wBMmmam*tm*mm<»tM*«i**' .rmmu am «>a«M»i a m* kV"» IS 6 NLH OOSSMSbT 3 SURGEON GENERAL'S OFFICE LIBRARY. j\b. iM^b, NLM005545693 - r A PRACTICAL TEEATISE ON SURGICAL DIAGNOSIS Designed as a Manual for Practitioners and Students BY AMBROSE L. RANNEY, A.M., M.D. '•r Adjunct Pbofessob of Anatomy and late Lectukeb on the Stogical Dibeases op the Gentto-Ubinabt Obqans and on Minub Suegeby in the Medical Depabtment op the Univeesity of the City op New Yobk, late Sfbgeon to the Noethwebteen and Nobthebn Disfensabxes, Resident Fellow op the New Yobk Academy op Medicine, Membeb op the Medical Society of the County of New Yobs, etc. -----i LIBRAUV SECOND EDITION—ENLARGED Amrfffiggif afMILRM.'Z OH .;'.. j HO') O * i NEW YORK WILLIAM WOOD & COMPANY 27 Great Jones Street 1881 NNO' K\65p IQ81 Copyright 1879, Bt William Wood & Co. TO WILLIAM DARLING, M.D., F.R.C.S., Professor of Anatomy in the Medical Department of the University of 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 EXPRESSION OF THE WARMEST PERSONAL REGARD ENGENDERED BY YEARS OF PLEASANT INTERCOURSE, Cbis WHaxk. is Inscribed BY HIS FRIEND, THE AUTHOR. PREFACE TO FIRST EDITION. 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 physician 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, dowmvards; 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 Madisox Avenue, January, IS79. iii PREFACE TO THE SECOND EDITION. Scarcely more than a year has yet elapsed since the first edition of this work was given to the public. At that time, the question whether the plan of the book would meet professional favor was certainly an open one, and it affords some personal gratification that the increasing demand for the work, both as a text-book and as an aid to the general practitioner, justifies a revision of its matter and an addition to its former pages. I have changed my opinion somewhat since this work was first issued, as to the advisability of employing the plan of contrast of symptoms, in the form of differential tables, to the exclusion of de- scriptive text; as I have found that, however valuable they might be as a summary to the student, or as an aid to the practitioner at the bedside, such tables alone will not fill the requirements of a text-book, or be as generally useful as if accompanied by a concise and general enumeration of the etiology and symptomatology of each of the more important diseases to which the attention of the surgeon is most often directed, and which must, therefore, form the basis of most lectures given to the student. In preparing this revised edition, I have followed, as far as my judgment approved, all those suggestions which have from time to time been made to me by different instructors throughout the country, and have endeavored to make this volume especially val- uable and attractive to the student in medicine, as well as to those more advanced in their knowledge of disease. The work, in its present form, cannot be called elementary in any sense, nor is that, in my opinion, a desirable quality in a text-book; , but it will, I trust, be found improved by the additions made, and better fitted for the purpose for which it was at first intended. In this edition, all errors of statement have been carefully ex- punged where detected by the author, and the first three sections of the present volume have been rendered much more complete than in the first edition of the work. v vi PREFACE TO TEE SECOND EDITION. In the section upon " Diseases of the Male Genitals," many ad- ditions and improvements have been made ; and in the section upon " Diseases of the Abdomen," the subject of hernia has been enlarged and many smaller alterations incorporated. I have introduced, as a preparation for the study of " Diseases of Tissues," a hasty summary of inflammation, arranged in a tabu- lar form, which is rather an outline sketch than a full resume, but which may possibly prove of some little value to those who need some guide to follow in studying more extensive treatises, or who wish to understand the first elements of pathological changes. A new index of this work has been made, which will be found quite complete, as the amount of new matter which has been added demanded it, and as the one of the previous edition did not seem to fill all the requirements of a book of reference. In the pages of bibliography, appended at the close of the volume, the full titles of the volumes from which extracts have been made have been supplied, where previously omitted, with the date and place of pub- lication, as a guide to those who wish to consult authorities upon any special subjects. It is not probable that everything has been added that would give additional value to the book, but time and the continued use of the work as a text-book will enable the author to be further enlightened as to its requirements. The author begs, in closing, to acknowledge the valuable hints afforded him in some of the able reviews of the first edition, and many other personal friends, who have also made suggestions of value ; also to his friend and student Henry C. Moir, for the valua- ble assistance which he has rendered me in preparing an index, which, from its completeness, will greatly facilitate reference, and thus add to the value of the work. 156 Madison Avenue, April, 1880. CONTENTS. PART I. DISEASES OF THE BLOOD-VESSELS. General table of diseases of the blood-vessels. Atheroma, its causes and diagnostic symptoms. Fatty degeneration of vessels, its causes and symptoms. Aneurism, its varieties, its causes, its most frequent situations ; the conditions affecting its growth ; the general symptoms of aneurism and their diagnostic value ; the symp- toms of special forms of aneurismal tumors ; the differential diagnosis of aneurism in general. Occlusion of Arteries, its etiology and symptoms. Diseases of the veins : Hypertrophy of the venous coats, its causes and symptoms. Atrophy of veins, its causes and surgical importance. Degeneration of the venous coats, its varieties, causes, and diagnostic importance. Adhesive inflammation of veins (thromballosis). Suppurative inflammation of veins (diffuse phlebitis), its causes and symptoms. Varicose veins. Parasites of veins. Phlebolithes (calculi of veins). Tables of con- trast of symptoms headed as follows : Aneurism and tumor on an artery. Aneurism and erectile tumors, Aneurism and aortic pulsations, Aneurism and abscess over a vessel. Diagnoses of special types of Aneurism : Abdominal aneurism and abdo- minal tumors, Abdominal aneurism and painful diseases of abdomen, Abdominal aneurism and psoas abscess, Thoracic aneurism and intra-thoracic tumors. Tho- racic 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 nsevi, 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 1-47 PART II. DISEASES OF THE JOINTS. General classification of joint diseases. Synovitis, its causes, varieties, and general symptoms. Acute synovitis, its causes and points of diagnosis. Suppurative synovitis (acute articular abscess), its causes, symptoms, and points of differential diagnosis. Chronic synovitis, its causes, symptoms, and differential diagnosis. Scrofulous synovitis, its causes, symptoms, and differential diagnosis. Rheumatic synovitis, its causes, symptoms, and differential diagnosis. Gouty synovitis, its causes and symptoms. Gonorrhoeal synovitis (gonorrhoeal rheumatism), its causes and symp- vii Vlll CONTENTS. toms. Syphilitic synovitis, its diagnostic symptoms. Arthritis, its causes, symp- toms, and varieties Chronic rheumatic arthritis (rheumatic gout, morbus coxre senilis), its causes, most frequent situation, and symptoms. Anchylosis of Joints, its varieties, causes, and symptoms. Dropsy of joints (hydrarthrosis), its causes and symptoms. Articular neuralgia, its causes and symptoms. Loose cartilages in joints, varieties, situation, and symptoms. Tables of contrast of symptoms of joint diseases, headed respectively : I. Diseases of the joints in general: Synovitis and rheumatic inflammation of joints, Scrofulous synovitis and hydrarthrosis, Acute arthritis and chronic rheumatic arthritis, Acute arthritis and syphilitic periostitis near a joint, Acute arthritis and suppuration external to a joint, Bony anchylosis and fibrous anchylosis. II. Diseases of special joints: Morbus coxarius, its varieties, its common symptoms, its diagnosis. Congenital dislocation of the hip-joint, its symptoms and differential diagnosis. Sacro-iliac disease, its causes, symptoms, and differential diagnosis. Tables of contrast of symptoms of the more important diseases of special joints. Differential 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 classification. Talipes, its varieties, Symptoms of talipes varus, Talipes valgus, Talipes equinus, Talipes equinus with paralysis of the extensors of the toes and flexors of the tarsus, Talipes valgus (spu- rious), Calcaneo-valgus of moderate severity (Chinese foot), Flat foot, Diagnosis be- tween spurious valgus and sprain of ankle-joint......................Pages 48-96 PART III. DISEASES OF BONE. Classification of bone diseases. Osteitis, its causes, symptoms, and differential diag- nosis. Osteo-myelitis, its causes, symptoms, and differential diagnosis. Abscess of bone, its causes, most frequent seat, symptoms, and differential diagnosis. Per- iostitis, its varieties, causes, and symptoms. Hypertrophy of bone, its causes and symptoms. Atrophy of bone, its causes and symptoms. Rachitic condition of bone, theories as to its cause, its symptoms, and differential diagnosis. Mollities ossium (malacosteon, fragilitas ossium, etc.), its causes and symptoms. Caries, its causes, pathology, symptoms, and differential diagnosis. Necrosis, its stages, causes, symptoms, and differential diagnosis. Cancer of bone, its most frequent situation, and its symptoms. Osteo-aneurism (pulsatile tumors of bone). Enchon- dvoma, its causes, situation, symptoms, and differential diagnosis. Exostosis, its varieties, causes, and symptoms. Cystic tumors of bone (osteo-cystoma), varieties causes, situation, and symptoms. Fibro-cystic tumors of bone (osteo-sarcoma). Fibrous tumors of bone. Entozoa of bone. Tables of contrast of symptoms of the principal diseases of bone : 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. Exostoses and cysts of bone, Cancer of bone and pulsatile tumors of bone, Pulsatile tumors 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 cranium.....................Pages 97-132 CONTENTS. ix 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 dis- location, Dislocation of jaw and chronic rheumatic arthritis of the tempero-maxil- lary articulation. II. Dislocations of the shoulder: Classification of the varieties. * Differential diagnoses between " Sub-glenoid " dislocation and fracture of neck of humerus, "Sub-clavicular" dislocation and "subspinous" dislocation, "Sub- spinous " dislocation and separation of the great tubercle of the humerus, " Sub- coracoid" dislocation and " supra-coracoid " dislocation. Comparative table of the three more important dislocations of the humerus at the shoulder joint. Disloca- tions of the clavicle. Varieties and etiology. Subluxation of outer end of clavicle (dislocation of scapula). III. Dislocations at the elbow joint: Classification of. Dif- ferential diagnoses between both bones of forearm backwards and fracture of humerus above the condyles, Both bones of forearm backwards and radius for- wards, 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. Com- parative table of the dislocations of both bones of the forearm at the elbow joint. 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 back- wards, and of dislocation of the os magnum. V. Dislocations at the hip joint : Varieties of dislocation of the upper end of the femur. Differential diagnoses between "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 knee joint: Varieties of dislocation of the tibia and of the patella. Symptoms of dislocation of the tibia forwards, backwards, in rotary displacement, in lateral dis- placement. Symptoms of dislocation of the patella inwards, outwards, upwards, and in rotary displacement. VII. Dislocations at the ankle joint: Varieties of dis- location of the astragalus. Symptoms of dislocation of the astragalus forwards, backwards, externally, internally, and upwards, Differential diagnosis between dislocation of the astragalus upwards and fracture of both bones of the leg, Dislo- cation at ankle and a severe sprain, Dislocation at ankle and a previous deformity associated with injury............................................Pages 133-188 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 table only, Fracture of outer and inner tables only, Fracture of inner table only, and apoplexy with complicating injury, Fracture of the base of X CONTENTS. 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 extracapsular fracture, Impacted intracapsular 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 " dislo- cation. V. Fractures at the elbow joint. Varieties of, and their location, Differential diagnoses between fracture of the condylesof humerus, fracture of coronoid and ole- cranon process, Fracture of the olecranon process and rupture of the triceps tendon, Fracture of the upper ends of radius and ulDa, 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 frac- ture of both bones near the wrist joint. VII. Fractures near the hip joint. Varie- ties of, and their location. Differential diagnoses between simple intra-capsular fracture and simple extra-capsular fracture, Impacted intracapsular and impacted extra-capsular fracture, Intra-capsular fracture of the femur and chronic rheu- matic arthritis with contusion, Fracture of femur with inversion of the foot and " sciatic notch " dislocation 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. Frac- tures of the sternum. Fractures of the vertebrae. Fractures of the ribs. Differen- tial 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, Frac- ture of the ribs and emphysema of tissues, Fractures in general in the vicinity of joints and dislocation of bone.....................................Pages 187-254 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. Haematocele 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- opment of testis. Congenital malformations of testis. Neuralgia of testis. Atrophv 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 fungous growth Orchi- tis and epididymitis. Diagnostic table of the four principal enlargements of the testicle. II. Diseases of the tunica vaginalis and the spermatic cord. Simple hydro- CONTENTS. xi 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 cysts of the testicle, Hydrocele and congenital hernia, Hydrocele of the cord and inguinal hernia, Hydrocele and hsematocele. III. Diseases of the bladder. Malformation of, and its varieties : Deficiency of, Multiplicity of, Extroversion of. Inflammatory conditions : 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, its causes, symptoms, and means of positive diagnosis. Calculi of bladder, etiology, number, and volume, consistency and ap- pearance, shapes, rational symptoms, physical signs, rules for sounding, causes of error in sounding. Foreign bodies in bladder. Tubercle of bladder. Paralysis. Atony. Spasm. Neuralgia. Retention of urine. Incontinence of urine. Over- flow of urine. Differential diagnoses between cancer of the bladder and vesical calculus, Rup- ture 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 hemor- rhage. 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 : Gonorrhoea, Urethritis, Chancre and chancroid of the urethra. Urethral stricture, its varieties, causes, symptoms, and means of positive diagnosis. Urethral dilata- tion. Urethral rupture. Urethral deformities. Urethral tumors. Urethral ab- scess. Urethral fistulae. Urethral spasm. Congestive stricture. Urethral calculi. Foreign bodies in the urethra. Symptoms of urethral rupture within the trian- gular 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, Or- ganic stricture, and Urethral tumors. VI. Diseases of the penis. Diseases 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 circum- scribed inflammation, Fracture of the penis, Anomalies of the penis. Differential diagnoses between chancroid and chancre, Herpes and balanitic abrasion........................................................Pages 255-332 PART VII. DISEASES OF THE ABDOMINAL CAVITY. Injuries to the abdomen : Contusions, Wounds, Foreign bodies in the intestinal canal. Diseases of the intestine: Faecal abscess, Intestinal obstruction, Hemorrhoids, Pro- lapse of the rectum, Fistulas of the rectum, Fissure of the anus, Stricture of the rectum, Cancer of the rectum, Polypi of the rectum, Pruritus ani, Neuralgia of the rectum. Hernia. Classification of hernia. Nomenclature of hernia. Predispos- ing causes. Exciting causes. Symptoms of hernia in general. Congenital hernia. Ventral hernia. Diaphragmatic hernia, its causes, symptoms, and means of posi- xii CONTENTS. tive diagnosis. Table of diagnoses of inguinal hernia. Diagnoses of femoral hernia. Differential diagnoses between typhilitis and peri typhi! itis, External hemor- rhoids and internal hemorrhoids, External hemorrhoids and condylomata of anu>s, Internal hemorrhoids and rectal polypus, Rectal prolapse and rectal polypus, Can- cer of rectum and stricture of rectum, Fissure of anus and fistulae of rectum, Direct and indirect inguinal hernia, Scrotal hernia and sarcocele, Scrotal hernia and hydro- cele, Scrotal hernia and varicocele, Scrotal hernia and haematocele, Incomplete in- guinal hernia and bubo, Bubonocele and undescended testicle, Inguinal hernia and impaction of faeces, Inguinal hernia and,hydrocele of the cord, Femoral hernia and enlarged glands, Femoral hernia and psoas abscess, Femoral hernia and varix of the saphenous vein, Femoral hernia and inguinal hernia, Femoral hernia and lipo- ma of the femoral canal, Ventral hernia and umbilical hernia, Thyroid hernia and perineal hernia, Diaphragmatic hernia and mediastinal tumors, Congenita] hernia and hydrocele, Congenital hernia and infantile hernia..............Pages 333-377 PART VIII. DISEASES OF TISSUES. Inflammation, its derivation, definition, classification of its varieties, its predisposing causes, its exciting causes. A classified table showing the different results of in- flammatory processes. The theories advanced to explain the various inflammatory phenomena. The variations in the rational symptoms of inflammation and the conditions which modify them. The constitutional effects of inflammation and the conditions which modify them. Special types of inflammatory processes. Catar- rhal inflammation. Fibrous or Croupous inflammation. Inflammation of serous membranes. Inflammation of lymphatic structures. Inflammatory condition of tissue : Tumefaction, induration, suppuration, ulceration. Gangrene of tissues. Erysipelas. Elephantiasis. Lupus. Differential diagnoses between anthrax (car- buncle) and furuncle (boil), Abscess and circumscribed local oedema, Acute abscess and chronic abscess, Iliac abscess and abscess of the abdominal walls, Psoas abscess and femoral hernia, Abscess of the abdominal walls and enlargement of the spleen, Moist gangrene and dry gangrene, Cutaneous erysipelas and phlegmonous erysipe- las. Tumors. Classification of solid tumors. Classification 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 integu- ment 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. Differential diagnoses be- tween benign and malignant tumors, Scirrhous 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 between 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, Encephalocele and dropsy of the brain, Encephalocele and cephaleematoma, Abscess of the antrum and solid tumors of the antrum, Epithelioma and lupus. Tumors of the breast: Classi- fication. Differential diagnoses between acute mammary abscess and chronic mam- mary abscess, Cysts of the breast and glandular tumors of the breast, Glandular tumor of the breast and hypertrophy of the mammae, Scirrhus of the breast and innocent tumors of the breast. Tumors of the Uterus : Classification. Differential CONTENTS. xiii diagnoses between congestive uterine hyperaemia and the early stages of pregnancy. Fibroid tumor of the uterus and pregnancy, Retained menstrual blood and preg- nancy, 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 : Classification. Differ- ential diagnoses between pelvic cellulitis and pelvic peritonitis, Pelvic haematocele and extra-uterine pregnancy, Vaginal polypus and inversion of the uterus, Pelvic haematocele and extra-uterine pregnancy. Tumors of the spine : Classification. Congenital tumors of the spine. Spina bifida. Differential diagnosis between spina bifida and congenital fatty tumor of the spine connected with the menin- ges.............................................................Pages 378-457 Bibliography Pages 459-462 DISEASES OF THE BLOOD-VESSELS. DISEASES OF THE BLOOD-VESSELS. The Diseases of the Aeteeies 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. The points of interest which bear upon the diagnosis of each of these conditions will be first separately reviewed, since a tabular form of statement often fails to meet the demands of the student or the practitioner. In the closing pages of this chapter, however, will be found the 3 4 SURGICAL DIAGNOSIS. points of special diagnostic value contrasted, to further assist memory and to facilitate reference. A. DISEASES OF THE AETEKIAL COATS. ATHEROMA. This condition may be produced by age, chronic alcoholism, gout, rheumatism, lead poisoning, syphilis, chronic diseases of the kidney, exposure, or traumatism. It is a direct result of an existing chronic endarteritis, the lining membrane of the vessels being invariably involved to a greater or less degree. It is most frequently found in the arteries, although the veins may develop an atheromatous condition when exposed to any source of prolonged irritation. It is also developed in the male sex in far greater proportion than in females; and is apparently influenced to some extent by climate. As a result of this condition, the affected vessel becomes im- paired in its contractile power, loses its natural tone, and, in conse- quence of its inability to sustain its accustomed internal pressure, undergoes, in many cases, dilatation at the seat of the disease. When the condition of atheroma is once developed, rings of ossifi- cation are often perceptible along the course of the affected vessel, if it be superficially situated; and an abnormal tortuosity of the artery is not infrequently present, if the atheromatous condition is diffused for some distance along the vessel. The existence of atheromatous changes is not always to be de- tected, however, by the sense of touch. DiminisJied arterial volume, and an impaired nutrition to tissues when an excessive arterial sup- ply is demanded (as occurs in inflammatory processes), are fre- quently points of value in the diagnosis of an atheromatous condi- tion of the vessels. Atheroma has especial surgical importance from a tendency which exists towards rupture of the affected vessels, either from an ulcerative destruction of their coats, or from the rigid and brittle condition of the walls of the vessel, produced by the cal- careous deposits. In cases demanding the application of a ligature to a vessel having pronounced atheromatous changes within its walls, the danger of secondary hemorrhage is greatly increased; and the application of the ligature itself is not infrequently rendered diffi- cult by the breaking of the vessel. Atheroma is most frequently developed at that bulging of the DISEASES OF TEE BLOOD-VESSELS. 