctly localized or affects the whole or greater portion of the spinal column. The sac DISEASES OF TISSUES. 373 consists of the membranes of the spinal cord and in rare cases the substance of the cord itself is spread out as a thin layer on the in- ternal surface of the membranous coverings. Its contents consist of an excessive accumulation of the subarach- noiclean fluid, occasionally portions of the cord itself or the cauda equina, and, in rarer instances, a deposit of fat and an increased quantity of connective tissue. The spinous processes of the verte- brae are absent over the tumor and the laminae are either imperfectly formed or entirely absent. Spina-bifida is not often present in the upper portions of the trunk, but is most frequently located in the lower dorsal or lumbar regions. The symptoms of spina-bifida and congenital fatty tumor arising from the membranes of the spinal cord Avill be given in the follow- ing pages. While they do not possess many points of strong re- semblance, still the location of the tumors, their congenital origin, the deficiency of the spinous processes of the vertebrae, and the possibility of associate muscular changes, and nervous symptoms dependent on spinal lesions seem to warrant a contrast of symp- toms rather than a separate enumeration of those associated with each. 374 SURGICAL DIAGNOSIS. SPINA-BIFIDA. CONGENITAL FATTY TUMOR (connected avith the Meai- branes of the Spinal Cord). Appearance of Tumor. The tumor may be circumscribed The tumor is usually distinctly or elongated for some distance in circumscribed. the longitudinal axis of the spine. Palpation of Tumor. The tumor is usually fluctuant The tumor never fluctuates. It or elastic. is doughy and soft to the touch. Nuaiber of Tumors. Multiple tumors are not infre- The tumor is usually solitary. quent. Size of Tumor. The tumor varies in size from The tumor is seldom of large size. that of a small bird's egg to the size of a child's head. Effect of Attitude. The tumor is usually tense when The tumor is not markedly af- the patient stands erect. fected by the attitude of the pa- Is fluctuant usually when the tient. patient lies upon the abdomen. Effects of Respiration. The tumor is often decreased in The tumor is not altered in size size by a full inspiration and is in- by the respiratory function. creased in size during expiration. Effects of Pressure. The tumor decreases in size on The tumor is often resistant to direct pressure being applied. pressure and is, as a rule, but slight- If other tumors of the same ly affected. variety co-exist, they often increase in size Avhen the pressure is applied. Symptoms of spinal compression Symptoms of spinal compression as evidenced by cries, pain, con- as the result of direct pressure over vulsions, paralysis, etc., etc., may the tumor are seldom present. accompany pressure if severely ap- plied and disappear when the pres- sure is removed. DISEASES OF TISSUES. 375 SPINA-BIFIDA CONGENITAL FATTY TUMOR (continued). (connected avith the Meai- branes of the Spinal Cord) (continued). Transmitted Light. The tumor is often translucent, as The tumor is always opaque. is perceived by holding a candle be- hind it. Appearance of the Integument. The integument covering the The integument is usually of nor- tumor may be reddened, thinned mal color and appearance, but is, as and transparent, or even absent, a rule, adherent to the tumor. In some cases hoAvever it is normal in appearance. 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Diseases of Arteries and Veins. 1815. Holmes, T. Surgical Treatment of Diseases of Childhood. 1869. Essay on Aneurism. (Holmes' Surgery.) Article on Diseases of Bone. Holthouse, Carsten. Injuries of the Lower Extremities. Howship, John. Discriminations in Surgical Diseases. 1840. Humphrey, G. M. Articles on Diseases of the Male Organs. (Holmes' Surgery.) Hunter, John. Essay on Venereal. (Bumstead.) 1853. Works. Edited by Palmer. Hutchinson. Injuries to the Elbow Joint and its Vicinity. 