5 aorta known as the Sinus Magnus, which is situated near the point of junction of the ascending and transverse arch; and it affects, next in frequency, the innominate artery and the left carotid artery. The excessive strain borne by these vessels, in resisting the direct press- ure of the heart, may possibly be considered as a mechanical excitant in producing the disease most frequently in these localities. No part of the circulatory system can, however, be considered as ex- empt from atheromatous changes. The extent to which atheroma affects the blood-vessels admits of large variation. In some instances, every vessel named by anat- omists is thus diseased, while, in others, only certain vessels, and even parts of vessels, are found to be affected. In extensively devel- oped atheroma, a symmetrical condition is usually present on the two sides. This point may in some cases be of importance, since a guide to diagnosis may be thus afforded. Cases, which have often been reported, of parallel and contemporaneous popliteal aneurisms in the same person, illustrate well the tendency towards a symmetrical development of atheroma. Atheroma develops more often in the lower limbs than in the upper, and the extent of its progress seems to be greater when sit- uated below the diaphragm than when above it. The dangers which result from ligation of a vessel which has un- dergone atheromatous changes within its coats, render the detec- tion of these changes important, even if the disease be unassociated with marked external evidences of its existence previous to the vessel being exposed. The process of repair cannot be perfected in an artery whose lin- ing membrane is tough or osseous, or in a state of fatty degenera- tion, whose middle coat has atrophied, and whose contractility, now destroyed, admits of no diminution in its calibre between the liga- ture and the next branch. FATTY DEGENERATION OF VESSELS. This condition of the vascular system may exist either as a pri- mary affection, or it may develop secondarily as a result of some previously existing condition. If it exists as a primary disease, it is usually detected in the aged, and is an indication of a general impairment in activity. When other tissues of the body are similarly affected, it may be reasonably conjectured that the blood-vessels have, to a greater or less extent, participated in the fatty degenerative process. 6 SURGICAL DIAGNOSIS. This condition of the vessels may occur, however, at younger pe- riods of life; but, if so, it is generally a secondary and not a primary disease. It frequently exists in connection with atheromatous changes, and, in this case, is probably the result of an increased nu- tritive activity in the affected parts. In the condition of fatty degeneration, no spots of ossification can be detected in the affected vessel, unless a complicating atheroma exists ; nor does the tendency to easy rupture, which is so markedly present in atheroma, manifest itself to any serious extent. The application of stimulation or cold to the affected parts will often, however, reveal a condition of defective contractility in the vessels affected with fatty degeneration of their walls ; and a dilated and tortuous condition of the vessels may occasionally be detected. When the superficial arteries, as the temporal or radial, exhibit a defective contractility, so that, in spite of the influences of external agents, such as cold, the rigors of fever, etc., etc., they present but trifling variations in their calibre, and appear soft and of uniform size, we may reasonably suspect the existence of fatty degeneration of the vascular system, especially if age has brought with it a failure in energy of the heart and the muscular system in general. Fatty degeneration of vessels is most common in the aorta, but it may affect any one, or even all of the blood-vessels. Occasionally, from the diminished calibre of the affected vessels, and from defective heart power, symptoms of disturbed circulation will exist, especially in the fingers and in the toes, if the condition be extensively developed. Patients in this condition suffer from a subjective feeling of cold, and often an actual diminution in temperature; and sensations of numbness and of formication are not infrequently present. Tri- fling injuries such as a moderate exposure to cold, may, in these cases, lead to inflammation and subsequent death of the part. In other cases, gangrene and mummifying of a part, apparently without any cause, may occur; and nature may mark out, as a result of such a change, an inflammatory line of demarca- tion. Spontaneous gangrene, oedema, and varicose veins are not infre- quent results of some form of disease affecting the coats of the blood-vessels; and should they appear, when both sides of the body present a like condition, the possibility of an embolus or a thrombus as an exciting cause can be safely excluded, and an abnormal condition of the general vascular coats be safely diag- nosed. DISEASES OF TEE BLOOD-VESSELS. 7 B. DISEASES AFFECTING THE CALIBRE OF VESSELS. 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./Evcrs, 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. A. Where all the coats of the vessel. are intact. 5 varieties. Aneurism classi- fied on a, path- ological basis. 2 great types. B. Where one or more of the ar- terial coats is rup- tured. 6 varieties. 8 SURGICAL DIAGNOSIS. 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 " Aneurismal Varix" and " Varicose Aneurism," while to the "Diffuse" type of Aneurism the term " Cystogenic" was applied by Broca, and is still frequently em- ployed. Aneurism may be classified, in the second place, on the basis of its anatomical location, as follows : Aneurism, classified on a basis of _ location. Internal" Aneurism. "External" Aneurism. {Thoracic. Abdominal. Pelvic. 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. DISEASES OF TEE BLOOD-VESSELS. g Causes of Aneurism. The causes of aneurism may be divided into the predisposing and the exciting. Under the first (the predisposing causes) may be mentioned the following conditions, which are not infrequently conducive to the development of aneurismal tumors : (1.) Atheromatous degeneration of the arterial coats. (2.) Fatty degeneration of the arteries. (3.) Exposure of a normally deep-seated vessel (thus creating an absence of the proper support). (4.) Weakening of the arterial coats, from long-continued pressure. (5.) Old age. (Probably by producing a fatty degeneration of the arteries.) (6.) Sex. (Women are seldom affected with external aneurisms.) (7.) Syphilis. (8.) Mercurial poisoning. (9.) Climate. (Frequent in cold climates, or in those where sud- den changes occur ; rare in Germany and Italy.) (10.) Chronic alcoholism. (11.) Paralytic relaxation of the arterial coats (from paralysis of the vaso-motor nerves). Under the second (the exciting causes) may be mentioned: (1.) Excessive strain to vessels in certain anatomical situations. This is illustrated in the aortic arch, in vessels near to joints, at the bifurcations of vessels, at the cceliac axis, etc. (2.) Cardiac Hypertrophy. (By increasing the arterial pressure.) (3.) "Aneurismal Diathesis." (Some anatomical defect in the arterial coats is usually present.) (4.) Laborious occupations. (By the tendency towards undue strain, excessive exertion, etc.) (5.) Violent mental emotions. (6.) Impaction of an embolus in a diseased artery (the artery dilating above it). (7.) Suppuration over a deep-seated vessel. (8.) Direct injury to a vessel from falls, blows, severe concus- sions, etc. (Traumatic Aneurism.) 10 SURGICAL DIAGNOSIS. Situation of Aneurismal Tumors. Aneurismal tumors are confined to no special localities of the body. They are most frequent in the arch of the aorta; next in frequency in the arteria innominata and the left carotid artery. They are especially common in the axillary, popliteal, femoral, and iliac arteries, and in the cceliac axis. Growth of Aneurismal Tumors. Aneurismal tumors grow either by compression of the surround- ing tissues, provided these tissues are elastic, or by absorption of cartilaginous or bony investments. The rapidity of the growth de- pends therefore somewhat upon the character of the tissues which surround the artery, and also upon the position and the size of the point of communication of the tumor with the artery, and the direc- tion of that opening in its relation to the blood-current. Should the opening be small, and so directed as to favor the passage of blood by, rather than through, the opening of the aneurismal tumor, the development would naturally be greatly retarded by such a condi- tion, irrespective of the character of the tissues which might invest the sac. We notice, therefore, great variations in the rapidity of growth of aneurismal tumors; and, in some cases, symptoms to come may be predicted with tolerable precision by a careful study of the situa- tion and configuration of the sac. Symptoms of Aneurismal Tumors in General. Aneurisms vary, in the symptoms produced, with the locality affected. Most of the symptoms are the result of pressure of the tumor upon either organs, nerves, muscles, bone, or joints, and must vary with the anatomical and surgical relations of the larger vessels. There are, however, certain definite and pathog- nomonic signs of aneurismal tumors, which are not all attainable in the arteries of the trunk, but which are most reliable and of the greatest value in external aneurisms of the head, neck, and ex- tremities. These symptoms may be thus enumerated. (1.) Diffusible or Expansive Pulsation.—This term is used to desig- nate the expansion of an aneurismal sac during the arterial throb, in contrast to the simple rising and falling pulsation which exists in any solid tumor when placed in close contact with a large vessel DISEASES OF TEE BLOOD-VESSELS. 11 The former indicates a transmission of the throb from the centre of the tumor in every direction; the latter the transmission of a force external to the tumor and in one direction only. Pulsation in aneurismal sacs cannot always be easily perceived, and may occasionally be lost. It is diminished in its force—1st, by large deposits of laminated fibrin or blood coagula in the interior of the aneurismal sac; 2d, by the depth of the tumor from the sur- face ; 3d, by the size of the tumor; 4th, by the character of the sur- rounding tissues; and 5th, by the condition of the supplying artery and the force of the heart. It is a custom with some surgeons in examining a tumor, where, with the hand softly grasping the growth, the pulsation is indistinct or absent, to place upon the tumor a small fleck of white paper, and, with the tumor between the vision and the light, to watch carefully for any movement which the paper may indicate. By this means pulsation has frequently been detect- ed, when the eye and hand had previously yielded negative results. (2.) Bruit.—By this term is designated a peculiar noise heard over the aneurismal sac, and created by the rush of the blood-current through its interior cavity. This "bruit" is usually single, and is always synchronous with the heart's action. In large vessels, it is occasionally a double sound. It is present over an aneurismal tumor in (ill possible positions both of the tumor and of the body, and in this respect differs from any sound transmitted, through a solid tumor or an organ, from a vessel to which it is not firmly attached. This bruit is usually of a rough and harsh character, and is most intense over the seat of the aneurism, although, in some conditions, this sound may ba transmitted through the surrounding tissues for a consider- able distance. (3.) Diminution of the Tumor in size on direct pressure.—Aneuris- mal tumors, when gently pressed upon, gradually yield to the pressure applied, and decrease in volume as the blood is forced from the interior cavity into the arteries. This subsidence is, how- ever, but temporary if the force be removed, as the sac soon refills, after sufficient time has elapsed for two or three beats of the heart to again propel sufficient blood into the cavity of the aneurism. This subsidence under pressure may occasionally be simulated by the displacement of a solid tumor from its immediate relation to an artery, which had previously given to it a pulsating movement. But, in this case, the tumor often loses its pulsation for an appreciable time after the pressure has been removed, or it may even require 12 SURGICAL DIAGNOSIS. some movement of the body to restore it to its former relation with the artery. A point of great diagnostic value is often thus offered, and the question of the existence of an aneurism is in such a case easily settled. (4.) Decrease in size of the Tumor by pressure on the proximal side of the supplying vessel.—This test is of great diagnostic value, but is not always capable of being satisfactorily applied. It requires, for its complete performance, that the artery be so compressed that the pulsation shall be either entirely or largely controlled, and that the quantity of blood received by the tumor shall be greatly reduced in amount. If the tumor be reduced in size to a marked degree, by thus controlling the flow within the vessel, the diagnosis of aneurism is positive. (5.) Increase in the size of the Tumor by pressure on the distal side of the supplying vessel.—This test, like the preceding one, it is not al- ways possible to apply. Its success depends not alone on reaching and compressing the distal side of the vessel, but also upon the character of the sac and of the surrounding tissues. It is not always a safe procedure, in case danger to the sac from over-distention be anticipated, or rupture appears imminent. Symptoms of Thoracic Aneurism. The ascending portion of the arch of the aorta, being enclosed within the pericardium, and being also the most frequently affected with aneurismal disease of any vessel in the arterial system, presents symptoms not in common with aneurismal sacs in other situations, and which allow of an explanation on a purely anatomical basis. If the aneurismal sac be situated low down, in the region of the aortic sinuses, the right coronary sinus in the heart becomes pressed upon early, from enlargement of the tumor in the anterior direction, since the regurgitation of blood produces the greatest pressure upon that aspect of the vessel, and the nutrition of the heart may thus be interfered with. In the more advanced stages of devel- opment, however, the tumor may, by pressure, impede either the current in the pulmonary artery, or in the superior vena cava; or possibly interfere with the free action of the right auricle, or even of the right ventricle. Thus cyanosis, distended jugulars, a bruit in the pulmonary artery on auscultation, or irregular heart's action may ensue. DISEASES OF THE BLOOD-VESSELS. 13 If the aneurism of the ascending arch be higher up, as is most com- mon, the tumor develops, as a rule, to the right of the median line, and, when of large size, tends to approach the anterior aspect of the thorax. We frequently, therefore, find the sternum and the ribs of the right side undergoing rapid absorption, and a pulsating tumor de- velops in the locality of the manubrium. By pressure of the tumor upon the neighboring parts, symptoms of apparent disease in the right lung, and those referable to impairment of the trachea, main bronchi, or oesophagus, may also simultaneously develop. Aneurism of the transverse portion of the arch of the aorta most fre- quently develops at its right extremity, and the posterior aspect of the vessel. At this point many important relations exist, which render the development of a tumor an inevitable associate of symp- toms referred to other localities. The trachea, oesophagus, and thoracic duct lie in the closest rela- tion posteriorly; the recurrent laryngeal nerve winds around the aorta on the left side; and the large arterial trunks given off from its convex or upper border furnish the blood-supply to the head and the upper extremities. For this reason the pressure of an aneurismal tumor in this lo- cality, by affecting the bronchi or the trachea, may produce dyspnoea, cough, haemoptysis, and stridulous respiration; by affecting the oesophagus, deglutition maybe impaired or destroyed; by creating pressure on the thoracic duct, the patient may die of inanition. Pressure upon the recurrent laryngeal nerve has often produced symptoms so analogous to those of inflammation of the larynx, that tracheotomy has often been performed from an error in diagnosis. By an obstruction of the innominate artery, either partial or com- plete, the radial pulse of the right side may be either diminished in its volume or entirely absent. By pressure upon the innominate veins the venous return from the head and upper extremities maybe impaired; and thus cyanosis, oedema, and diminished temperature of the parts in which the circulation is obstructed, may result. When an aneurismal dilata- tion of the arch of the aorta develops to a great size in an upward direction, it may simulate aneurism of the arteria innominata, by appearing above and to the right of the sternum; and by reaching the brachial plexus of nerves in the neck, it may produce shooting pains running down the upper extremity to the tips of the fingers. Aneurism of the descending portion of the arch of the aorta is usually situated upon the left side of the vessel, and develops in a backward direction. By pressure, it most frequently causes absorption of the 14 SURGICAL DIAGNOSIS. adjoining ribs and bodies of the vertebrae. It may, however, pro- duce also symptoms referable to pressure upon the trachea, left bronchus, oesophagus, and of the right and left lung. In case of spontaneous rupture of the sac, the blood may be poured out into the pleural cavity (usually that of the left side); or, in rare cases, into the trachea, left bronchus, oesophagus, or into the substance of the left lung. In this variety of aneurism, an intercostal neuralgia of a severe and constant type is produced by pressure of the grow- ing tumor upon the intercostal nerves which lie between it and the ribs. Differential Diagnosis. The diagnosis of aneurism as a disease is often difficult, and a discrimination between its types is frequently impossible. A. It may be confounded as a disease with— 1. A tumor lying upon some large vessel. 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. C. The seat of aneurismal tumors, especially those of the inter- nal type, is to be differentiated by variations in the rational and physical signs pertaining to the various localities in which the tumor may be situated. In subsequent pages of this volume will be found enumerated the various points of differential diagnosis of aneurism from those diseases liable to be confounded with it; and also tables to assist in the discrimination between its various types. DISEASES OF TEE BLOOD-VESSELS. 15 OCCLUSION OF ARTERIES. The calibre of arteries may be occluded by pressure, emboli, thrombosis, and foreign bodies. In certain positions of the trunk, the blood-current may often be temporarily arrested from the first-mentioned cause, provided the artery be so placed as to perceive the pressure created. This may occur, in the radial and ulnar arteries, on flexion of the elbow; in the tibial or popliteal, on flexion of the knee; and, occasionally, in the subclavian, through a compression exerted by a depressed clav- icle or during forced expiratory efforts, the artery, in tMs case, being situated above its normal position. Pressure upon arteries from fragments of bone often produces partial or complete occlusion of some vessel, which may disappear after a proper adjustment of the fragments is effected. Osseous tumors may occlude vessels and produce marked effects on the tissues supplied by the vessels compressed. Thus exostoses of the femur not infrequently impair the femoral, and bony tumors from the rib, the subclavian artery. Cancerous and occasionally benign tumors may involve and destroy arterial trunks, and thus gangrene is sometimes produced. It is rare, however, for gangrene to follow the obliteration of arteries from the pressure of growing tumors upon them, since the compression is too gradual to cause a complete and sudden cessa- tion of nutritive supply to the parts to which the vessel is distributed. Vessels may, in the second place, be occluded by embolism. By the term emboli, we mean all movable bodies in the circulation formed at a spot more or less distant from the seat of lodgement within the vessel. Among the various forms of emboli detected may be mentioned, 1st, vegetations of fibrin, detached from the valves of the heart; 2d, blood coagula, usually the result of mechanical or inflammatory stasis; and 3d, broken-down fragments of morbid growths which have been swept into the circulation. Emboli are usually found within the arterial system. The most frequent seat of embolic obstruction is the left middle cerebral artery, since this artery affords the most direct channel for blood propelled from the left heart; but the various organs of the body are also not infrequently affected. Embolism results in either a partial or complete obstruction to the normal current in the vessel occluded. If the obstruction to the direct circulation is complete, and the collateral circulation is imper- 16 SURGICAL DIAGNOSIS. fectly performed, gangrene of the parts supplied becomes inevitable. If, however, the obstruction to the vessel be incomplete, or the collat- eral circulation of the part be sufficient to sustain its nutrition, the foreign particle may create but a temporary interference with the nor- mal functions of the part affected, and may, possibly, be eventually removed by fatty degeneration, if the embolus be of organic origin. Organs with a single arterial trunk, as the retina, testicle, or spleen, may be entirely deprived of their function by the entrance of an embolus into the mouth of the supplying vessel. In very young subjects, complete obstruction of even large vessels is seldom followed by gangrene. Cases are on record of the ob- literation of the aorta in an infant without mortification ensuing; while, in a case reported by Savory, complete obliteration of all the main arteries of the extremities, and of the left side of the neck ex- isted (probably a congenital malformation) without the appearance of gangrene in any part. The occlusion of arteries by thrombosis is not, however, to be con- founded with embolism, since a thrombus signifies the existence of coagulated blood formed at the seat of obstruction. It can thus be un- derstood, by a definition of the terms, that a disintegrated throm- bus may result in embolism, and that thrombosis may follow em- bolic obstruction, without the two being identical. Thrombosis of vessels may follow any condition which impairs the calibre of the vessel, alters its anatomical construction, or inter- feres with its blood-supply. It may follow diseases of the vessel or the surrounding structures ; pressure upon the vessel; injuries to the vessel; enfeebled heart's action; valvular disease of the heart; impaired venous return from any cause; and finally pyaemic poisoning. The clot, so formed, may become adherent to the coats of the occluded artery, and organize, in which case the vessel becomes permanently obliterated ; or it may disintegrate by a process of suppuration, and the particles so detached may be swept into the blood-current and become emboli. Pyaemia, when occurring with the existence of open wounds, seems to manifest the presence of its peculiar miasm within the blood of the infected by a marked tendency towards spontaneous coagulation of the blood in the capillary vessels, where the rapidity of the blood-current reaches its lowest point. It is to this fact that some authors en- deavor to explain the simultaneous appearance of secondary abscesses in many portions of the body, since these thrombi, being the re- sult of pyaemic poisoning, act as generating centres for suppurative inflammation. DISEASES OF TEE BLOOD- VESSELS. 17 DISEASES OF THE VEINS. The diseases of the veins encountered in a surgical practice have been already enumerated, and will now be separately considered. HYPERTROPHY OF THE VENOUS COATS. This condition is usually associated with an increased size of the vein. It is a natural and healthy provision of nature to afford en- larged channels for an excessive venous return. Thus in pregnancy, the uterus is provided with abnormally large venous channels, to allow of the removal of the excess of blood from that organ; in can- cer of the omentum, the portal vein is frequently enlarged to nearly double its normal size; in cases of obliteration of veins from any cause, the neighboring veins usually undergo compensatory hyper- trophy of their coats as their calibre is increased. Finally, hypertro- phy of veins occurs often in connection with chronic inflammatory processes. This hypertrophied condition may be either transient or perma- nent as the exigencies of the case demand, and has no great surgical interest save as a help to the diagnosis of other conditions. ATROPHY OF VEINS. This condition is a natural consequence of disuse. The veins of limbs undergo atrophy after amputation till their size corresponds to the amount of blood which is returned from the part. After the removal of organs, as the testicle, penis, etc., or in extensive cystic degeneration of glands dependent on the occlusion of the excretory duct, the veins rapidly diminish in their calibre. Persistent ex- ternal pressure also often leads to atrophy of the veins, whose cur- rent is thus impaired or arrested. DEGENERATION OF THE VENOUS COATS. The venous coats are less subject to degeneration processes than the arterial coats. Fatty degeneration of veins is somewhat rare, but calcification is more common. In this latter condition, osseous plates or rings are found imbedded in the venous coats, and the veins of the lower ex- tremity are most frequently so affected. Calcification of veins seldom occurs without a previous dilatation of the vein. 2 18 SURGICAL DIAGNOSIS. Amyloid degeneration seldom affects the superficial veins of the body, and its diagnosis is therefore not usually possible during life. It occurs in extensive amyloid degeneration of organs, and usually is most apparent in the large systemic trunks and in the portal vein. It may affect the entire thickness of the venous coats, or only the middle and internal coats. Practically, therefore, the surgeon is called upon to recognize dur- ing life only hypertrophy, atrophy, and calcification of veins. These three alter the resistance of the tube as perceived by the touch, and also affect the extensibility of the vein in its relation to the amount of blood pressure. Cancerous degeneration of veins is more common than that of the arterial trunks. It is almost always secondary to a similar condi- tion of neighboring tissues. It may penetrate the vein and produce thrombosis, or particles of the cancerous mass may escape into the circulation and produce embolism of vessels at a point remote from the seat of disease. The symptoms and results of carcinoma of the veins differ in no respect from those of thrombosis. ADHESIVE INFLAMMATION OF VEINS. {Adhesive Phlebitis, Thromballosis.) This condition is primarily a disease of the venous coats. It is usually circumscribed in character, and may occasionally occur in a condition of otherwise perfect health. It may follow injuries to venous trunks, pressure on venous trunks, ligation of veins, ampu- tations, or abnormal blood conditions which predispose to irrita- tion. It is associated with local pain and tenderness along the course of the inflamed vein, with possibly some constitutional disturbance, with oedema which is often well marked and whose severity depends upon the amount of obstruction to the free circulation in the af- fected vein, and with prominence of the neighboring veins which are obliged to carry abnormal amounts of blood, if the inflamed vein fails to perform its proper function. It is not usually associated with pyaemic symptoms, since the coagula formed within the vein at the seat of inflammation do not usually disintegrate through subsequent suppuration. In adhesive phlebitis, complete and permanent obliteration of the Vein is by no means uncommon. The affected vein, if entirely ob- literated, becomes a shrunken, firm, and sometimes a calcareous cord. In fractures, the oedema from a local phlebitis produced by DISEASES OF TEE BLOOD-VESSELS. 19 the injury may often greatly impair union, and in some cases greatly interfere with the circulation of the injured part. If the deep veins of a limb are affected with adhesive phlebitis, the superficial veins will often show marked increase in size before the oedema is apparent; the limbs will feel hot and dry, and will usually be maintained in a flexed position. Extension of the limb » will often produce considerable pain, and a well-marked constitu- tional disturbance will occasionally exist. If the superficial veins be affected, they can usually be felt as hard cords under the finger, the induration being due either to the formation of clots within the vein, or to thickening of the surrounding tissues, or, more often, to the two conjointly. An accompanying redness and tenderness will usually mark the seat and extent of the inflammatory process. SUPPURATIVE PHLEBITIS. (Diffuse Phlebitis.) This condition is properly a variety of diffuse phlegmonous in- flammation. It never occurs in patients with robust health, and re- quires some exciting cause to produce it. It arises usually from some local irritation, as in venesection, division of a vein, amputa- tions, inclusion of the venae comites during the ligation of large arterial trunks, tying of the funis, severe injuries, etc. It begins, as a rule, as an extension of inflammation from the tissues surround- ing the vein to the vein itself, and shows a tendency to rapidly ex- tend along the course of the vein, proceeding from smaller to larger venous trunks. In this condition,the coats of the veins are frequently destroyed; and disintegrated blood coagula form, and are often swept into the blood-current. These small coagula subsequently lodge in the capillaries of other organs, and there generate metastatic abscesses, producing general pyaemic symptoms. In this respect, they differ in their results from the occlusion of vessels from emboli, which are not the result of suppurative inflammation; since they create, by their irritative properties, a recurrence of the condition to which they were originally due. The symptoms which accompany these changes of diffuse or sup- purative phlebitis are a tendency to develop a low grade of typhoid manifestations, ushered in with rigors and accompanied by a gen- eral increase in the severity of the preexisting signs of local inflam- mation of the veins, as well as those of general debility and exhaus- tion in the patient. When infants are attacked with this condition through ligation of the funis, death almost invariably supervenes. 20 SURGICAL DIAGNOSIS. VARICOSE VEINS. (Varix, Phleledasis.) By the term varix, is meant an excessive dilatation of a vein. Com- pensatory dilatation of venous trunks, which has been considered under hypertrophy of the coats of veins, is not to be confounded with a true varicose condition. True varices are most common in the submucous veins of the rectum (hemorrhoids), in the spermatic veins (varicocele, circocele), and in the veins of the lower extremity. Varicose veins have, however, been reported as existing at the elbow, on the arm between the elbow and the shoulder, in the neck, upon the internal jugular vein, on the face near the eyelids and the lips, and in the veins of the stomach, pharynx, oesophagus, and the small intestine. Such cases are, however, exceptional. Varices are due to various causes. Among the most prominent may be mentioned—1st,an hereditary predisposition; 2d, a congenital tendency; 3d, a relaxed and debilitated condition of the system and of the venous coats; 4th, a slow heart's action, by which the venous return is retarded; 5th, occupations requiring prolonged standing upon the feet, or excessive and long-continued muscular exertion; 6th, certain diseases of the heart and lungs, which impede venous return; 7th, cirrhotic liver, or other conditions of that organ by which pressure is made either upon the portal vein or its radicals; 8th, constipation, by creating pressure upon the iliac veins; 9th, throm- bosis of veins ; 10th, pressure of tumors upon veins ; 11th, hernial trusses, tight garters, and other common appliances which often im- pede venous return, and thus distend the veins below the point of pressure ; 12th, violent exercise of certain sets of muscles, by which blood is propelled forcibly into veins naturally weak in their coats, as in long feats of running, jumping, waltzing, etc. Varicose veins may be either circumscribed as a distinct sac, or the affected vein may be lengthened and tortuous, or unequally distended into a series of indistinct pouches. The coats of the vein may undergo a compensatory hypertrophy, or may remain thin and atrophied. The tissues about the vein gradually become absorbed by long-continued pressure, and even bones may thus become indented. The dilated veins yield symptoms of a severe local pain of an aching character, in advanced stages, and often a sense of fullness, distention, and fatigue. CEdema about the ankle is often caused, after any severe exertion, by varices of the leg; and walking is sometimes impeded if the varicose tumor be DISEASES OF TEE BLOOD-VESSELS. 21 of large size. Itching is not an infrequent symptom of varicose conditions. The appearance of these tumors is usually of a soft bluish tint, with a series of minute bluish vessels clustered around it. Varicose veins often induce eczema and other skin affections dependent on irritation of the integument and its adjacent struc- tures. If the veins of the lower extremity be affected, a sense of coldness in the feet is quite a constant symptom, when the return circulation becomes markedly interfered with. A peculiar tingling pain, distinctly localized at the seat of the tumor, may be developed if the minute nerve filaments be pressed upon or put upon an unnatural state of tension. Attacks of lymphangitis and ulceration of the neighboring tis- sues are not infrequent complications of varices of old standing. Rupture of varicose tumors often results in alarming hemorrhage unless controlled. Varicose veins of the rectum (hemorrhoids) will be considered in detail in a subsequent chapter of this volume. They are associated, however, with all the symptoms mentioned as common to all vari- eties of this condition, and with certain other special symptoms, which are to a certain extent dependent upon the anatomical con- struction of the lower portion of the bowel. PARASITES OF VEINS. Occasionally the embryos of the taenia are found in veins; aceph- alocysts have been detected in the pulmonary veins; and in Egypt and at the Cape of Good Hope, parasites of a peculiar species are found in the portal system, and the veins of the mesentery and bladder, in fatal cases during epidemics, where death is preceded by haematuria and diarrhoea. PHLEBOLITHES. (Calculi of Veins.) These are round or oval masses not infrequently found in veins, and sometimes attached to the inner wall of the vein by a slender pedicle. They are found in the greatest frequency in the veins of the prostate gland during a state of hypertrophy, and in the veins of the pelvis, especially in those in the vicinity of the bladder. These masses are usually found upon examination to be arranged in concentric layers, and are composed of albuminous or fibrous sub- stances mixed chiefly with the phosphate of lime. The origin of 22 SURGICAL DIAGNOSIS. ^ these bodies has been explained on the theory of transformed blood clots which have become impregnated with the least soluble salts of the blood, and also on the theory of their absorption through the walls of the vein. A sluggish circulation within a vein is supposed by some to favor the development of phlebolithes. Many of these enumerated conditions, which may affect the arte- rial or venous system, require but the description already given to aid in their successful recognition during life, should a diagnosis be possible. I have appended, however, in the following pages, as a fit closing of the chapter on the surgical diseases of the blood- vessels, all those conditions, which to my mind seem liable to be confounded, arranged in the form of diagnostic tables. Aneurism in general will be here found contrasted with all conditions liable to result in error in diagnosis; the various types of aneurism will be found differentiated from each other, and from atheroma; and fatty degeneration of arteries, embolism, thrombosis, adhesive phlebitis, suppurative phlebitis, and varices of veins will be found with their symptomatology concisely stated. DISEASES OF TEE BLOOD-VESSELS. 23 ANEURISM. TUMOR LYING 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. u a " absorption of bone, caries, or necrosis. 24 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 is 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 TEE BLOOD-VESSELS. *5 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 back 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. (Edema. (Edema of the extremities not in- (Edema 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. SYMPTOMS IN COMMON. Both yield an abnormal area of pulsation. " may be associated with^am in the back. 26 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. tous. 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. it tt a a a pain# DISEASES OF TEE BLOOD-VESSELS. 27 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. " " " " pain. " " " " change in volume of femoral pulse. 28 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 TEE BLOOD-VESSELS. 29 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 back. « " " " a tumor in abdomen. " may be associated with fluctuation. 30 SURGICAL DIAGNOSIS. THORACIC ANEURISM. INTRA-TIIORACIC 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 area 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 vary 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 TEE BLOOD-VESSELS. 31 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 didness on percussion. " " " "a murmur on auscultation. 32 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 tence. 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 TEE BLOOD-VESSELS. 33 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. 34 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 presence of a tumor. " " " " pulsation. DISEASES OF TEE BLOOD-VESSELS. 35 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 presence of a tumor. a <( tt « pulsation. n tc " " pain. 36 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- The vein implicated becomes en- cinity of the tumor, both as to their larged, tortuous, and sacculated. direction and apparent structure. The venous coats also become thick- ened, so as to resemble those of an artery. Force of Pulse. The arterial volume and force of The force of the arterial pulse is the pulse are either normal or de- usually preternaturally increased. creased. Auscultatory Signs. A bruit of a blowing character is A "pathognomonic fremitus" is usually present. heard over the tumor, resembling the "buzzing of an insect," "the purring of a cat," etc. This bruit is not continuous. A " continuous souffle " is heard in the vein. No venous pulsation exists. 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. DISEASES OF TEE BLOOD-VESSELS. 37 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 often to a belief, on' the part of the patient, that an insect is imprisoned within the af- fected part. 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. " " affected by pressure over tumor and its supplying vessel. 38 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. " may be " " fluctuation. DISEASES OF TEE BLOOD-VESSELS. 39 CIRSOID ANEURISM. NjEVL 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. 40 SURGICAL DIAGNOSIS. ANEURISM OF ARCH OF ANEURISM OF INNOMINATE. AORTA. ARTERY. 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 oedematous 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, when 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 TEE BLOOD-VESSELS. 41 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. a a a venous pulsation. " are associated with change in the color of adjacent skin. a a tt a defective venous return (often). a n a a alterations in size and appearance, on pressure upon, or obstructed circulation within the artery. 42 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 ter go. 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 TEE BLOOD-VESSELS. 43 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. tt a a << « dilatation of vessel at the affected portion. a a << " " tortuosity of the vessel. a a tt a ft impaired nutrition to tissues when excessive arterial supply is de- manded, as in inflammation. tt a tt tt tt \oea\ gangrene. ft " " " " local oedema. " " " " " varicosities of veins. 44 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. (Edema. (Edema is seldom present as the (Edema 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 TEE BLOOD- VESSELS. 45 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 venae tion. comites with large arterial trunks. It occurs in infants from ligating the funis. Pyemic Symptoms. Pyaemic symptoms are absent, as Pyaemic 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. " tt a " " oedema. tt tt tt a a prominence of neighboring veins. DISEASES OF THE JOINTS. DISEASES OF THE JOINTS. The surgical Diseases of the Joints may be thus enumerated: r Acute. Subacute. Chronic. A. Inflammatory Diseases. Scrofulous. 1st. Of the synovial membrane : "Syno- - Rheumatic. vitis." 9 varieties. Gouty. Pyaemic. Gonorrhoeal. Syphilitic. 2d. Of the general structures entering Acute. Chronic. Rheumatic. _ Syphilitic. into the formation of " Arthritis." 4 varieties. a joint: -1 B. . . (1. Fibrous. ANCHYLOSis-vaneties, j 2 Qsseous. C. Dropsy of Joints : " Hydrarthrosis. > D. Articular Neuralgia. E. Loose Cartilages in Joints. F. Congenital and Acquired Malformations. -The important points, which directly bear upon the diagnosis of each of these conditions, will first be separately reviewed, and, as a summary, the points of the more important diseases will be found arranged in contrast, in the closing pages of this chapter. 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. 4 49 50 SURGICAL DIAGNOSIS. I. DISEASES OF JOINTS IN GENERAL. SYNOVITIS. By this term, is commonly designated those changes within a joint dependent solely upon an inflammatory condition of its synovial membrane. Inflammation affecting this membrane is frequently of an ordi- nary and simple character, such as may result from injury di- rectly applied to the joint, from some severe strain or wrench, from exposure of the joint to dampness or to atmospheric influences, or by an extension of inflammation from some neighboring struc- tures. If this form of disease exists, no special form of nomenclature is generally used, although the terms simple synovitis and common syno- vitis are not infrequently applied to it. This type of disease is essentially local in its character, and is confined, as a rule, to one articulation only. Its various degrees of severity have led authors to describe it as of three types: the acute form, where the inflammatory changes are excessive; the subacute form, where the symptoms of disease are less active; and the chronic form, where the evidences of active inflammation no longer exist. There are constitutional conditions, however, in addition to those of a local character, which predispose towards the develop- ment of synovitis. Among these constitutional causes may be men- tioned ; 1st, scrofula, which not only may prolong an attack of simple synovitis, causing it to assume peculiarities common to that condi- tion of the system, but may even, in itself, become an exciting cause; 2d, rheumatism, which, among the poorly clad and nourished, and especially in those exposed to variations in temperature, tends also to induce synovial inflammations; 3d, gout; 4th, pycemia, as occurs often after operations, severe injuries, parturition, etc.; 5th, syphilis ; and 6th, urethral inflammation of an acute gonorrhoeal type, from some unexplained reason, is not infrequently followed by symptoms of synovitis, in joints often far removed from the seat of disease. To these various types of synovitis, special names have been given from their apparent source of origin, such as scrofulous, rheumatic, 'gouty, pyemic, gonorrhoeal, and syphilitic. DISEASES OF TEE JOINTS. 51 Acute Synovitis. This condition is relatively more frequent in males than in females, and occurs more often in adult life than during youth. It may remain confined in its progress to the lining membrane of the joint only, or it may extend and gradually involve the carti- lages, bone, and ligaments (in which case it is more properly called arthritis). The symptoms indicative of acute synovitis vary greatly with its exciting cause, the joint affected, the severity and extent of the inflammatory process, and with the constitutional condition of the patient. When the hip-joint is the seat of the disease, greater constitutional disturbance is usually produced, in proportion to the extent of the disease, than in any other joint of the body. There are certain symptoms which, however, are of diagnostic value, and which, although they admit of variations, are still com- paratively uniform. Among these we have : (1.) Pain.—This is accompanied, as a rule, by a sense of distention within the affected joint. It is greatly increased by movement of the joint in certain directions, and is often located away from the seat of the disease, especially when the hip-joint is affected. This peculiarity arises from irritation of nerves in relation with the af- fected joint; the evidence of this irritation being perceived at the peripheral distribution of the nerve. (2.) Swelling.—This is not, usually, a uniform swelling, but an irregular protrusion of the distended pouches of the synovial mem- brane, which appear most distinctly where the tissues which cover them are the least resistant. The situation and appearance of these distended pouches vary with the anatomy of the diseased joint. * (3.) Fluctuation.—In superficial joints, fluctuation can often be detected, if the amount of fluid secreted into the joint sufliciently distends the synovial pouches. This symptom, however, is not as well marked in conditions of a chronic character, or in an exces- sively prolonged case of simple synovitis, since the products of the inflammatory process become gradually more solid, and transmis- sion of the impulse wTave is thus impeded. (4) Local heat and redness.— This symptom depends somewhat upon the joint affected. It is most marked in those joints which lie superficially and in close proximity to the integument. It is also greatly modified by the extent of the inflammatory process. (5.) Position of the limb.—In almost all joints affected with acute synovial or articular inflammations, there exists a marked tendency 52 SURGICAL DIA GNOSIS. toward flexion of the diseased joint. The joint also gradually be- comes more or less rigid in proportion as the muscles become involved, through irritation of the articular nerves and a subsequent reflex act upon the muscular structures. This condition of flexion of the joint is due, in part,toover-disten- tion of the joint from the rapid increase of the synovial fluid, and, in part, to the effect of contraction of the flexor muscles, whose power surpasses that of the extensor muscles of the extremities. The position of limbs affected with articular inflammation is often of great diagnostic value. If it remain too long unrelieved, there is danger of anchylosis of the joint. Suppurative Synovitis.. In acute synovitis, the secretion within the joint occasionally loses its synovial character and suppuration commences. This condition is sometimes called acute articular abscess. It is usually accompanied by rigors, and by a very marked degree of constitutional disturb- ance. Occasionally typhoid symptoms develop in connection with suppuration within the cavity of joints, and the local evidences of disease usually become markedly intensified. Thus we often perceive a rapid increase in the tumefaction about the affected joint; and a decidedly phlegmonous appearance to the investing tissues is developed. Abscesses form within the sur- rounding areolar tissue, and if at first separate from, soon join with the articular cavity. The general tissues entering into the formation of the joint soon become involved, the ligaments soften, the cartilages and bone become affected, and the joint disorganizes. Subsequently the sinuses may become closed as the discharge di- minishes, and an anchylosed condition of the joint may ensue ; or the pain and discharge may exhaust the patient, and excision or amputation may be required. Acute synovitis is to be differentiated from rheumatism, from localized periostitis near a joint, from suppuration external to a joint, and from hydrarthrosis. The points of distinction will be found embodied in differential tables at the close of this chapter. Chronic Synovitis. This condition may follow the acute or subacute form of simple synovitis, but it is more commonly the result of some constitutional condition, such as syphilis, scrofula, gout, rheumatism, or gonor- * rhoea. DISEASES OF TEE JOINTS. 