1856. Johnstone, A. A. Diseases of Joints. (Holmes' Surgery.) Lawrence, Wm. Treatise on Ruptures. Lee, Henry. Monograph on Phlebitis. Monograph on Syphilis. London, 1863. Lectures on Practical Surgery. London, 1870. Liston, Robt. Work on Practical Surgery. Philadelphia, 1846. Little, W. J. Monograph on Deformities of the Human Frame. London, 1853. Loomis, A. L. Work on Physical Diagnosis. New York, 1876. Lonsdale, Edw. A Practical Treatise on Fractures. London, 1848. Macleod, G. H. B. Work on Surgical Diagnosis. New York, 1864. Maclise, Jos. Dislocations and Fractures. 1858. Markoe, T. M. A Treatise on Diseases of Bone. New York, 1872. Malgaigne, I. F. Traite des Fractures. 1855. Translation by Packard. Philadelphia, 1859. Miller, Jas. Principles of Surgery. Edinburgh, 1864. Moore, C. H. Article on Cancer and Tumors. (Holmes' Surgery.) " " Injuries to Vessels. " " Paget, Sir Jas. Work on Tumors. Lectures on Surgical Pathology. London, 1870. Peaslee, E. R. Monograph on Ovarian Tumors. 1872. BIBLIOGRAPHY. 379 Pirrie, W. Principles and Practice of Surgery. London, 1860. Poland, Alfred. Article on Injuries to the Chest. Prize Essay on Injuries to the Abdomen. Pollock, George. Article on Injuries to the Abdomen. (Holmes' Surgery.) Porter. Monograph on Aneurism. Pancoast, Jas. Treatise on Operative Surgery. Philadelphia, 1844. Pott, Percival. Chirurgical Works. London, 1808. Quain, J. Work on Anatomy. New York, 1877. Quain, Rich. "Diseases of the Rectum." London, 1854. Ricord, Ph. Treatise on Venereal. (Drummond.) 1845. Rokistansky. Treatise on Pathological Anatomy. London, 1854. Roux, Jos. Essay on Osteo-Myelitis. Sanderson, J. B. Tubercle and Lymphoma. 1869. Savory, Wm. S. Article on Scrofulous Diseases. (Holmes' Surgery.) Sayre, Lewis A. Diseases of Joints. Monograph on Orthopedic Surgery. Scarpa, Antonio. Translation of Treatise on Hernia. 1814. Translation of Treatise on Aneurism. (Wishart.) 1808. Shaw, A. Diseases of the Spine. (Article in Holmes' Surgery.) Skey, F. C. Work on Operative Surgery. 1850. Smith, Henry. Article on Diseases of the Rectum. Smith, R. W. Treatise on Fractures in the Immediate Vicinity of Joints. Dublin, 1847. Stanley, Edw. Treatise on Diseases of Bone. London, 1849. Syme, I. Observations on Chemical Surgery. Edinburgh, 1861. Thomas, T. G. Treatise on Diseases of Women. Philadelphia, 1876. {Monograph on Stricture of the Urethra. Philadelphia, 1869. Diseases of the Urinary Organs. Philadelphia, 1869. Monograph on the Enlarged Prostate. London, 1858. Travers, Benj. Monograph on Injury to the Intestines. London, 1812. Todd, Benj. Treatise on Urinary Diseases. Philadelphia, 1857. Van Buren, Wm. H. Monograph on Diseases of the Rectum. 1873. Van Buren and Keyes. Genito-Urinary Diseases and Syphilis. New York, 1874. Velpeau, A. L. M. Works on Surgery (Mott). 1847. Monograph on Cancer. 1840. Virchow, R. Cellular Pathology. 1871. Wardrop, Jas. Essay on Aneurism. London, 1828. Year Book on Surgery. Sydenham Soc. Trans. 1861. Ziemssen. Article on Diseases of the Vessels. INDEX OF SUBJECTS. PAGE Abdomen, contusion of.............. 270 wounds of................ 270 Abdominal aneurism................ 11 Abdominal cavity, diseases of........ 270 Abdominal diseases with pain........ 12 Abscess, acute...................... 319 Abscess and local oedema............318 chronic or cold............. 319 faecal...................... 273 iliac........................ 320 mammary acute............. 349 mammary chronic.......... 349 of abdominal wall....... 320, 322 of antrum................79, 346 of bone..................... 73 over a vessel................ 10 pelvic......................365 perineal.................... 256 psoas............13, 47, 300, 321 Anchylosis........................ 40 Aneurism, abdominal............. 11, 12 and abscess.............. 10 and aneurismal varix..... 20 and encephaloid cancer.... 19 and erectile tumors....... 8 and psoas abscess......... 13 and a relaxed aorta........ 9 and tumor on an artery.... 7 cirsoid and erectile tumors. 22 cirsoid and naevi........... 23 cirsoid and pulsatile bone tumors............... 18 classification............. 4, 5 of arch of the aorta....... 24 of bone and cancer........ 16 of innominate artery...... 24 thoracic and thoracic tu- mors ................ 14 thoracic and pul. consoli- dation............... 15 varicose and aneurismal varix................ 25 varicose and varicose veins 26 Aneurismal varix................... 20 and varicose aneurism 25 Ankle, congenital deformities of...... 132 dislocations of............127,131 fractures in vicinity of........ 189 sprain of..................63,131 Anomalies of the penis.............. 