53 It is not always possible to define, however, the exact blood con- dition upon which the inflammatory process is dependent, since the distinctive features of each may not be well marked. In this condition, there may often exist considerable swelling, some pain, and usually a marked impairment in the normal move- ments of the affected joint. Occasionally a peculiar crepitus — (of a crackling character) — may be detected, and, in some cases, a sensation of some loose body within the joint may be perceived by the hand if placed in contact with it. This latter symptom has been explained by the presence of local plastic effusions. Chronic synovitis, if unconnected with some constitutional taint, generally terminates in recovery, although a marked tendency to- ward relapse into a state of subacute inflammation is very often present. Scrofulous Synovitis. This condition is one which is developed in connection with a scrofulous diathesis. It has been described by some authors under the head of gelatinous or pulpy degeneration of the synovial mem- brane of joints. It is usually associated with changes in the carti- lages and the bone. It is most frequent in early life, and usually occurs before the age of puberty. It frequently owes its origin to some exciting cause, such as a wrench, contusion, fall, etc., but, in some cases, it seems to be of spontaneous origin. In its early stages, the symptoms seldom exhibit an acute form, but the disease is evi- denced r;ither by a stiffness in the affected articulation, associated with a soft, elastic, and colorless swelling, which is spread over the whole aspect of the joint. This peculiar swelling is most apparent when the superficial joints are involved. No distinct sense of fluctuation can be detected in scrofulous synovitis, since the exudation is too gelatinous to transmit a wave impulse ; but a peculiar doughy feel exists which is characteristic. Scrofulous synovitis, in its white color, differs markedly from cancer or abscess ; and, in its doughy feel and indistinct fluctuation, from dropsy of a joint, or synovitis of a purely inflammatory type. Pain is not a prominent symptom in the early stages of scrofulous synovitis, but, as the disease develops into an arthritis, and the car- tilages and the bone become involved, the " starting" and " grow- ing" pains, so often described, become a prominent symptom, espe- cially at night-time. Crepitation also appears, when the destructive process involves the 54 SURGICAL DIAGNOSIS. cartilaginous and bony structures, unless exuberant granulations for a time mask the true condition of the joint. Suppuration not infrequently accompanies the disease when ad- vanced, and often indicates the fact that destruction of the joint is fast being accomplished. In these cases, all the symptoms of acute articular, abscess, as described under acute synovitis, may be present. If the progress of the disease is, however, toward recovery, the swelling external to the joint becomes gradually more solid and less elastic, and diminishes also in its size; and the appearance of the part more nearly approaches the normal standard. The joint seldom, however, regains its full capacity of movement, and a tendency toward relapse is present, which may often prove most obstinate. Scrofulous synovitis is to be diagnosed from suppuration exter- nal to a joint, from acute articular abscess, from cancer, from dropsy of a joint, and from synovitis of the acute type. These points will be found enumerated in the diagnostic tables at the close of this chapter. Rheumatic Synovitis. This condition is not to be mistaken for acute articular rheuma- tism, since, in rheumatic synovitis, the joint is primarily affected, and the constitutional disturbance is a secondary result of the local disturbance; while, in rheumatism, the contrary is the case. This condition is one which seems to be developed by exposure, dampness, low vitality, and all the other causes which ordinarily predispose to the rheumatic diathesis. It seems to centre itself, however, in the synovial membrane of the joint rather than in the fibrous tissue, as is the case in acute rheumatism or rheumatic fever, and to be, to a certain extent, independent of any excess of lactic acid in the blood. It has no point of special surgical distinction from other forms of synovitis, save in its mode of origin and its apparent indirect connection with some abnormal condition of the system at large. Gouty Synovitis. This condition is produced by sudden excess of uric acid in the affected part, if the attack be acute in character. It may, however, gradually assume a chronic type and be indefinitely prolonged. The gouty form of synovitis is almost invariably associated with a deposition of either uric acid or some of the urates (principally DISEASES OF TEE JOINTS. 55 that of soda), into the cavity of the joint, its cartilages, the sub- stance of its ligaments, its investing muscles, and the connective tissue of the part. The deposit of urates has been also perceived in the bone and its periosteum. These deposits are often termed chalk stones or chalky deposit, from their whitish color and their consistence. They are usually found in the smaller joints, especially in the joints of the feet and the hands, although a deposition may occur in any joint, and even in the cartilages of the ears, and in the prepuce. Protuberances are thus produced which distort and cripple the articulation affected, until they approach the surface, when they often ulcerate through the integument, and are thus discharged. Pycemic Synovitis. This condition is dependent upon an abnormal blood condition termed pyaemia. It may follow parturition, injury, phlebitis, ampu- tation or operations, fevers, and all other causes which may tend to create or favor systemic infection. The condition present in the joints is but one of the many results liable to occur from this variety of blood-poisoning. The variety of exudation into the joint is usually a thin sero-pus; and changes, dependent on excessively rapid cell growth, are developed. These changes are accompanied by pain (which may often be violent in character), and, later on, by heat, redness, swelling, and fluctuation, if the affected joint be superficially situated. The number of joints involved may vary considerably. It is not infrequently the case, to find almost every joint infiltrated with pus, while, in some cases, only one articulation may be attacked. The extent of the disease, as regards the structures of the joint, also admits of great variations. In some cases, only the synovial membrane is implicated in the inflammatory process, while, in others, the joint becomes thoroughly disorganized. Gonorrhoeal Synovitis. Sir Benj. Brodie first described this disease under the name of gonorrhoeal rheumatism, although he, at that time, recognized the de- pendence of a similar condition, in some cases, upon an existing purulent ophthalmia, and, in others, upon the urethral irritation produced by the introduction of an instrument into the cavity of thp bladder. It may attack only one, or occasionally several joints, and the 56 SURGICAL DIAGNOSIS. knee-joint seems to be the one most frequently involved. It may continue for a period of time varying from a few weeks to several months, or even years. A marked tendency to relapse seems to be a distinguishing trait of this affection, and joint after joint may become involved in suc- cession. Suppuration is rare in this form of synovitis, but the movements of the affected joint are often permanently impaired from a thickened and indurated condition of the synovial membrane. Permanent rigidity of the joint sometimes occurs if the inflammation involves the cartilaginous structures. A theory has been advanced by Barwell that this condition is associated with a prostatic phlebitis, in those cases dependent upon any urethral inflammation. Syphilitic Synovitis. This type of synovitis is usually of a sluggish character, and may appear in the early stages of secondary syphilis, although it is per- haps more frequently an associate of the tertiary form of disease, especially when the bones or their periosteal coverings are involved. It seldom affects one joint only, and is characterized by nocturnal pains which are often extremely severe. It usually is accompanied by symptoms elsewhere which indicate a syphilitic condition, and which assist greatly in confirming the diagnosis. If the disease occurs during the early stages of secondary syphilis, it more fre- quently accompanies some of the papular eruptions. ARTHRITIS. By the term arthritis is meant an inflammatory disease of an acute or chronic type, which involves the ivhole or greater part of the structures, which enter into the formation of a joint. It may commence either in the synovial membrane, in the cartilages of the joint, in the articular ends of the bone, and, in rare instances, in the capsular or investing ligaments. In arthritis, the principal changes which occur within the joint are detected in the cartilaginous structures. In the acute form of the disease, the cartilages undergo erosion and ulceration, and portions of the articular ends of the bone are thus denuded and rendered vascular and roughened. The synovial membrane also becomes thickened, opaque, and vascular; the latter condition bein syphilis, etc. 66 SURGICAL DIAGNOSIS. ACUTE ARTHRITIS. CHRONIC RHEUMATIC ARTHRITIS. (Rheumatic Gout.) Pain. v 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 50th 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 TEE JOINTS. 67 ACUTE ARTHRITIS CHRONIC RHEUMATIC (continued). ARTHRITIS (continued). Location. Is not confined to any special Attacks 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. 68 SURGICAL DIAGNOSIS. ACUTE ARTHRITIS. SYPHILITIC PERIOSTITIS NEAR A JOINT. Signs of Effusion. The synovial pouches are promi- 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 TEE JOINTS. 69 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 starlings 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. 70 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 Anesthetics. Anaesthesia is negative in its re- Anaesthesia 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 TEE JOINTS. 71 These important symptoms are 1. Pain. 2. Suppuration. 3. Dislocation. 4. Anchylosis. Other common symptoms also coexist 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. Morbus coxarius is most frequently of traumatic origin; some blow, fall, wrench, or excessive strain having been experienced. It is not infrequently associated with a scrofulous diathesis, which usually predisposes those so affected to inflammatory conditions, if any exciting cause be present; but it may also occur in subjects free from constitutional impairment. It is most common in the young, and is seldom developed after the age of puberty. 72 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. FEMORAL. Pain is referred to the knee joint in the early stages of the dis- ease, and is often slight at the onset. This symptom is produced by irritation of the ob- turator nerve; which passes in close relation to the capsular liga- ment of the hip-joint, and which is, further- more, distributed to it. 2d Symptom : Suppuration. 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. Dislocation is rare. When present, it is due either to rupture of the capsule, or caries of the head of the bone. "3d Symptom : Dislocation Dislocation into the pelvic cavity occasion- ally occurs from caries of the acetabulum. 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. 4th Symptom : 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 TEE JOINTS. 73 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, howrever, 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 due to Dr. Lewis A. Sayre, of New York, for the 74 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. CONGENITAL DISLOCATION OF THE HIP-JOINT. This is a rare form of disease. It is apparently more frequent in females than in males, as the number of recorded cases shows over two-thirds to have existed in female children. It has been found to result from one of the following conditions: Abnormal shortening of the neck of the femur. Abnormal obliquity of the neck of the femur. Absence of the neck of the femur. Partial or entire absence of the acetabulum. Abnormalities in the insertion or length of the round ligament of the hip-joint. Absence of the round ligament. It is characterized by shortening of the affected limb at birth, and a prominence of the trochanter of the femur of the affected side. The motions of abduction and rotation, at the hip, are usually less free than on the healthy side; and the tuberosity of the ischium is rendered abnormally apparent by the drawing of the soft tissues over this bony prominence. As the child acquires the power of walking, the ball of the foot only touches the ground, and the shortening of the limb is in- creased. Many of the symptoms of this disease become much less apparent when the patient is in the recumbent position, and extension upon the leg reduces the deformity to a still greater degree. DISEASES OF TEE JOINTS. 75 In advanced stages, the lower part of the trunk is usually thrown forward, while the thoracic portion is carried backward. Some lateral curvature of the spine may also result from the shortening of the affected limb. The points of diagnosis between this condi- tion and morbus coxarius will be found contrasted in the latter pages of this chapter. SACRO-ILIAC DISEASE. The joint between sacrum and the ilium is seldom subjected to such a form of injury as to create local inflammatory changes. Some severe and peculiar form of injury, such as falling and catch- ing by the feet, or slipping and having one leg retained in its posi- tion, is required to produce it. It is said to follow, in rare instances, a severe form of inflammation external to, or in the neighborhood of the joint. In this condition, many of the symptoms revealed by examination are closely allied to those of morbus coxarius, provided the ilia are not fixed and rendered immovable. When this is insured, however, pain on concussion in the axis of the femur ceases, and all the mo- tions possible to the hip-joint become free from pain; but, when the ilia are not made immovable, pain is present, if either of these tests is applied. This disease is characterized by a limping gait, and an inclination of the body toward the side opposite to the affected joint. Direct pressure over the diseased joint, if the patient be laid upon the abdomen, will invariably cause pain. The affected limb is actually lengthened, but, as the alteration in length is above the hip-joint, the measurement from the anterior iliac spine to the internal malleolus, will be found identical on the two sides of the body. A great point of diagnostic value is the absence of the develop- ment of abduction or eversion of the thigh, as the disease advances, which is so prominent a symptom of morbus coxarius. This is due to the fact that changes within the sacro-iliac joint, even if exten- sive, are not capable of influencing the coxo-femoral articulation. The eversion of the foot and abduction of the thigh occur prom- inently in disease of the hip-joint, since the capsular ligament of the hip, when distended with fluid, as it usually is in morbus coxa- rius, during the stage of effusion, is crowded to its utmost capacity, and the thigh necessarily assumes an attitude which will best ^insure the greatest amount of space within the capsule of the joint, viz., ab- 76 SURGICAL DIAGNOSIS. duction and eversion. It must be remembered, however, that this attitude of the thigh, which is of so great diagnostic importance in determining the existence of morbus coxarius, and in differentiating between it and sacro-iliac disease, ceases with perforation of the capsular ligament, when adduction of the thigh and impaired mobility will usually be detected. The points of contrast between sacro-iliac disease and morbus coxarius will be found in a differential table in subsequent pages of this chapter. DISEASES OF TEE JOINTS. 77 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. 78 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. " " " " impairment of the power of abduction of the limb. " " " " impairment of the power of rotation. " " " " abnormal attitude of the trunk. ^/y^^/.^y^,., .*■/ s^E-trr?.^ /s*t^ >*^'. ,*:.',#? KfS""** * sS~*''-*£*✓ *^U DISEASES OF TEE JOINTS. 79 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. " " " relation 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. 80 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. actual, but not apparently so, if measurement be made from the an- terior spinous process of the ilium to the inner malleolus at the ankle-. joint. 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 TEE JOINTS. 81 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. tt tt tt ft " " pressure over trochanter. tt a tt t( formation of abscess and sinuses. 6 82 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. it tt a a a spme# " " diseases of childhood. DISEASES OF TEE JOINTS. 83 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 are common Abscess is rare. symptoms. Complications. No disease is present simulta- Other joints are, as a rule, simul- neously in other joints. taneously involved. SYMPTOMS IN COMMON. Both are associated with impaired motion. a a ft << possible immobility. ft a tt ft << crepitus. ft a << « pain on pressure. te tt tt tt a tt motion. 84 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- the 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 TEE JOINTS. 85 MORBUS COXARIUS. INFLAMMATION OF A 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. ft f *< " pain on motion of the limb. a a a << impaired, or restricted function in the joint " may be associated with pelvic distortion. " " « " " spinal curvature. 86 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 urement 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 sudden loss of mus- pain in the knee, etc., is present. cular power is present, in the ma- jority of cases. SYMPTOMS IN COMMON. Both may be associated with alteration in the length of the limb. " a tt a " spinal curvature. " " " " " atrophy of the limb. DISEASES OF TEE JOINTS. 87 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 eitJier 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 ail 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. 88 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 TEE JOINTS. 89 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 inward* 4. " Valgus...........where the sole of the foot is turned outward. .where a combination of the equinus and varus deformities exists. .where a combination of the equinus and val- gus deformities exists. .where a combination of 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. Talipes. 8 distinct - 5. a Equino-Varus... types. 6. (C Equino-Valgus... 7. « Calcaneo-Valgus 8. K Spurio-Valgus.. 90 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 TEE JOINTS. 91 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. it tt a a increased width of the foot, from separation of the metatarsal bones. tt n tt a projection forward of the astragalus. tt ft " " elevation of the heel. a a tt tt contraction of the muscles of the calf. Both may occur in the young, and, possibly, in the adult. 92 SURGICAL DIAGNOSIS. TALIPES VALGUS (Spurious). TALIPES, CALCANEO-VALGUS of moderate 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 TEE JOINTS. 93 TALIPES VALGUS. TALIPES, SPURIO-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 The tarsal arch is destroyed is elevated, the foot is twisted so through relaxation of the calcaneo- that pressure falls upon the internal scaphoid ligaments, and those be- malleolus and inside of the instep, tween the scaphoid, and the cuboid and the metatarsus and toes do not and internal cuneiform bones. The touch the ground. No projection astragalus projects in front, the of the astragalus, or widening of the foot is widened, and the convexity foot is present. of the dorsum of the foot is lost. Length of Foot. 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. 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. Ankle Joint. The motion within the ankle joint The ankle joint remains useful is rapidly impaired. for a time, but gradually loses its capabilities of motion. Outer Margin of Foot. 94 SURGICAL DIAGNOSIS. TALIPES VALGUS (continued). TALIPES, SPURIO-VALGUS ("Flat Foot") (continued). Pain. The pain is of an unimportant character and is often absent. Pain exists previous to the com- 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 deformity in a slight degree in the early stages, but the normal atti- tude of joint is not re-assumed, even in the recumbent position. In the early stages the plantar arch is effaced on standing, but re- turns when the weight is removed. DISEASES OF TEE JOINTS. 95 TALIPES, SPURIO-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 a a pain on standing or walking. " may be " " a history of excessive exertion or debility. tt n a « long duration and progressive symptoms. DISEASES OF BONE. 7 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 conditions. As an enumeration of the various types of diseases of bone liable to be encountered, I would present the following table : 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 Bone 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. 99 100 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 : 1 Encephaloid, and ( Scirrhus. 3. Malignant cysts—" Spina Ventosa." In accordance with the method pursued in previous chapters of this work, each of these conditions will first be separately described before the symptoms of the more important diseases are contrasted in tabular form. It will be perceived, however, that, in the diseases of bone, the etiology and the history of the patient are of particular importance, since, in most of the conditions above mentioned, the initial symptoms are often vague and difficult to positively locate, and, in many cases, they are precisely similar. It has been the endeavor of the author to render these descrip- tions as concise as is consistent with the character of the work, and yet to furnish all the essential points required for a diagnosis. OSTEITIS. This condition is one of simple inflammation, and is, as a rule, dependent upon external violence or exposure to cold as exciting causes ; although some predisposing causes can usually be detected, such as rheumatism, syphilis, scrofulous taint, or defective nutri- tion from local or constitutional conditions. It is most frequent in those bones which are the most exposed, and is, therefore, commonly found in the tibia, the bones of the skull, the sternum, the ribs, and the bones of the hand and foot. It is not an uncommon affection, and is often present when the dis- ease is supposed to be confined to the periosteum only. The obscu- rity of its early symptoms often prevents its early diagnosis, and, especially so, if they are masked by the accompanying symptoms of some injury, which has been its exciting cause. Osteitis is usually accompanied, in its early stages, by pains in the affected bone, which are increased by dampness, and which usu- ally exacerbate in the night. The bone rapidly loses its normal power of resistance to pressure, on account of the absorption of the DISEASES OF BONE. 101 mineral elements of the bone, and a fatty change within its animal constituents; and an increase in its volume also occurs from exudation and from periosteal thickening. An apparent increase in the size of the affected bone is due, often, to a simultaneous oedema and induration of the soft tissues which surround it; and care should be used to determine how much of the enlargement depends solely upon the bone itself, since, if markedly developed, it is a valuable guide in the diagnosis of this disease. The softening can rarely be positively detected, as it seldom in- volves the whole thickness of the bone, and seldom, therefore, alters its form; while the extreme sensitiveness of the soft tissues renders firm pressure unendurable by the patient. It may also be often rendered incapable of detection by oedema of the soft tissues. The symptoms of osteitis, from this point in its progress, are modified by the character of the inflammatory process. Suppura- tion may develop, if the case is one of the acute type, or hardening of the bone or sclerosis may occur, if the case be one of chronic in- flammation, by a deposit of lymph in the bone interstices, which subsequently ossifies. In many cases, resolution however occurs without either of these processes being developed. Osteitis is to be diagnosed from inflammations either of the peri- osteum or of the soft tissues which surround the bone. The points of discrimination will be found arranged in the form of diagnostic tables in the latter pages of this chapter. OSTEO-MYELITIS. This term is applied to a diffuse suppurative inflammation of bone tissue. It is closely allied to pyaemia, if acute in form, and is, as a rule, rapidly followed by a fatal termination. It is often unrecog- nized during life, as it usually is produced by and accompanies an injury, whose symptoms often mask the graver disease. This disease is seldom unassociated with some form of injury, such as contusions over bones which are superficially situated, com- pound fractures, amputations, gun-shot wounds, etc., etc. The changes in the bone consist of an infiltration of the medul- lary and cancellous portions with pus, gangrene of the endosteum, central necrosis, and greatly increased vascularity of the bone and the lining membrane of the medullary canal. Changes in the soft tissues about the seat of injury may also be detected, as the result of the diseased condition of the osseous structures. 102 SURGICAL DIAGNOSIS. The symptoms of this disease are frequently obscure in the early stages, and, later on, they are often masked by the symptoms pro- duced by the inflammation of the surrounding soft tissues. The occurrence of rigors, marked exacerbations of temperature, and fre- quent sweatings, if following an injury which has opened the medul- lary cavity of a bone, are symptoms of the gravest import. The partial or complete cessation of the discharge from the wound, and the loosening of the periosteum and its recession from the bone, can usually be detected; and a pain of a severe character, which is diffused throughout the diseased bone, is a valuable diag- nostic symptom. The recession of the periosteum and the soft tis- sues, especially in cases where this disease follows amputation, often leaves the end of the bone as a projection from the stump. Necrosis of the exposed portion rapidly follows, and reamputation of the member is often demanded, if pyaemic symptoms should be still absent, but, if present, surgical relief is no longer pos- sible. Osteo-myelitis may be of a chronic type, in occasional instances, and progress to the development of a sequestrum of necrosed bone without the occurrence of pyaemic symptoms, if the disease be local- ized ; or, if the disease be diffuse in character, amputation may be demanded as the only remedy for a source of irritation which would otherwise prove fatal. Osteo-myelitis is to be confounded only with osteitis, and their symptoms will be found contrasted in a diagnostic table in the closing pages of this chapter. ABSCESS OF BONE. This condition is one of circumscribed suppuration of bone tissue, and differs from the disease just described (osteo-myelitis), in its causation, its course, its extent, its rapidity, and its termination. The first description of this disease is credited to Sir Benj. Brodie, to whose admirable investigations we are chiefly indebted for the knowledge now afforded us as to the symptoms and course of this obscure affection. This disease is most frequently situated in the articular extremities of some of the long bones of the body, and chiefly in the region of the knee, ankle, and elbow. Of all the separate bones of the body, the tibia is most frequently affected in its upper extremity. The cause of this disease is often obscure, but it is probably pro- duced by some form of injury received at a time more or less remote from the date of appearance of the first symptoms. It is affected, DISEASES OF BONE. 103 without question, by local and constitutional causes, which impair the vigor of the part, and possibly by climatic conditions. The symptoms of this disease may be, at first, simply a dull pain, which is worse at night, and which is increased by exercise and by pressure. This pain may also manifest a tendency to remissions and exacerbations, but this is also frequent in all diseases of the bone and periosteum, where pain is an early symptom. The tonderness on pressure is distinctly localized, as the disease advances, and its persistency and long duration are points of value in discriminating it from the superficial tenderness of a localized peri- ostitis, which is characterized by swelling, even in its early stages, and by a rapid development or an equally rapid subsidence. As the disease progresses, a tumefaction of the soft parts over the inflamed bone appears, which is subsequently followed by the discharge of pus externally, and the formation of sinuses; unless the abscess chance to extend towards the articular surface of the bone and involve the joint. In this latter case, the symptoms of an ap- proaching synovitis will indicate the effect of irritation of the struct- ures of the joint by the encroaching pus, and, if neglected until the rupture actually takes place, the condition becomes a most serious one. The establishment of free drainage of the cavity by the trephine or the chisel often prevents, if done in time, this most serious com- plication. Abscess of bone is to be differentiated from synovitis or arthritis of the neighboring joint. The points of contrast between it and these diseases will be found in the closing pages of this chapter. PERIOSTITIS. The periosteum may be affected by inflammatory processes of a simple, suppurative, or chronic type. In the simple form, although the disease may be essentially acute in its development, the tend- ency of the inflammatory process is towards the formation of either a lymph deposit, or a cell growth which is not sufficiently rapid to induce suppuration, from its inability to organize. In the suppurative or the diffuse type of periostitis, the inflamma- tory process is more extended, and the cell proliferation is so rapid that organization cannot take place, and pus therefore forms and accumulates between the bone and its periosteal covering, often de- stroying the nutrition of the bone by tearing off the periosteum, and thus inducing superficial necrosis. In tho chronic type of the disease, the tendency is towards thick- ening of the periosteum at the seat of the inflammatory process, 104 SURGICAL DIAGNOSIS. which is, as a rule, distinctly localized ; and, often, to the formation of osseous nodes, by means of changes in the thickened periosteum. Periostitis, in all of its forms, is frequently the result of some form of injury, and it is therefore most liable to affect the long bones, and those which are superficially situated. It may, however, follow syphilis, scrofula, rheumatism, mercurial poisoning, and gonorrhoea. The diffuse or suppurative type of the disease is usually of trau- matic origin, but it is, furthermore, associated, as a rule, with some impairment of constitution or hereditary taint. Its importance rests in its tendency towards rapid and extensive progress, and in the dan- ger of necrosis of the bone from the separation of the periosteum by the accumulated pus. It is characterized by great pain, marked constitutional disturbance, diffuse cellular inflammation of the soft tissues, fluctuation after pus forms, and by being confined between two joints. It is most common at about the age of puberty, and usually affects the long bones. It is to be diagnosed from suppu- ration of the tissues external to the bone, from suppurative erysipe- las, from acute rheumatism, synovitis, and arthritis. In severe cases, pyaemia may develop and prove a source of immediate death. The chronic form of periostitis is most frequently present in syphilis, and it most commonly affects the anterior surface of the tibia. It is associated with severe pain in the region of the seat of the disease, with tumefaction dependent on swelling of the perios- teum, with extreme tenderness to pressure, and with exacerbations at night and during damp weather. The swellings upon bones affected with chronic periostitis are called nodes. If situated upon the tibia, they show a marked tend- ency to ossify; although when present in other parts of the body they may closely simulate the hardness of bone, without any evi- dence of ossific granules being detected after death. Periostitis is seldom unassociated with some inflammatory condi- tion of the adjacent bone, except in that form where syphilis is the exciting cause. HYPERTROPHY OF BONE. As an evidence of the close vital relation between the soft tissues of the body and the bony structures, the conditions of hypertrophy and atrophy of bone are of great surgical interest. Hypertrophy of bone is an augmentation of healthy bone tissue, in contradistinction to inflammatory induration of bone. It occurs both in long bones and those which are chiefly composed of can- cellous tissue, as the bones of the face. DISEASES OF BONE. 105 If long bones be affected, the circumference is more often increased than the length, although the latter may, in exceptional cases, be markedly increased. The tibia and the fibula seem to be the most frequently affected of all the long bones, and reported cases of an increase of three inches over the normal length of these bones, as well as a proportionately increased circumferential measurement, are on record. In the face, the superior maxillary is the bone which is most lia- ble to undergo hypertrophy, and, in severe cases, the orbit, the nasal cavity, and the antrum may be seriously encroached upon. A form of hypertrophy of bone which is circumscribed, and which results in the formation of osseous swellings upon the bone in- volved, occasionally occurs; and the tumors so formed differ from true exostoses only in the absence of a fibrous or a cartilaginous stroma, as revealed by a microscopical examination. Hypertrophy of bone is unaccompanied by pain, and is exceedingly slow in its progress, often extending over a period of many years. It may, however, be accompanied by superficial exfoliations of bone, if the newly formed bone is poorly nourished, and also by signs of inflammation of the adjacent structures. If the long bones of the lowrer extremity be hypertrophied in their length, the gait may be impaired, and suspicion may be created of either existing or of previous disease of some neighboring joint. Local enlargements of bone, dependent upon true hypertrophy, are found at the points of insertion of tendons, at the ends of bones where amputation has been performed, on the bodies of the dor- sal and lumbar vertebrae, and, in advanced life, on the bodies of the cervical vertebrae. They can only be differentiated, during life, from the different forms of tumors of bone, by the absence of some of the special symptoms of other forms of tumors, or by the absence of an exciting cause; and, after death, by a microscopical section. ATROPHY OF BONE. This condition is one of actual diminution in the size of a bone from its previous or normal point of development. It may progress to so great an extent as to render the affected bone comparatively hollow, like the bones of a bird, or the bone may present a simple decrease in its size without any apparent alteration in its micro- scopical structure. It is much more frequently met with than hy- pertrophy of bone, and possesses a greater clinical significance. This condition depends, to a great extent, upon some cause 106 SURGICAL DIAGNOSIS. which creates either decreased blood-supply to, or defective nutrition of, the part. It may follow lack of use, as occurs in paralysis, or after amputation in certain regions; anchylosis of a joint, which is complete and of long standing; congenital defect in a joint, which im- pairs its utilitj^; abscess in the affected bone, through stasis produced in the vessels, or from the pressure created; rickets, which seems to influence the development of bones in their length rather than in their circumference; and, finally, deficient heart power and general weakness, without the existence of any actual disease being detected. Atrophy of bone is often the cause of lameness, where the long bones of the lower extremity are deficient in length ; and, in this condition, a lateral curvature of the spine may be created by the atti- tude assumed by the patient to obviate the effects of the shortening. In cases of excessive salivation in early life, non-development of the inferior maxillary bone is liable to occur from the injury done at that time to the soft parts, in which the bony structures seem sub- sequently to sympathize, although the bone may not have been directly involved to any marked degree at the time of the accident. Atrophy of bone may occasionally follow the occurrence of & frac- ture; and if so, it is probably produced by some injury to the nutri- ent artery. Cases are on record of apparent atrophy of bone, in its length, being produced by a separation of the epiphyseal cartilages. Such a condition is to be explained only as an evidence of the suspension of growth between the shaft of the bone and the epiphysis, which has become detached. RACHITIC CONDITION OF BONE—RICKETS. By this term is defined a condition of body which usually appears between the seventh month and the seventh year of life, and which is characterized either by an absence of the normal amount of mineral deposit within the bones, or, in certain localities, by an excessive deposition of earthy salts in the bony structures. It has been explained as the result of an excess of lactic acid in the blood, which holds these salts in solution, and thus favors their excretion by means of the kidneys; also on the ground that a diminished supply of chalky salts is afforded from defect in the charac- ter of the food; and, finally, it is regarded as a direct result Of an inflammatory process in the epiphyseal cartilages and the periosteal coverings of the affected bones. In some instances there appears to be a hereditary predisposition to the disease which favors its de- velopment. DISEASES OF BONE. 107 Rachitic bones are distorted either by angular deformity, by curva- tures, or by local enlargements. The angular deformities are most common at the diaphyses of bones; the curvatures, at the epiphyses, and at the points of cartilaginous union of those bones which have not epiphyses; while the local enlargements are mostly due to a widening of the transverse diameters of the epiphyses of the long bones. The action of muscles upon those bones, which are affected by the rachitic condition, often becomes a powerful agent in producing the varieties of deformity above mentioned; and many of the others are due, in a great measure, to the weight of the head and trunk. Atmospheric pressure is, without doubt, also a prominent factor in producing that deformity of the sternum and chest to which the term "chicken-breast" is vulgarly applied, and the other deform- ities of that region are often secondary to curvature of the spinal column. In the head, the sutures, which are analogous to the epiphyses of the long bones, are slow to ossify, and the fontanelles are late in closing. The deposit of earthy salts is imperfectly performed at the centres of ossification, and thinning of the bones occurs in these localities, which often allows the dura mater and the periosteum of the skull to come in contact, thus forming the condition called cranio-tabes. In the region of the pelvis, the antero-posterior diameter is shortened at the expense of the transverse diameter, the sacrum is altered in its curve, and the sacro-vertebral angle is rendered prominent. The cordiform or heart-shaped pelvis is also often pro- duced by a curvature at the point of junction of the pubis with the ischium. In the long bones, besides the curvatures and angular deformities previously mentioned, the medullary canal is often compressed at the seat of deformity, and the bone may, in extreme cases, become so thinned as to cause a spontaneous fracture. During the process of resolution from an attack of rickets, a tend- ency towards the too rapid ossification of the enlarged epiphyses of the long bones seems to be developed, and thus the further growth of these bones is seriously interfered with. This possibly accounts for the dwarfish stature of adults who have been victims to a ra- chitic condition in infancy. The late closure of the sutures and the small development of the facial bones, in proportion to that of the skull fully ossified in adult life, renders the appearance of the head also conspicuous. 108 SURGICAL DIAGNOSIS. The premonitory symptoms of rickets are often of great diagnostic value, and may be thus enumerated. Disposition of the child to lie quiet when previously playful, a tendency to cry at any attempt at mo- tion ; general hyperesthesia of the skin, as shown by crying on being handled; a tendency towards a chronic intestinal catarrh, as shown by a yeast-like diarrhoea; profuse sweatings and a dislike to covering dur- ing sleep. The actual symptoms of the disease first manifest themselves by the appearance of enlargement of the epiphyses of the long bones, which is most noticeable at prominent and superficial joints, as the knee and elbow. If this symptom appears before attempts at walking have been made, much of the later deformities of the long bones may be avoided, although the condition of cranio-tabes is more liable to be produced in those attacked during the first year of age. During the existence of rickets, the symptoms of a chronic bronchial catarrh are seldom absent, the teeth are cut at a date long after the normal period, the body emaciates rapidly, the sitting posture is no longer straight, since curvature of the spine usually commences at an early date, and the deformities of the chest and extremities are gradually developed. When rickets attacks children who have reached the age of three or four years, the initial symptoms of pain, hyperesthesia, etc., are generally absent, and a sense of muscular weariness after exertion is the first evidence of the disease, before the tendency towards de- formity of the long bones begins to manifest itself. Rickets, being essentially a disease of childhood, can hardly be mistaken in diagnosis after the tendency towards deformity is markedly developed. Its symptoms, however, will be found tabulated in the closing pages of this chapter. MOLLITIES OSSIUM. (Malacosteon, Fragilitas Ossium, Osteo- Malacia.) These terms are used to express abnormal conditions of bone, where either actual softening or a brittle condition is developed. They are classed and described together, as it is questionable if they are not, properly speaking, different phases of the same dis- ease, and dependent upon the same general set of causes. These conditions are generally those of adult life, and are more frequently present in the female sex than in males. They may be associated with some form of constitutional disease, prominent DISEASES OF BONE. 109 among which may be enumerated the rheumatic diathesis, second- ary or tertiary syphilis, and scurvy. These conditions are not to be confounded with the atrophy of bones which occurs normally in advanced life, or with carcinoma- tous disease of the bones; since they differ from the first, in being often fatal diseases, and, from the second, in not being localized, as a rule, but affecting the whole skeleton to a greater or less ex- tent. Moreover, the pathological conditions found in these two dis- eases differ markedly from that of carcinoma or of simple atrophy, in the very large proportion of fatty matters contained in the bones affected, and in the alterations of the normal appearance and arrangement of the bone substance. Mollities ossium is regarded by some as rickets attacking the adult, by others as a true fatty degeneration of bone, and finally by some as closely allied to cancer. It is a disease rarely met with, and the exact pathology and etiology of it are still matters more of theory than of absolute knowledge. In some reported cases, a marked hereditary tendency seems to have existed, while in others a previous history of rickets during childhood was present. As a result of these changes within the bony structures, a tend- ency either to progressive deformity or of fracture of bones from trivial causes is developed. Frequently several fractures may occur almost simultaneously, or, if the bone be rendered rather flexible than brittle, the long bones and those of the pelvis will become bent and twisted to a marked degree. The form of pelvic deformity produced by mollities ossium dif- fers from that produced by rickets, in that the transverse diameter is shortened in the former, from pressure of the thigh bones against those of the pelvis, while, in rickets, the antero-posterior diameter is generally decreased. It has been observed, that if the various foldings of a pelvis, distorted by mollities ossium, could be unfolded, that the pelvis would again have its normal shape and size, while, in the rachitic pelvis, the parts would be of dwarfish size, and of undue shapes and proportions. Mollities ossium is to be differentiated, during life, from rickets, simple atrophy of bone, and from cancer. The points of contrast will be found in the closing pages of this chapter. CARIES OF BONE. This condition is sometimes called ulceration of bone, since it is analogous to ulceration of the soft tissues. It is essentially an in- flammatory process, although of low grade, and its primary seat is 110 SURGICAL DIAGNOSIS. usually the cancellous bone structure. It may be superficial or central in its situation, and is most frequent in the articular extrem- ities of long bones, if centrally located. It is met with in scrofulous subjects, in syphilis, or in other con- ditions of low vitality; and it may also follow injury, or an extension of inflammation from other parts to the neighboring bone. It consists of a molecular death of bone tissue, in contrast to the condition of necrosis, which consists of the death of bone tissue in mass, and not in molecules. It is associated, sooner or later, with inflammatory changes in the soft tissues, and the formation of abscess and sinuses. If the ulcerative process be superficially situated, the periosteum becomes loosened from the surface of the bone, and thickened and altered in its structure. Carious bone is easily broken down by the pressure of a probe, and yields to the touch a grating sensation, similar to that perceived on rubbing an instrument over sand-paper. This peculiar sensation is a point of diagnostic value in the discrimination between caries and necrosis. The symptoms of caries are, at first, those of a low grade of in- flammation, and comprise constant pain in the neighborhood of some bone, swelling, more or less impairment of function, and the symptoms of abscess over the affected portion. Later on in the disease, a con- stant escape of pus, having a putrefied and offensive odor, the forma- tion of sinuses, and the development of granulations at the mouth of the sinus, which gives it a pouting or elevated appearance, are in- dicative of the irritation produced by the diseased bone upon the surrounding parts. A positive diagnosis of caries is only revealed, however, by prob- ing, when the absence of extreme sensitiveness, and the detection of a grating surface, which is soft, and which bleeds readily, is pathognomonic; in case the direction of the sinuses will admit of the introduction of the probe to the seat of the disease. In some cases, light percussion over the affected part is of diagnos- tic value, as a sharp pain is experienced by the patient similar to that perceived when injury is done to a carious tooth. In the condition, described as abscess of bone, the cavity in which the pus is contained is formed, to a great extent, by carious degen- eration, which is liable to continue after the pus is evacuated. Caries of bone is to be diagnosed chiefly from necrosis. The points of contrast between these diseases are appended in the form of a table in the closing pages of this chapter. DISEASES OF BONE. Ill NECROSIS. (Gangrene of Bone.) By this term is meant the death of bone tissue in mass, and not in molecules. It is analogous to gangrene of the soft tissues. This condition is one essentially of the compact tissue of bone, since that part of the bone, which is the least vascular, is most liable to be the primary seat of gangrene when the nutrition of the part is either impaired or totally arrested. The causes of necrosis may all be grouped under the head of agents, which impair or totally arrest the blood-supply of the af- fected part. Thus the causes may be made to include both those local causes, which interfere with the nutrition of bone, such as sep- aration of the periosteum, traumatisms, escharotics, exposure to cold, thrombosis or embolism of the nutrient artery or some of its branches, acute osteitis, etc., etc. ; or they may also embrace those constitutional conditions, which so alter the character of the blood as to impair its life-giving properties, and thus to predispose to gan- grene of the bony structures in those situations where the blood is, in health, but scanty, and which immediately feel any influence which tends to impair its nutrition. These constitutional conditions which predispose to necrosis are too numerous to individually men- tion, but they include all the fevers, scrofulous conditions, syphilis, cancerous cachexia, poisoning from mercurials, phosphorus, ergot, the condition of scurvy, etc., etc. The changes which are induced in a bone, where the nutrition is locally or generally impaired to a serious degree, may be summa- rized in the following stages : 1st. Death of tlie bone, as indicated by its white color, unless it be exposed to the air, when it becomes darker, its insensibility, the absence of vascularity, and the existence of a hard denuded surface which emits a sonorous sound when struck with an exploring probe. 