264 Anthrax...........................317 Antrum, abscess of...............79, 346 PAGE Antrum, cystic tumors of............ 80 malignant tumors of....... 80 solid tumors of............. 79 Anus, condylomata of............... 285 fissure of..................275, 289 pruritus of...................275 Aortic pulsation.................... 9 Arthritis, acute..................... 36 and abscess of bone........ 73 and syphilitic periostitis... 38 and suppuration near a joint 39 chronic rheumatic......... 36 rheumatic of jaw.......... 89 Ascites............................ 363 Astragalus, dislocations of... .128, 129, 130 Balanitic abrasion.................. 268 Balanitis..........................261 Barton's fracture................... 172 Bladder, atony of................235, 243 bar of..................... 234 calculi of...............235,238 cancer of..................238 deficiency of............... 233 diseases of (classification).. . 233 extroversion of............. 233 foreign bodies in........... 235 hernia of.................. 234 hypertrophy of............. 234 inflammatory conditions of.. 234 inversion of................ 234 malformations of...........233 multiplicity of............. 233 neuralgia of................ 235 paralysis of.............235, 243 spasm of.................. 235 tubercle of................. 235 tumors of................. 234 Boils.............................. 317 Bone, abscess of................... 73 aneurism of................. 16 cancer of.................... 76 caries of..................... 70 cysts of (spina ventosa)....... 75 diseases of (classification)..... 67 exostoses of................75, 342 inflammation of............69, 71 malacosteon................. 74 necrosis of................... 70 pulsatile tumors of..........18, 76 rickets of.................... 74 Brain, compression of............... 146 concussion of................ 146 381 382 INDEX OF SUBJECTS. PAGE Brain, dropsy of.................... 344 Breast, abscess of..,................ 349 cysts of.....................351 glandular tumors of......... 350 hypertrophy of.............. 351 scirrhus of.................. 352 tumors (innocent)............ 352 tumors of (classification)......348 Bubo.............................. 295 Bubonocele........................ 296 Cancer, colloid..................... 337 encephaloid............. 19, 335 epithelioma................ 336 of axillary glands........... 338 of omentum................ 339 of rectum.................. 288 scirrhus.................335,337 Cancerous tumors................... 332 Carbuncle......................... 317 Caries of bone...................... 71 Cephalasmatoma....................345 Cerebral compression............... 146 concussion................. 146 Chancre............................ 266 Chancroid......................... 266 Chinese foot........................ 60 Clavicle, dislocations of.............. 96 fractures of........155, 156, 157 Colles' fracture..................172, 174 Colloid cancer...................... 337 Compression of the brain............ 146 Concussion of the brain............. 146 Condylomata of anus...............285 Contusion of the hip................ 119 Corpora cavernosa, diseases of... .263, 264 Cystitis acute...................... 242 chronic....................244 varieties of, etc.............. 234 Cysts of breast..................... 350 of kidney..................... 366 of ovary...................... 360 Deformities of ankle................ 57 of joints (table).......... 55 Diagnostic points of tenderness in joint inflammations.................. 55 Diseases of abdominal cavity......... 269 blood-vessels (table)....... 3 bone (table).............. 67 joints (table)............. 33 male genitals (table)......203 testicle (diagnostic table).. 216 tissues (classification)..... 311 Dislocation........................ 85 and fracture in general... 199 of the ankle (table)....... 127 of the ankle.....128, 129, 130 of the clavicle (table)..... 96 of the elbow joint (table)... 97 both bones backwards 101, 102 Radius forwards, ulna backwards........ 101 Both bones forwards .. . 102 Ulna alone, backwards 104,106 PAGE Dislocation, Radius alone, backwards 105 Radius forwards....... 