2d. Inflammation of the surrounding tissues, from the irritation produced by the dead bone, which has now become a foreign body. This inflammatory process in the soft tissues leads to suppuration, and its subsequent evacuation, and the formation of sinuses, which present the pouting appearance at their mouths, mentioned as pres- ent also in caries, and which is due to the process of exuberant granulation as a result of the irritating character of the pus which is constantly exuded. In this inflammatory process, the periosteum also participates ; and it becomes loosened from the affected portion of the bone and perforated with openings to allow of the escape of 112 SURGICAL DIAGNOSIS. pus into the sinuses through the soft tissues. These sinuses, lead- ing from the surface to the seat of necrosis, are called cloaav. 3d. Separation of the necrosed portion of the bone now occurs, and the term sequestrum is applied to the loosened piece of bone. The sequestrum may not be always movable, however, as it is often held in its original position by bands of newly formed bone which are poured out by the detached periosteum. This process of detach- ment of the necrosed bone is often a very slow process, and may extend over a period of months. 4th. Gradual extrusion of the sequestrum now occurs from pressure produced by the development of newly-formed bone granulations, underneath the sequestrum, which are destined subsequently to re- place the necrosed portion, and to which the term invducrum is applied. This process is, in some cases, rendered impossible, as the sequestrum is retained by newly formed bone; but, if the necro- sis be superficial in its situation, Nature, even when unassisted, will remove the dead portion of the bone, although the process must of necessity be a slow one. 5th. A modelling of the invducrum into the normal shape of the bone, after the sequestrum has been either artificially removed or extruded, generally takes place, and the bone thus regains its nor- mal strength and often its normal appearance. Necrosis may be divided, on a basis of its location and extent, into three varieties, viz.: superficial, when on the surface; central, when imbedded in the bone beneath the surface; and total, when the whole thickness of the bone is involved. The symptoms of necrosis are but little at variance with those of caries, save that, in superficial necrosis, the suppuration is more rapidly developed and the symptoms of onset more marked. In central necrosis, deep-seated pain, throbbing, rigors, general debility, tumefaction over the seat of the disease, and some pain on pressure are usually present. In some cases, acceleration of the pulse and temperature may likewise be detected. In this condi- tion, surgical relief affords the only prospect of recovery, as the ex- trusion of the sequestrum is an impossibility. Some general idea of the extent of the disease may be formed, as a rule, by the number and situation of the sinuses ; as they usually bear a direct relation to the amount of necrosis present. CANCER OF BONE. The bony structures may be affected by the various forms of DISEASES OF BONE. 113 cancer either as a primary disease, or as a secondary result of cancer in some region, more or less remote from the bone attacked. All malignant tumors of bone are not necessarily cancerous in their nature, as they may lack the characteristic microscopical appear- ance of epithelial growths; thus those cysts, called spina ventosa, as well as some forms of pulsatile tumors of bone, often manifest great malignancy, although they may have none of the microscop- ical appearances of true carcinomatous structure. No bone in the body may be said to be exempt from cancerous disease, but the femur is, by far, the most frequently attacked, and the long bones of the leg are more commonly selected than those of the upper extremity, the cranium, spine, or pelvis. Cancer of bone seems also to select the immediate neighborhood of joints as its most frequent situation, and it may commence either as a disease of the periosteum or of the bone structure. It is to be differentiated from tumors of the non-malignant type, chiefly by the length of their period of development, and their slow and indolent course; also by the presence of glandular complications, which sel- dom exist in innocent tumors, and subsequently by the large size, the soft consistence, and the unequal density of different parts of cancerous tumors, by the marked increase in the size of the superficial veins, the extent of their attachment to the bone, and the pain with which their growth is attended and often preceded. In the diagnosis of cancer of bone, a careful examination of the glandular organs of the body for symptoms of a similar condition, and the general appearance of the patient, who will often give evi- dence of the effect of the disease upon the general system by the peculiar cachexia, which is often pathognomonic, will help greatly to render a positive conclusion possible. OSTEO-ANEURISM. This term is applied to pulsatile tumors of bone, since, by some, these tumors are believed to be analogous to aneurism of the arte- ries situated in the soft tissues. The name is often, however, a mis- nomer, since these pulsating tumors are sometimes exceedingly malignant in their character, and are therefore not truly aneurismal in their origin. This form of tumor springs from the cancellous tissue of the bone affected, and, by a process of absorption, expands until it protrudes beyond the limits of the bone, and yields a distinct pulsation which often renders the exclusion of true aneurism difficult. It is to be differentiated from cancer and from aneurism of a neighboring 8 114 SURGICAL DIAGNOSIS. artery. The points of contrast between these diseases will be found in the closing pages of this chapter. NON-MALIGNANT TUMORS OF BONE. These include a group of tumors which affect the bony structures, and which are composed, in some instances, of the same structures as the bone itself. In others, although the structure of the tumor may differ greatly from that of bone, and in this respect they may resemble the malignant tumors in their composition, still they give evidence of no malignant tendency in their progress or devel- opment, and, for that reason, must be classed under a different heading. The six varieties of non-malignant tumors which affect the bones have already been mentioned in the first pages of this chapter, and need not be here repeated. The points of diagnostic importance pertaining to each, will, however, be separately considered, although they will be found, in many instances, arranged in the form of con- trast in the closing pages of this chapter. ENCIIONDROMA. Cartilaginous tumors are usually associated with more or less ossification, and can rarely be found exempt from more or less evi- dence of malignancy in their origin and development. They may be circumscribed, when a state of complete ossification of the new growth will occasionally be found, or diffuse, when the cavities of the bone are, as a rule, completely filled, and the infiltration of the bony structures extends over a large extent of surface, and is seldom associated with more than a state of partial ossification. True cartilaginous tumors of bone differ, however, from cancer- ous growths in one marked peculiarity, viz.: that they affect sur- rounding parts only to the extent attributable to the pressure cre- ated by them, while cancer rapidly infiltrates the neighboring struct- ures. This point is, however, of less diagnostic value, during life, than would, at first, be supposed, since the rapidity of growth of enchondromatous tumors is usually slow. The seat of these tumors is chiefly confined to the phalanges of the fingers and toes, but, in occasional instances, they attack some of the larger long bones. Solitary enchondromatous tumors are not infrequently met with upon the last phalanx of the great toe, and a great source of inconvenience in wearing a boot is thus occasioned. The only surgical relief to be obtained, in case of the development DISEASES OF BONE. 115 of tumors of this type, lies either in the removal of the growth, in case it be situated so as to render such a procedure practicable, or in the amputation of the diseased part. EXOSTOSIS. Under this term, should properly be included only innocent tumors of bone, of a limited size, having a structure analogous to that of the bone from which it springs, and formed independently of any inflammatory condition which may have existed, either in the bone itself or in the periosteum, before the occurrence of the tumor. Such a definition, however, might exclude many forms of osseous growths, which are commonly described as true exostoses, since it is questionable if inflammatory action does not precede the larger proportion of circumscribed enlargements of bone, even if their course of development be a slow one, and their symptoms those of a benign character. In chronic rheumatic arthritis, the tendency toward the production of masses of new bone is one of the chief char- acteristics of that disease, and it is as positively proven that these masses become joined to the original bone and so thoroughly incor- porated with its structure as to be a source of annoyance only from the mechanical irritation which may be the result of their presence, rather than from the character of the growths themselves. Local inflammations of the periosteal covering of bone may also, in some cases, produce a product which may completely ossify and subsequently coalesce with the original bone. It is quite probable, however, in spite of these occasional methods of origin, that the large majority of exostoses are a variety of local hypertrophy of the bone elements, and are independent of any inflammatory causation. These cases are to be explained as analogous processes in bone to those in the softer structures, where fatty, fibrous, and other inno- cent tumors are developed without any apparent exciting cause. Exostoses are of two varieties, as regards their microscopical structure, viz.: the cancellous and the ivory-like growths. The former of these seems to be a reproduction of the central portion of a bone, and the latter the reproduction of the external or compact layer. The ivory-like tumors are found most frequently upon the bones of the cranium, and are of such extreme hardness that steps for their removal have often proved useless from the inability of the cutting instruments to affect their structure. The cancellous variety of exostoses are probably preceded by a car- tilaginous formation and a subsequent process of ossification within 116 SURGICAL DIAGNOSIS. it. They are found in other situations than the cranial bones more often than the preceding variety, and are much less dense in their structure. They are most frequently situated upon the long bones of the extremities, especially in the femur at its lower portion. Exostoses of the cranium are to be differentiated from tumors dis- connected from the bone, and from the other forms of bone tumors. If situated in the region of the orbit or the frontal sinuses, they may be overlooked until some marked evidence of their presence is made manifest by abnormal conditions of the neighboring organs or by some abnormality of the bony contour of the adjacent regions. Exostoses, even if small, often create serious symptoms by press- ure upon important structures. Thus, if growing from the first rib, the subclavian artery may be displaced or compressed; if affecting the lower cervical vertebrae, the same result may ensue, and cases of gangrene of the upper extremity are on record from such inter- ference with the supplying vessel; in both of these situations, the oesophagus may be pressed upon, and dysphagia will then be pro- duced. Cases of growths from the odontoid process have caused spinal softening, and even fatality, from the direct pressure created. In the pelvis, growths from the pubic bones may cause retention of urine and subsequent organic changes in the bladder. The causes of exostosis may be summarized as follows : (1.) Blows or external injuries. (2.) The effect of muscular strain at the seat of its bony point of attachment, especially if a process of bone normally ex- ists at this point. (3.) A peculiar ossific diathesis, tending to induce excessive osse- ous development from slight exciting causes. (4.) A perversion of the normal nutritive processes, from inflam- matory conditions of the bone or of its periosteal cover- ing, from fracture of the bone, chronic rheumatic ar- thritis, etc. True exostoses should not be an indication for surgical interfer- ence, unless some mechanical effect is produced upon surrounding parts which tends to disturb the proper performance of their nor- mal function. CYSTIC TUMORS OF BONE. (Osteo-Cystoma.) Cysts of bone may be of two varieties, viz.: serous and sanguin- eous. The serous cysts are sometimes called mucous cysts, as the DISEASES OF BONE. 117 contents are often of a glairy or a gelatinous character, and re- semble mucus in its appearance and consistence. True cystic tumors of bone are most frequently developed in the region of the jaws, and are often the result of an abnormal growth or position of the teeth. They enlarge by creating an expansion of the bony structures, and by a gradual absorption of the bone from the pressure which they cause upon the nutrient vessels of the part. Cystic tumors of bone are not to be confounded with those cysts which accompany hydatids, although the two may not be capable of differentiation during life ; except as is stated by some authors, any situation may be regarded as opposed to the development of true cysts, if not confined to the region of the face. In the closing pages of this chapter, the symptoms of cysts, in the region of the antrum, will be found arranged in contrast with those of solid tumors of that portion of the face. The sanguineous form of cyst, which occasionally affects bones, is a rare type of disease, and, in the few reported cases on record, seems to be closely allied to either cancer or some of the malignant forms of bony tumors. By some authorities, however, this form of tumor is regarded as analogous to a haematoma of bone, and is ex- plained as the result of some form of external violence, which has injured the cancellous bone tissue, and thus predisposed to rupture of the vessels of the bone. It would seem, however, that this theory is not well sustained, in the majority of cases, as the date of an injury previously received is often separated from the date of the appearance of the tumor by a long interval; while, in other cases, no history of traumatism can be detected. The diagnosis between the two varieties of cystic tumors of bone can be made, after fluctuation can be detected, by the exploring needle, which will disclose the character of the contents of the cyst FIBRO-CYSTIC TUMORS. (Osteo-Sarcoma.) This form of disease is of rare occurrence, and is often confounded with cancer. It may, however, prove itself, in some cases, an inno- cent form of tumor, and cannot therefore be properly classed under either innocent or malignant tumors of bone. These tumors may affect almost any part of the human skeleton, and are not always capable of diagnosis during life, as they are often associated with many symptoms which tend to create a suspicion of malignant growth. Their name is indicative of the microscopical appearance which renders the diagnosis positive, as the presence of fibrous 118 SURGICAL DIAGNOSIS. tissue in large quantity stamps the tumor as not one of the ordinary cystic tumors of bone. FIBROUS TUMORS OF BONE. The most typical illustrations of this variety of tumor are found in the fibrous polypus of the nasal cavity and in epulis, which is situated within the mouth. This form of tumor seems to develop as an outgrowth of the periosteal covering of the bone affected, and is closely allied to the enchondromatous and the myeloid types of disease. In this form of tumor, the symptoms are usually of a benign char- acter, except in case of epulis, where the tumor occasionally takes on ulcerative action and assumes a tendency toward the develop- ment of fungoid growth. ENTOZOA OF BONE. Hydatids have, in a few reported cases, been found to exist in the bony structures to such an extent as to render the affected part a cause for surgical interference. The variety of hydatid present is usually that developed from the echinococcus. In this condition, the course of the disease is a very gradual one, and if a long bone be affected in its shaft; the first evidence of the condition may be afforded by the occurrence of a spontaneous frac- ture, or one possibly associated with some slight form of injury. This disease may not be confined to long bones but may be pres- ent in the flat bones also. Cases have been reported where the bones of the cranium and the os innominatum have been the seat of extensive diseases. In case of fracture of bone from the presence of hydatids within its substance, all evidence of attempts at union are usually wanting, and the disease has in some cases been detected during attempts to produce union by exposure and refreshing of the fractured ends of the bone. Hydatids of bone cannot usually be detected during life, since they are slow in development, and are often unproductive of symp- toms, unless their existence is made manifest by fracture. DISEASES OF BONE. 119 OSTEITIS. OSTEO-MYELITIS. Origin. or It may result from disease from traumatism. It occurs in scrofula, syphilis, rheumatism, and follows exposure. Is always traumatic in origin; follows amputations, fractures, etc. It occurs, as a rule, where the me- dullary canal is exposed to the air. Most Frequent Seat. The tibia, bones of the head, and The long bones are most frequent- ribs are most frequently affected. 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. Pyaemic symptoms often rapidly follow, associated with 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. The disease often terminates in recovery. Termination. Recovery is rare. SYMPTOMS IN COMMON. Both may be associated with a traumatic history. tt tt ft " marked pain. 120 SURGICAL DIAGNOSIS. CARIES. NECROSIS. Definition. Is a molecular death of bone Is a death of bone tissue in mas.^ 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 which 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. Always results from a low grade May be traumatic in origin, and of chronic inflammation, as in acute; is always due, however, 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. 121 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. ft a ft tt enlargement of the bone. " " " " sensitiveness to pressure. tt a a a constitutional disturbance of ten. tt n tt 0ften with traumatic history. 122 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. Paln. 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. 123 ABSCESS OF BONE. ARTHRITIS. Motion. The motion of the neighboring The affected joint early manifests joint is seldom affected. pain when 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 slow 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 involved, but a continued es- organization. cape of pus through a sinus is lia- ble to remain indefinitely until the cause be relieved. Appearance of "Tissues. Often normal over seat of disease Venous congestion, oedema, and till the pus reaches the surface. a boggy condition of the soft tissues are often present. History. Is of slow and insidious develop- May develop rapidly, ana is al- ment, as a rule. ways preceded by marked local symptoms. SYMPTOMS IN COMMON. Both are associated with pain in the vicinity of a joint in the early stages. Both may be associated with suppuration. a a a a a sinuses in late stages. n a a a " the detection of carious bone by probing. 124 SURGICAL DIAGNOSIS. RICKETS. MALACOSTEON. Osteo-malacia.—Mollities Ossium. Time of Origin. Rickets commences, as a rule, in A softening of bone which 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 with 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 with 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 necessarily recovery. May prove fatal, from tend to shorten 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. 125 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 slow in growth and then suddenly rapid, or vice versd. 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. a a often with symptoms referable to irritation of nerves, muscles, joints, or vessels. 126 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 vascular 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 veins are 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. 127 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. 