105 Ulna forwards......... 106 of the hip (table)......... 114 congenital............ 45 " Dorsum ilii"........ 115 "Pubic"..........117, 186 " Sciatic notch " 115,116,185 "Thyroid"............ 117 ofthejaiv..............86, 87 congenital of jaw ..... 88 of the knee joint (table)... 121 Patella inwards........ 125 Patella outwards....... 125 Patella by rotation..... 126 Patella upwards....... 126 Tibia backwards....... 123 Tibia forwards......... 123 Tibia by rotation....... 124 Tibia laterally......... 124 of the shoulder joint (table) 90 " sub-clavicular " .... 93 " sub-coracoid"..... 95 " sub-glenoid"___91, 162 " sub-spinous "___93, 164 " supra-coracoid " .... 95 of the scapula........... 97 of the ivrist joint (table)... 107 Symptoms.....108, 110, 174 Os magnum........... 113 Elbow, dislocations of............... 97 fractures in vicinity of... .165, 166 Elephantiasis....................... 314 Embolism of vessels................ 28 Emphysema of tissues from fracture of the ribs (diagnosis).............. 198 Encephaloid cancer................. 335 Encephalocele...................344, 345 Epididymitis....................... 214 Epithelioma....................336, 347 Epithelioma of penis................ 261 Erectile tumors..................... 8 Erysipelas.......................... 314 cutaneous................ 324 phlegmonous............. 324 Exostoses of bone................... 75 cranium................ 82 Exomphalos....................... 304 Fatty degeneration of vessels........ 27 Fatty tumor of thigh............... 303 of scalp................ 341 Femur, dislocations of at hip........ 114 (diagnostic table). 120 fracture of (varieties).....178,187 fracture of with inversion of foot................116,185 Fissure of the anus................. 289 Fistula of the rectum............... 289 Flat foot........................... 62 Forearm, dislocation backwards...... 99 fracture at wrist........110, 175 separation of epiphyses..Ill, 176 Fracture........................... 135 and dislocation............ 199 its general symptoms....... 136 INDEX OF SUBJECTS. 383 Fracture at the ankle (table)......... 189 both bones transversely... 189 Pott's fracture.......... 190 internal malleolus....... 190 compound of ankle...... 191 near the wrist joint (table).. 172 Colles' fracture . .108, 172, 174 transverse of both bones.. 175 of the clavicle (table)....... 155 inside of coracoid process. 157 outside of coracoid process 157 of the femur at the hip (vari- eties, etc.)............ 178 extra-capsular simple.... 183 extra-capsular impacted.. 181 intra-capsular simple.....183 intra-capsular impacted.. 181 Avith inversion of foot.... 185 of the femur at the knee ... 187 of the leg bones at the knee. 187 of the patella.............. 188 of the humerus at the shoul- der joint (table)...... 158 extra-capsular simple.... 159 extra-capsular impacted.. 161 intra-capsular simple..... 159 intra-capsular impacted.. 161 separation of great tuber- cle ................. 164 of the humerus at the elbow (table)................ 165 inner condyle........... 168 outer condyle........... 168 transverse above condyles 167 T-shaped fracture........ 165 of the lower jaw........148, 150 of the upper jaw........... 148 of the scapula (varieties).... 151 of the body of the scapula.. 152 of the neck of the scapula. 153,163 of the spine of the scapula.. 152 Fractures of the skull (varieties)...... 139 complete fracture......... 142 inner table only........... 143 outer table only........... 142 of the base............... 145 Fractures of the sternum............ 193 of the ulna at elbow....... 166 coronoid process........ 169 olecranon " ........ 171 upper end of shaft...... 171 of the vertebras........... 193 Furuncle.......................... 317 Ganglion at wrist................... 114 Gangrene of tissues................. 313 dry.................. 323 moist................ 323 hospital............... 314 Glans penis, diseases of............. 261 Glands of groin (enlarged)........... 299 cancer of................... 338 tubercle of.................. 339 Haematocele of testis................ 218 Hemorrhoids...................... 274 external...........284, 285 Hemorrhoids internal............... 284 Herpes progenitalis..............261, 268 Hernia, causes of................... 278 classification of............. 276 congenital..........230, 308, 307 diaphragmatic.............. 306 differential diagnoses (table). 280 femoral.............299. 301, 302 infantile................... 308 inguinal............231, 297, 302 inguinal (direct)............ 290 inguinal (indirect).......... 290 inguinal (incomplete)....... 295 perineal.................... 305 scrotal............ .226, 291, 293 thyroid.................... 305 testis (benign fungus)... .206, 213 umbilical.................. 304 ventral.................... 304 Hip Joint, contusion of.............. 119 dislocation (congenital).... 45 dislocations of (diagnostic table)................ 120 deformity, rheumatic..... 51 fractures in vicinity of.... 178 Humerus, dislocations (table)........ 90 fracture above condyles... 99 fractures of at elbow..;... 165 fractures of at shoulder... . 158 fracture of (extra-capsular) 159 fracture of (intra-capsular) 159 fracture of (impacted)..... 161 separation of the great tu- bercle................ 164 Hydrarthrosis...................... 35 Hydrocele......................212, 218 and congenital hernia..... 230 and scrotal hernia........226 congenital................ 220 encysted.................. 220 encysted and cyst of testis 229 multilocular.............. 219 of cord and inguinal hernia 231 of spermatic cord (diffuse). 221 " " _ " (encysted) 222 of tunica vaginalis (encyst- ed)................... 221 Hydro-sarcocele.................... 220 Ilium, disease of.................... 52 Impaction of fasces................. 296 Induration of tissues................ 311 Infantile paralysis of hip............ 54 Intestine, diseases of (table)..........273 foreign bodies in.......... 272 obstruction of.........273, 283 Jaw, dislocation of................86, 87 '' (congenital)....... 88 fractures of.................... 148 Joints, Ankle, sprain of............. 63 " dislocations of.......... 127 " fractures of............ 189 deformities of............... 55 diseases of (table)............. 33 diagnostic points of tenderness of...................... 55 384 INDEX OF SUBJECTS. Joints, dropsy of................... 35 Elbow, dislocations of........ 97 " fractures of.......... 165 Hip, diagnosis of diseases of.. -43 '' diseases of.............. 40 " dislocations of.......... 114 " fractures of............. 178 Knee, dislocations of......... 121 " fractures of........... 187 rheumatism of............... 34 Shoulder, dislocations of...... 90 fractures of, 151,155,158 Wrist, dislocations of........ 107 " fractures of........... 172 Knee, dislocations of................ 121 fractures in vicinity of........ 187 Lupus.........................315, 347 Malacosteon of bone................. 74 Mollifies ossium.................... 74 Morbus coxarius, diagnosis of........ 43 and congenital dis- location of hip 45 and disease of ilium 52 and disease of tro- chanter....... 49 and infantile paraly- sis............ 54 and psoas abscess .. 47 and rheumatic de- formity........ 51 and sacro-iliac dis- ease.......... 48 and spinal curvature 50 Naavi.............................. 23 Necrosis of bone................... 70 CEdema, local...................... 318 Omphalocele........................ 304 Orchitis, chronic................... 207 malignant.............204, 211 simple inflammatory... .203, 209 specific.................204, 210 tubercular..............204, 210 Os magnum, dislocation of........... 113 Osteitis...........................69, 71 Osteo-malachia..................... 74 Osteo-myelitis...................... 69 Ovary, cysts of...................... 360 cyst (unilocular).............. 366 dropsy of................... 363 fluid tumors of............... 365 tumors of (classification)...... 362 tumors of (diagnosis)......... 367 tumors of (solid)............. 359 Painful diseases of abdomen......... 12 Paralysis, infantile of hip........... 54 Patella, dislocations of (table)........ 121 dislocations (special varie- ties).................125, 129 Penis, anomalies of.................. 264 diseases of corpora cavernosa.. 263 inflammation of............ 263 calcification of............. 263 gummata of............... 263 fracture of................. 263 diseases of glans.............261 Penis, Balanitis................... 