128 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 walls 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. SYMPT03IS IN COMMON. Both are associated with a tumor. " " " " pulsation. " " " often with symptoms referable to irritation of joints, nerves, muscles, or vessels. DISEASES OF BONE. 129 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 : toms are present (such as pain, Chills, oedema, great sensitiveness and con- Great pain, stitutional disturbance). " sensitiveness to touch, (Edema 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 No tendency towards a sponta- pus through the teeth sockets, or neous discharge of the contents of through the nostril during forced the cavity of the antrum is appa- expiration, or in certain positions rent. 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. tt ft tt a deglutition. tt tt parchment-like crepitus when the bone becomes thin. 130 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. te si " " bulging of the cheek. DISEASES OF BONE. 131 SPECIAL TYPES. EXTRA-CRANIAL TUMORS. INTRA-CRANIAL TUMORS. Respiratory Movements. The tumor shows no respiratory The tumor shows " 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 removed. 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 COMMON. Both may be associated with an absence of cerebral disturbance. tt a << " similar feel and consistence. ft tt tt a rapid or slow formation. tt tt tt tt aDSence of apparent causation, or knowledge of congenital defect. 132 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 over 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 sohdion 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- 135 136 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. 3d. 4th. 5th. 6th. 7th. 8th. Shoulder Joint. Clavicle. Elbow Joint. Wrist Joint. Hip Joint. Knee Joint. 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 will be considered as the special dislocations are reviewed, since it is im- possible to group into a general classification the many points of differentiation which 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 widely 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. 137 UNILATERAL DISLOCATION OF JAW. BILATERAL DISLOCATION OF JAW. Separation of Teeth. The teeth are displaced, but are The teeth are widely separated, not widely separated. and the mouth is open. Displacement of Chin. The chin is deflected towards the The chin is projected forwards, unaffected 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. Hollow at Ear. An indistinct hollow is felt at An empty space is felt in front of the ear. and below each ear. Power 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 with deformity and pain. impaired mobility. " articulation of words. " mastication. salivation. change in expression. projection of the under teeth. 138 SURGICAL DIAGNOSIS. UNILATERAL DISLOCATION CONGENITAL DISLOCATION OF JAW. OF JAW. Mobility. The movements of the jaw 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. 139 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. culation 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 jaw 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. a a tt a projecting under teeth. tt f •< " pain. a a tt tt impaired function. 140 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 below 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-coracold " 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, however, 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 following 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. A general and useful test, to decide the existence of dislocation at the shoulder, can be made by applying a straight ruler to the acro- mion process of the scapula, and the external condyle of the hu- merus. If the ruder can touch both points simultaneously, a dislocation is present, since the normal prominence of the deltoid muscle ren- ders it impossible, when the shoulder joint is normal. DISLOCATIONS. 141 ^B-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 below 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 down 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 Arm. The length of the arm is in- The length of the arm is dimin- creased. ished. Direction of Elbow. The elbow 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, hutperma- Reduction is easily accomplished, nent when accomplished. but is transient if the force be re- moved. 142 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 elbow, when 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. Ruler Test, A flat board or a ruler can be This test is impracticable in case made to touch the acromion process of fracture. and the external condyle of the hu- merus simultaneously. DISLOCATIONS. 143 SUB-CLAVICULAR DISLO- SUB-SPINOUS DISLOCATION. CATION. History. Occurs in falls upon the shoulder Occurs in falls upon the shoulder or elbow, when 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 Arm. 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 backwards, The elbow 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. Communicated Motion. Communicated motion is restrict- Communicated motion is restrict- ed outwards and. forwards. ed backwards only. Head of Humerus. The displaced head is felt as a The displaced head of the hu- tumor rotating with 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 with deformity. " " " " altered axis of limb. " " " " pain. " " " " possible crepitus. tt tt n a increased circumferential measurement of the joint. a tt tt tt impairment of function. 144 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 with deformity. " " " " pain. " " " " impairment of function. " " " "a history of accident. DISLOCATIONS. 145 "SUB-CORACOID" DISLO- " SUPRA-CORACOID " DISLO- CATION. CATION. Origin. Occurs in falls upon the shoulder Occurs from the same form of ac- or elbow when the arm is directed cident, but with force enough to usually fracture the coracoid pro- backwards. cess. Shortening. The arm is slightly shortened. The arm is usually markedly shortened. Mobility of Arm. Motion of the arm is restricted The motion of the arm is re- outwards as the bone impinges upon stricted forwards and outwards. the coracoid process. Location of Tumor. The tumor is felt underneath the coracoid process of the scapula and is obscure in its outline. The tumor is felt upon the coraco- acromial ligament, touching ex- 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 and is separated from the chest. The elbow is not directed mark- edly backwards, but is slightly separated from the chest. Acromion. The acromion process is most The acromion process may be prominent posteriorly and the de- masked 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 with deformity. impairment of function. abnormal axis of limb. pain. restricted movement. history of an accident. 146 SURGICAL DIAGNOSIS. " SUB-CLAVICULAR " DISLO- " SUPRA-CORACOID " DISLO- CATION. CATION. Prominence of Acromion. Most marked posteriorly. Acromion may be masked, ante- riorly, by prominence of the deltoid over the dislocated head of humerus. <0 Length of Arm. Slightly shortened. Markedly shortened. Position of the Elbow. Directed backwards. Directed backwards, but not markedly so. Motion. Voluntary motion is very limited. All motion is restricted in a Communicated motion is restricted forward and outward direction. outward and forward. Situation of Head of Humerus. Below the clavicle. Upon the coraco-acromial liga- ment, touching externally the inner border of the acromion. History. Fall upon shoulder or elbow, Fall upon shoulder or elbow when where arm is directed backwards. the arm is directed backwards, but with force enough to usually frac- ture the coracoid process. SYMPTOMS IN COMMON. Both are associated with shortening of the arm. " " " " restricted motion in a forward and outward direction. DISLOCATIONS. 147 TABLE OF DISLOCATIONS AT THE SHOULDER JOINT. " SUB-GLENOID." " SUB-SPINOUS." " SUB-CORACOID." Prominence of Acromion. Most marked later- Most marked anteri- Most marked poste- ally. Increased. orly. Length of Arm. Normal, or slightly increased. riorly. Slightly shortened. Position of the Elbow. Directed outwards. Directed forwards. Directed backwards. Voluntary motion lost, and communica- ted motion limited in extent. Motion. Voluntary motion less limited than any other dislocation. Communicated motion restricted backwards only. All motion outioards is restricted. Situation of Head of Humerus. High up in axilla. Under spine of scap- Underneath the co- A fall on the hand or elbow, when removed from the chest; or a direct blow downwards on the upper part of the humerus. ula, near its angle. History. A fall upon the shoulder or elbow, when the arm is directed for- wards. racoid process, and ob- scure in its outline. A fall upon the shoulder or elbow, when the arm is di- rected backwards. 148 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 backwards ; 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 follows: 1. " Supra-acromial,"—when 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,"—when 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 wall, 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 clavicle. Thus, in several cases, have symptoms of ap- DISLOCATIONS. 149 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 first class, A, may be enumerated : 1. Dislocation of both bones of the forearm directly back- 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 inwards. 3. Dislocation of both bones of the forearm backwards . and outwards. 4. Dislocation of both bones of the forearm forwards. This dislocation is very rare, and when present is usually associated with fracture of the olecranon process of the ulna. 150 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. " " " inwards. 3. " " " forwards. 4. Dislocation of the radius backwards. 5. " " " outwards. 6. " " " forwards. 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. 151 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, when 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 below 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, which exhibits the outline displaced bones. of the two 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 meruSt humerus is normal. Mobility. The joint is usually immovable. Extreme mobility is present. 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. The humerus is normal in length The humerus is shortened, as de- on measurement from the acromion tected by measurement from the process to the external condyle. acromion process to the external condyle. 152 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. Both are assoc SYMPTOMS IN COMMON. ated 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. 153 BOTH BONES OF FOREARM RADIUS FORWARDS AND BACKWARDS. 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 Forearm. The forearm is not twisted from The forearm and hand are slight- its normal attitude. ly flexed and twisted inwards. Diameters of the Joint. The transverse diameter of the The antero-posterior diameter of joint is normal, and the antero- the joint is markedly increased, and posterior diameter only slightly in- the transverse diameter diminished. creased. Condition of Tendons. 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 when the hu- associated with twisting of the fore- merus was fixed, is present. arm exists. SYMPTOMS IN COMMON. Both are associated with altered relations between 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 length of the humerus. 154 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 with fracture of be associated with 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 Forearm. 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. 155 BOTH BONES OF FOREARM BOTH BONES OF FOREARM FORWARDS BACKWARDS (continued). (continued). Pain and Swelling. The pain and swelling 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. 156 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 swelling at the joint. " " a history of an accident. " " shortening in the forearm. " " alteration in measurements of the joint. DISLOCATIONS. 157 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 when pronated and extended, ex- when supinated and extended, is ists. present. SYMPTOMS IN COMMON. Both are associated with free but painful extension of forearm. a a a inability to permit of flexion to a right angle. tt a "an abnormal tumor. a it a a " depression. a a a impaired motion of hand and pronation. a tt a pain at elbow joint. 158 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 somewhat 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 Forearm. 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- backwards. 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 with shortening of the ulnar side of forearm. " " " " normal position of radius. " " " " impaired function of joint. " " " " local pain and swelling. " " " " history of an accident. DISLOCATIONS. 159 TABLE OF DISLOCATIONS OF THE ELBOW JOINT. BOTH BONES OF FORE- ARM FORWARDS. Slightly flexed, or may be extended. Forearm can be ex- tended straight, and more than straight. BOTH BONES OF FORE- ARM BACKWARDS. Position of Forearm. Extended, as a rule. Motion in Joint. Immobility, or slight flexion and extension. Tension of Tendons. radius forwards and ulna back- WARDS. Slightly flexed and twisted inwards. All motion lost. Parts anterior to joint Biceps tendon is Biceps and triceps are very tense. tense, but the integu- tendons are both re- ment is normal. laxed. Length of Forearm. Increased. Diminished. Projection of Olecranon. Absent. Prominent. Condyles of Humerus. Prominent posteri- Prominent anterior- Diminished. Prominent. Not prominent. orly. ly. Circumference of Joint. Diminished. Increased. Increased. History of Accident. Fall upon hand, or Fall upon hand, or upon forearm, when upon forearm, when humerus was rendered humerus was rendered immovable. immovable. Fall upon hand, as- sociated with twisting of the forearm. 160 SURGICAL DIAGNOSIS. DISLOCATIONS AT THE WRIST. Dislocations of the hand from the lower end of the radius, though described by all surgical authors, from the time of Hippocrates to the commencement of the present century, as of frequent occur- rence, is now known to be an extremely rare form of injury. Pouteau first pointed out that fracture of the inferior extremities of the bones of the forearm is liable to be mistaken for it, and his observations were subsequently confirmed by Dupuytren. In those cases, where actual dislocation does occur, the presence of fracture of some part of the lower end of the radius may be usu- ally detected as a complication; or the dislocation, if fracture be not present, is extremely liable to be of the compound variety. This form of dislocation, is most frequently in the forward or backward direction, and, as a rule, is the direct result of a fall upon the hand. A. The carpus may, however, be dislocated in four directions from the radius, as follows : 1. Dislocations of the carpus Forwards. 2. " " " Backwards. 3. " " " Inwards. 4. " " " Outwards. Dislocations of the carpal bones from the radius are to be diag- nosed from 1st. Sprain of the wrist joint. 2d. Colles's 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- vidually 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. DISLOCATIONS. 161 The points of diagnosis between dislocation of the os magnum and " ganglion of the wrist," will be found contrasted in subsequent pages of this volume. C. The lower end of the ulna 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 usually follows violent attempts at pronation or supination of the hand. 162 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 wrist, 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 wrist. " " " " local pain and swelling. " " " " abnormal appearance of the styloid process of the ulna. " " " " loss of function. DISLOCATIONS. 163 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 elbow 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 tt n a a a swelling. " " " " " deformity about the joint. tt ft ft « « history of an accident. « tt a a " impaired motion. 164 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 with shortening of the upper extremity. " " " " local pain. " " " " " swelling. " " " " " deformity. " " " " impaired function. DISLOCATIONS. 165 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 with the absence of crepitus. " " " " shortening of the upper extremity. " " " " smoothness of the tumor. " " % " " impaired function. " " " " history of an accident. " " " " local pain and swelling. « " « " easy reducibility. 166 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. " " " " an internal displacement of the hand. " " " " normal regularity in the line of the ulna. " " " " limited and painful flexion and extension of the hand. " " " " shortening from inner condyle of the elbow to the tip of the little finger. " " " " 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. " " " " absence of crepitation. " " " " increased circumference of joint. " " " " local pain, swelling and ecchymosis. DISLOCATIONS. 167 DISLOCATION OF THE " OS GANGLION AT WRIST. MAGNUM." History of Causation. Is usually produced by a fall Is usually the result of excessive upon the hand when 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 always on the either surface of the wrist. back of the wrist. Variation in Size of the Tumor. The size of the tumor is often The size of the tumor is not ac- augmented by flexion 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 wrist. a tt n a freedom of motion. tt tt tt "little pain or discomfort. 168 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. Nelaton's guide, to detect any displacement of the femur at the hip joint, consists of a line drawn from the anterior superior spine of the ilium to the most prominent part of the tuberosity of the ischium. This line, in the normal condition of the joint, should cross the upper border of the trochanter of the femur, and it also crosses the centre of the cavity of the acetabulum. To properly apply this test, however, the thigh should be semi-flexed and slight- ly adducted. DISLQCATIONS. 169 "DORSUM ILII." "rSCIATIC 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 marked. 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 with displacement upwards of the fold of the nates. " " " shortening of the limb. " " " inversion of the foot. " " " displacement of the trochanter. " " " impaired voluntary motion. " " " impossibility of abduction of the limb. tt tt tt tt a outward rotation of the limb. " " " flexion of the thigh upon the pelvis. tt a « << " leg " " thigh. 170 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 intra-capsular in variety, it and is associated with direct vio- may occur in the old, and from lence. slight 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. SYMPT03IS 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. 171 "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, while the the limbs are separated, especially thigh is fixed. when a burden is upon the back. Fold of Nates. The fold of the nates is raised. The fold of the nates is lowered. Location of Head of Femur. The head of the femur is felt un- The head of the femur is felt be- der the psoas and iliacus muscles. low the groin, and almost in the perineum. Position of Trochanter. The trochanter of the femur is The trochanter of the femur is carried forwards, 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 straight forwards. SYMPTOMS IN COMMON. Both are associated -with pain which is very severe. " " " tension of the psoas and iliacus. " " " limited voluntary motion. " " " loss of the power of adduction. " " " " " " " rotation outwards. " " " the axis of the femur pointing downwards and outwards. " " " the history of an accident. 172 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 with eversion of the foot. " impaired voluntary motion. " shortening of the limb. " a history of an accident. " severe local pain. " swelling and possible ecchymosis. DISLOCATIONS. 173 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 anaesthe- be established under anaesthetics. tics. Trochanter. The trochanter is altered from The trochanter is normal in its its normal relation. position. Head of Femur. 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. " " " loss of function and voluntary motion in joint. " " " " apparent shortening of limb. " " " " the history of an accident. " " " " eversion of the foot. 174 SURGICAL DIAGNOSIS. TABLE OF DISLOCATIONS AT THE HIP JOINT. "SCIATIC." "DORSUM ILII." "THYROID." "PUBIC." Length of Limb. Slight shortening. Marked shorten- Lengthening. Slight shortening. ing. Position of the Foot. Toe on opposite toe. Slight flexion of the thigh and leg. The femur points inwards. Little affected. Toe on opposite instep. Foot straight. 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. inwards. The femur points downwards and out- wards. Position of the Trunk. Little affected. Bent forwards. Psoas and iliacus tense. Location of Head of Femur. Behind lum. Raised. acetabu- Behind and above acetabulum. Below the groin. Raised and car ried backwards. Fold of the Nates. Lower than nor- mal. Effects upon Motion. Adduction and Abduction and int. rotation easy. flexion easy. Abduction and Adduction, ex- outward rotation ext. rotation impos- tension and int. ro- sible. tation impossible. Appearance of Hip. Prominent and Flattened and sun- raised, ken. Adduction and ro- tation easy. Abduction and impossible. Hip is prominent. 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 flexed. The femur points downwards and 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. 175 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 which several cases have been re- ported. Of these five dislocations the forwards and backwards 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 upwards, 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 Tiblv,—called the " Rotary Displacement." In this case the patella is twisted upon itself, turned upon its edge, and impacted between the two bones forming the articu- lation at the knee joint. Of the dislocations to which the patella is subject the lateral dis- placements are, by far, the most common; and of the two lateral displacements the outward variety is the one most frequently en- countered. 176 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 swelling, thus rendering palpation negative in its results. In this latter case, however, 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. 177 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 Limb. The axis of the limb is markedly The axis of the limb is not greatly irregular. altered. Length of Limb. 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. Communicated 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 with pain. " " local numbness and oedema. " " ecchymosis. " " increased circumference of the joint. " " absence of crepitation. " " displacement of the patella. " " impaired function. " " " motion. 173 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, with 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 verted, 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. 179 DISLOCATION OF PATELLA DISLOCATION OF PATELLA INWARDS. 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 sideways to avoid an tella forcibly inwards. accident, from wrestling, or it may follow injury from sudden falls upon the knee, especially if the inner side of the patella be struck. Capsular Ligament. 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. SYMPT03IS IN COMMON. Both are associated with increased breadth of the knee. " " " " slight flexion. " " " " fixation of the joint. " " " " marked pain on communicated attempts at mo- tion. " " " " abnormal anterior aspect of joint. " " " " abnormal lateral projection of edge of the pa- tella. 180 SURGICAL DIAGNOSIS. ROTARY DISLOCATION OF UPWARD DISLOCATION OF PATELLA. PATELLA. Origin. Occurs most frequently from di- Occurs either from violent muscu- rect blows upon the patella, when lar effort to prevent falling back- the knee is bent, but it has been wards which results in rupture of known 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 twisted so that its The patella is carried upwards lateral borders take the position of upon the anterior surface of the fe- its upper and lower borders. The mur, and a marked hollow exists outer edge is frequently buried be- below, it at the anterior aspect of tween the condyles. the joint. Reducibility. The patella is reduced with diffi- Is reduced easily by elevation of culty. It is performed either by the heel and strong extension upon forcible flexion of the knee, by pres- the quadriceps extensor muscle. sure upon the edges of the bone when 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. DISLOCATIONS. 