261 Posthitis..................261 Herpes.................... 261 Vegetations................ 262 Venereal sores..........262, 266 Epithelioma................ 262 diseases of the prepuce........ 262 Phimosis................... 262 Paraphimosis............... 263 Pelvis, cellulitis of..................368 haematocele of............... 370 peritonitis................... 369 tumors of (table).............. 368 Perineal abscess.................... 256 Perineal hernia..................... 305 Periostitis acute.................... 71 syphilitic................ 38 near a joint.............. 72 Perityphlitis...................... 282 Phlebitis adhesive................. 29 suppurative............... 29 Pleurisy with contusion.............. 196 Pneumo-thorax...................... 197 Polypus of rectum.................. 286 Posthitis........................... 261 Potts' fracture...................... 190 Prepuce, diseases of................. 262 Prolapse of the rectum............... 287 Prostate, atrophy of................246 calculi of.................. 247 cancer of.................. 246 cystic disease of........... 246 diseases of (table)........... 245 hemorrhage of............247 hypertrophy of.........245, 250 phlebolites of.............. 247 tubercle of................ 246 wounds of................. 247 Prostatic abscess.................... 245 enlargement............... 250 Prostatitis, acute................245, 249 chronic..............245, 249 Psoas abscess......................13, 47 Psoas bursa, inflammation of........ 53 Pulmonary consolidation and thoracic aneurism....................... 15 Radius, Barton's fracture of.......... 172 Colles' fracture of............ 172 dislocations of.............. 105 fractures of at elbow.....166, 171 fractures of at wrist......... 172 Rectum, cancer of...............275, 288 diseases of (table)........... 274 fissure of...............275, 289 fistula of................274, 289 hemorrhoids of..........274, 284 neuralgia of................ 276 polypus of..............275, 286 prolapse of.............274, 287 pruritus of................275 stricture of................ 275 Retraction of the testicle............ 225 Rheumatic arthritis of jaw.......... 89 Rheumatic deformity of hip.......... 51 Rheumatism of joints............... 43 INDEX OF SUBJECTS. 38o PAGE Ribs, fractures of (table)............ 194 fracture of and emphysema..... 198 fracture of and pleurisy........196 fracture of and pneumothorax.. 197 Rupture of the. triceps tendon........170 Sacro-iliac disease.................. 48 Sarcocele........................... 291 Sarcoma, cystic of testicle........... 204 Scapula, dislocation of.............. 97 fracture of................. 151 Scrotal hernia and hydrocele.....226, 292 and varicocele........293 and sarcocele......... 291 and haematocele...... 291 Scirrhus........................335, 337 Separation of greater tubercle of the humerus....................94, 164 Shoulder, dislocations of (table)...... 90 fractures of............... 155 Skull, fractures of (varieties)......... 139 tumors...................... 340 Spasm of cremaster muscle.......... 225 Spermatic cord, diseases of........... 219 hydrocele of........ 222 lipoma of........... 223 varicocele of........225 Spina ventosa...................... 75 Spinal curvature................... 50 Sprain of ankle joint................ 63 Sternum, fracture of................ 193 Stone in the bladder................238 Stricture of rectum................. 288 of urethra (organic).....250, 259 (congestive)...... 253 (spasmodic)......253 Suppuration of tissues.............. 311 Talipes calcaneo-valgus............. 60 equinus.................... 59 equinus with paralysis of the flexors of tarsus........ 59 spurio-valgus.............60, 63 valgus....................58, 61 varieties of (table)........... 57 varus...................... 58 Testicle, benign fungus of........... 206 calcareous deposit in........ 208 cancer of...............204, 212 cartilaginous tumor of..... 206 cheesy degeneration of...... 204 chronic inflammation of.... 207 cysts of............204, 212, 229 diseases of (table).......203, 207 diseases of (diagnostic table). 216 fatty tumor of............. 205 fibrous tumor of............ 205 haematocele of............. 205 hernia of...............206, 213 malformations of........... 207 malignant fungus of........ 213 neuralgia of............207, 209 specific deposit in.......... 204 undescended............... 297 Thrombosis........................ 28 Tibia, dislocation of...............• 121 dislocation of (spec, varieties) 123,124 25 PAGE Tibia, fractures of.........187, 189, 190 Tissues, diseases of.................. 311 elephantiasis...............314 erysipelas.................. 314 gangrene of................ 313 induration of............... 311 lupus..................... 315 suppuration of............. 311 tumefaction of.............. 311 tumors of..................325 ulceration of................ 312 Trochanter of femur, disease of...... 49 contusion of............. 119 Tubercular disease of axilla......... 339 Tumors............................ 325 abdominal................. 11 benign (symptoms).......... 334 colloid..................... 337 cystic (classification of)......327 encephaloid....... ........ 335 epithelioma................ 336 erectile....................8, 22 exostoses of cranium........ 82 extra cranial.............81, 341 fatty of scalp............... 341 intra-craniai.............81, 341 malignant..............332, 334 malignant of bone.......... 76 mediastinal................ 306 of antrum (cystic)......... 80 " " (malignant)...... 80 " " solid............ 79 of axilla (table).............331 of bladder (table)........... 234 of breast (table)............ 348 of groin................... 331 of head (table)......... 328, 340 of neck (table).............. 329 of ovary (table)............. 362 of rectum (table)............ 275 of testicle, cartilaginous.....206 cystic............ 204 fatty............205 fibrous........... 205 haematocele....... 205 malignant....... 204 of the trunk (table).........330 of urethra...............253, 260 of uterus (table)............. 354 pulsatile................... 18 pulsatile of bone...........76, 78 scirrhus................335, 337 sebaceous.......... ..82, 341, 343 solid (classification of)....... 326 thoracic.................... 14 Tunica vaginalis, diseases of........219 Typhlitis.......................... 282 Ulceration of tissues................. 312 Ulna, dislocation of, at elbow.....104, 106 dislocation of, at wrist......... 112 fractures of, at elbow.......... 166 fractures of, at wrist.......... 172 separation of epiphyses of...... Ill Undescended testicle................ 312 Urine, incontinence of...........236, 241 386 INDEX OF SUBJECTS. Urine, overflow of..................236 retention of.............235, 239 suppression of............... 240 Urethra, abscess of.................253 calculi of.................. 253 congestive stricture of......253 deformities of.............. 253 dilatation of............... 252 diseases of (table)........... 251 fistula of.................. 253 foreign bodies in........... 254 inflammations of........... 251 rupture of..........252, 256, 257 spasm of.................. 253 stricture of............251, 259 tumors of..............253, 260 Uterus, congestive hyperaemia of..... 355 early pregnancy of...........355 fibroid tumors of.........356, 359 fibro-cysts of................360 hydatids of.................358 inversion of................. 371 polypus of.................. 361 pregnancy of............357, 358 pregnancy (extra uterine).... 370 Uterus, retained menstrual blood in cavity of............... 357 tumors of (table)............ 354 Vagina, polypus of................. 371 Varicocele of spermatic cord......... 223 causes (table)............. 224 Varicose aneurism.................. 26 Varicose veins...................... 26 Varix of tne saphenous vein.........301 Vegetations of penis................ 261 Veins, diseases of (table)............ 3 inflammation of.............. 29 varicose..................... 26 Vertebrae, fracture of................ 192 Vessels, atheroma of............... 27 diseases of.................. 3 embolism of................ 28 fatty degeneration of........ 28 thrombosis of............... 27 White swelling of knee.............. 35 Wrist, dislocations of............107, 174 fractures in the vicinity of.... 172 ganglion at.................. 113 sprain of.................... 109 NLM005548119