181 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 twisted 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 between 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 " 182 SURGICAL DIAGNOSIS. DISLOCATION OF ASTRAGA- DISLOCATION OF ASTRAGA- LUS BACKWARDS. LUS 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. DISLOCATIONS. 183 DISLOCATION OF ASTRAGA- FRACTURE OF BOTH BONES. LUS UPWARDS. 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 down- 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 with 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, swelling 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 with shortening of the leg. " " " " severe pain. ft " *< " marked and rapid swelling. " " " " crepitus, as a rule. tt ft a a history of an accident. 184 SURGICAL DIAGNOSIS. DISLOCATION OF ASTRAGA- DISLOCATION OF ASTRAGA- LUS EXTERNALLY. LUS 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. 185 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 anaes- 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 swelling. " " " " altered attitude of joint. ft « « " impaired function of joint. " " " " impaired mobility. « " " " a history of accident. 186 SURGICAL DIAGNOSIS. DISLOCATION OF ANKLE. CONGENITAL OR ACQUIRED DEFORMITY OF ANKLE, 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 will 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 will 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. FEACTUEES. 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, where the bone is broken into frag- ments of small size. D. Multiple Fracture, where 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. 189 190 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 when 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- pecially in 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 191 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 will 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 Llmb. It is not infrequent in both dislocation and fracture, that alteration does occur both in the nor- mal length and in the an is of the injured member. In 192 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 will be considered in connection with the various parts of the body, and in the following order: A. Fractures of the Skull. b. << a Face. c. a a Shouldee D. tt tt Humerus at Shouldeb. E. it AT THE Elbow Joint. F. a a Wrist k G. k it Hip « H. ti a Knee « I. a tt Ankle tt J. a tt Trunk. I pass first then to the consideration of the diagnoses pertaining to fractures of the skull. FRACTURES. 193 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 tine brain are produced. It is a frequent form of fracture, and, when the depression is slight in degree, ordinary examination will usually fail to detect it provided 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 194 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 complicating hem- orrhage of the meninges of the brain, or the develop- ment of symptoms of local abscess within the skull at the seat of injury, might give grounds for a reasonable conjecture of the existence of a fracture. 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, however, an incised wound 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 will enable the surgeon to make a positive exclusion of fracture. G. Elevated Fracture. This form of fracture, where the frag- ment is forced outwards is rare, but is still supported by several reported specimens. Two such specimens are now exhibited in the St. George's Hospital Museum. It is usually due to some pointed instrument, acting as a lever after it has punctured the skull. FRACTURES. 195 H. 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- 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 masked 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. 196 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 well-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. Symptoms of Compression. Symptoms indicative of cerebral Symptoms indicative 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. 197 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 discovered. 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 sequelae ; or they possibly may exist at the time of the injury. SYMPTOMS IN COMMON. Both are associated with a history of injury to the head. " may he " " external symptoms of contusion. " " " " constitutional disturbance. 198 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- al tered. 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. 199 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 a a a alteration in temperature. tt tt n tt impairment of special senses. 200 SURGICAL DIAGNOSIS. CEREBRAL COMPRESSION. CEREBRAL CONCUSSION. Insensibility. The coma is profound. The coma is incomplete. " " may not directly fol- " " " usually immediate. low 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 weak 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/%# 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 ways sluggish and show decreased generally sensible to light. sensibility to light. FRACTURES. 201 CEREBRAL COMPRESSION CEREBRAL CONCUSSION (continued). (continued). Sphincters. The urine is retained *as a rule, Incontinence of urine and invol- and the bowels are obstinately con- untary evacuations occur. stipated. Stomach. Vomiting is rare. Vomiting is frequently present, as the effects of concussion pass away. 202 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 with 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. H 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. 203 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 below 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 process, the bone retains nearly its normal power of resistance, save in those cases where comminution exists, in which case great mobility is often present. Fractures of the lower 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. 204 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 with dribbling of saliva. " " " " impairment of power of articulation. " are " " deformity. " " history of traumatism. n tt FRACTURES. 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 severe 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 following 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 when 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. 206 SURGICAL DIAGNOSIS. FRACTURE OF THE BODY FRACTURE OF THE SPINE OF THE SCAPULA. OF THE SCAPULA. Relation of the Fragments. 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 lower 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. Both are associated with a history of severe contusion. " " " " restricted and painful motion of arm. " " " " absence of the symptoms of fracture of the hu- merus. " " " " local pain and swelling over the scapula. FRACTURES. 207 FRACTURE OF THE NECK FRACTURE OF THE NECK OF SCAPULA. OF HUMERUS. Prominence of the Acromion. The acromion process is very The acromion process is usually prominent. normal in its appearance. Hollow below Acromion. A hollow exists below the aero- No hollow exists immediately be- mion process, but less marked than low the acromion process. in dislocation downwards 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 elbow, and rotation of the hu- sion and subsequent rotation, or by merus while the other hand is placed carrying the elbow inwards, while upon the shoulder. extension is continued. Reducibility. Reduction of the deformity is Reduction is effected by simple produced by raising the elbow. 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. n " " " easy reduction and crepitus. tt a a a a marked tendency towards return of the de- formity. a a a « severe pain in shoulder, and often in the hand. tt a ft r " marked swelling in shoulder, and often in the hand. n ft << " change in length of arm. 208 SURGICAL DIAGNOSIS. FRACTURE OF THE NECK DISLOCATION OF HUMERUS. OF SCAPULA. Length of Limb. The arm is lengthened. The arm may be lengthened or shortened. Reducibili.ty. 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. Elbow. The elbow can be made to touch The elbow of the affected limb the side. cannot be approximated to the chest. Axis of Limb. 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 hollow beneath the acromion. " " " " change in the length of the arm. " " " " local pain and swelling. " " " " impaired function. FRACTURES. 209 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 however 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 with 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 whether 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. 210 SURGICAL DIAGNOSIS. It is seldom, however, that the clavicle is broken without giving in itself distinctive signs of deformity; still when 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. 211 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 downwards, for- tured bone. wards and inwards. Appearance of Shoulder, The shoulder is sunken and drawn 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 Arm. 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 elevation 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. ^, Swelling and Ecchymosis. Swelling and ecchymosis are pres- Swelling and ecchymosis are often ent and are especially marked if the absent. fracture be due to direct injury. 212 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 below 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 will 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. 213 SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HU- FRACTURE OF THE HU- MERUS. MERUS. Acromion. 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 two inches below the acromion. Position of Elbow. 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 f-rom the shaft, and fails to rotate with 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 elbow being carried inward to- of the arm. wards the chest. Pain and Swelling. Pain and swelling are present in Pain and swelling are present the vicinity of the joint only. both at the seat of fracture, and often in the hand and fingers. 214 SURGICAL DIAGNOSIS. SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HU- FRACTURE OF THE HU- MERUS MERUS (continued). (continued). Ecchymosis. Ecchymosis is infrequent. Ecchymosis is usually present. Displacement. The lower fragment only is dis- The upper fragment is displaced placed inwards. upwards and outwards, and the lower fragment inwards. SYMPTOMS IN COMMON. Both are associated with a history of injury. " " " " crepitus. " " " " altered appearance of shoulder. " " " " pain and swelling. FRACTURES. 215 I MPACTED 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 hollow beneath the acromion No hollow beneath the acromion is marked. is present. Length of Arm. The arm is shortened. The arm is normal in length, as a rule. Humerus. 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 which case, holding the joint firmly, while an pressure over it, combined with 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 swelling Great pain and marked swelling is present. and ecchymosis are usually present. SYMPTOMS IN COMMON Both are associated with a history of traumatism. a a a tt impaired function of limb. a a a a local pain and swelling. a n a a crepitation, in some instances. {( a tt ft frequent prominence of the acromion. 216 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 low 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 Arm. The length of the arm is short- The length of the arm is in- ened. creased. Position of Elbow. 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. 217 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 low it, but one may exist lower under the acromion process which down. is well marked. Coracoid Process. The coracoid process is immova- The coracoid process moves with ble, save with 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 elbow 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 with a history of traumatism. " " crepitus. " " easy reduction, but of a transient character. " " loss of motion. " " severe pain in the shoulder and hand. " " marked swelling in the shoulder and hand. a "a change in the length of the arm. 218 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, which, 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. Both are associated with a tumor on the scapula. " " " " absence of crepitus. " " " " impaired functions. " " history of an accident. " " local pain in region of the shoulder. FRACTURES. 219 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 with 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. f 4th. " severe sprain or contusion of the joint 220 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. 221 TRANSVERSE FRACTURE OF DISLOCATION OF BOTH HUMERUS ABOVE THE CON- BONES OF FOREARM DYLES. BACKWARDS. History. Occurs in falls upon the elbow. Occurs in falls upon the palm of the hand, or upon the forearm when the humerus is fixed. Anterior Tumor. An anterior tumor exists which is An anterior tumor exists (lower small and pointed (upper fragment), end of humerus), which is broad and lies above the crease of the elbow, and large, and lies below the crease of the elbow. Posterior Tumor. 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. Extensive mobility is present. The joint is usually immovable. 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 Humerus. 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 when sient if the force be removed. effected. SYMPTOMS IN COMMON Both are associated with shortening of the upper extremity (as a whole). a a a a an anterior and posterior tumor. n a a " impairment of function. a a ft " a history of an accident. a it « " possible crepitus. an a " local pain and swelling. 222 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 Forearm. The radius is frequently displaced The ulna is usually retained in from its normal position. its normal relation to the humerus. Nerve Symptoms. 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 with a displacement of the fragment towards 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. 223 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 elbow when the arm is bent, is present. Presence of Dislocation. It is rarely unassociated with dis- It may occur without displace- locationof 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 elbow 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- when 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 with deformity. ft << « " possible dislocation. a « l( " impaired function. " " " " crepitus. a l( a " history of an accident. tt a << " local pain and swelling. 224 SURGICAL DIAGNOSIS. FRACTURE OF THE OLEC- RUPTURE OF THE TRICEPS RANON 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 Swelling. 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. ft (( " an empty space behind the elbow. " " " a tumor high up behind the joint. f( " "a history of traumatism. " " " local pain. " " " local swelling. FRACTURES. 225 FRACTURE OF THE UPPER END OF THE RADIUS. FRACTURE OF THE UPPER END OF THE ULNA. Deformity. No displacement of the upper fragment will exist, if the seat of fracture be above the tubercle of the radius ; but if below it, a marked displacement is apparent on exten- sion of the forearm, from tension of the biceps tendon. A displacement will be easily de- tected, as a rule, on the posterior part of the forearm, on account of the superficial position of the bone in that locality, although it may not be discovered on the anterior 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. he 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. " marked swelling. " severe local pain. " frequent ecchymosis. crepitus. impaired function and motion. altered, or a fixed position of the hand. 226 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 1^ inches from its lower articular extremity, and asso- ciated with 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 wrist. 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 wrist 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 low 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 blow received over the seat of injury. It is to be diagnosed from Colles' Fracture and from dislocation of the carpal bones. D. Separation of the Epiphyses at the W^rist. Like all sepa- FRACTURES. 227 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 with 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. 228 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 fork " ap- No abnormal curves in the line of pearance, due to the displacement the radius are perceived. 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 is both sharp and pointed. which is smooth and rounded. Length of Radius. The radius is shortened. The radius is normal in length. Length of Limb. 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 ia 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 ia 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 swelling. " " " " impaired function. " " " " a history of an accident. FRACTURES. 229 FRACTURE OF BOTH BONES DISLOCATION OF THE NEAR THE WRIST. WRIST. Seat of Displacement. 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 lower 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. a ft << " impaired function. ft f< " " local pain and swelling. a ft " n of tlie bowel is ever Produced- Skin. The skin is normal in color. The skin is often discolored over tumor. Cough Impulse. May be detected by flexion and Is often absent but may exist. adduction of the thigh, with the body bent forwards. 370 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. turn 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 TEE ABDOMINAL CAVITY. 371 FEMORAL HERNIA. LIPOMA OF FEMORAL CANAL. Density of Tumor. 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 Impulse. 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. a tt a tt tt inside of the femoral vessels. ft ft ft ft ft external to the pubic spine. " " " " " below the spine of the pubes. 372 SURGICAL DIAGNOSIS. VENTRAL HERNIA. UMBILICAL HERNIA (Omphalocele ; 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 Tumor. The tumor has a well - defined The tumor usually has no appa- neck. rent neck, but consists of a simple bulging at the navel, which 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 somewhat difficult. pressure upon the protrusion. History. A previous history of traumatism, The history of traumatism or ab- abscess, or weakening of the abdo- scess is seldom present. minal walls, is present. SURGICAL DISEASES OF TEE ABDOMINAL CAVITY. 373 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 when 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. it tt a tt resonant percussion. tt ft ft ft reducibility. tt n a tt impulse on coughing, as a rule. tt tt tt tt p0SSible intestinal embarrassment. 20 374 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, shown 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, when a bruit will be detected. Advent. The patient is conscious of the The tumor develops without any sudden advent 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 No peritoneal symptoms are ever rapidly after the appearance of the produced. tumor, if it be strangulated. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 375 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. with 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 he 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 with a marked gurgle and occasions a peculiar sickening sen- sation during its passage through the inguinal canal. 376 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 portion of the tumor from gravita- tion of the peritoneal fluid into the sac. The tumor is frequently translu- cent at the upper portion of the sac. The reduction of the fluid con- tents and the intestinal portion of the tumor leaves the testicle appa- rent, which also reduces with a gur- gle and marked pain. Never affects adults unless a pre- vious attack has existed in infancy. Fluctuation is absent. The tumor is not translucent. The reduction of the tumor leaves the testicle irreducible. Is most common in infancy, but may occur at any age from an ab- normal condition of the parts. Translucency. Reduction of Tumor. Age Affected. diseases of tissues. DISEASES OF TISSUES. Before proceeding to the considerations of the surgical diseases of tissues, it may not be out of place to hastily review the essential points pertaining to inflammatory processes in general, and, subse- quently, to note the characteristic peculiarities which are assumed, when certain individual structures are affected. The subject is one of too great magnitude to consider in detail, and the following tables and classifications can hardly serve as more than a guide to the reader, in case the subject prove one of special interest to him. While inflammation and its results are present in almost every form of disease to which the attention of the surgeon is directed, and, for that reason, should be thoroughly mastered, still the com- pass of this work precludes the lengthy discussion of pathological processes, and can admit of little more than is absolutely required to afford the student or practitioner a practiced insight into its bear- ings upon diagnosis. INFLAMMATION. Derivation. Flamma, cpXeypa—to set on fire. Definition. An abnormal condition of tissue, dependent upon irritation, associated with vascular and cellular changes, and alteration in the nutrition and function of the affected part. f (1.) on a pathological basis. T , , .n , (2.) on a basis of its severity and Inflammation may be classified < v -, ,. J duration. [ (3.) on a basis of its causation. In accordance with the basis from which inflammation is con- sidered, the following 'names have been applied to special condi- tions, which would perhaps be unintelligible to the reader, unless their meaning is first made clear by a short and concise definition. 379 380 SURGICAL DIAGNOSIS. A. Varieties (classified on a pathological basis). (1.) Vascular. Where the vessels of the affected part ex- hibit the most marked inflammatory changes. (2.) Cellular. Where the cells of the part are extensively involved. (3.) Necrotic. Where the inflamed part suffers death, from arrested nutrition. (4.) Necrotic-reparative. Where the affected part is partly destroyed, but eventually regains its activity (as in bruise). (5.) Hyperplastic. Where new connective tissue develop- ment is the chief feature. (6.) Tubercular. Where miliary tubercle is deposited. B. Varieties (classified on a basis of its severity and duration). (1.) Acute Inflammation. Where the changes in the affected part are rapid and the effects severe. (2.) Chronic Inflammation. Where the changes in the affected part are grad- ually developed, and not of as severe a type as in the acute form. C. Varieties (classified on a basis of causation). (1.) Traumatic. When produced by external injuries, and mechanical or chemical violence. (2.) Infective. When produced by the transmission of in- fective materials, by means of the blood-vessels or lymphatics, from some local infecting centre (as in acute pyaemia, miliary tuberculosis, etc.). (3.) Idiopathic. In which no obvious exciting cause exists. (4) Specific. Where the inflammatory process exhibits distinctive peculiarities, as in small-pox, syphilis, ty- phoid fever, diphtheria, scrofula, carbuncle, erysip- elas, etc., etc. DISEASES OF TISSUES. 381 In Acute Inflammation, The irritation must be severe to produce it. The duration is usually short. The changes in tissues are rapid. The injury sustained by the blood-vessels and tissues is cor- respondingly severe. The vascular phenomena are prominent. The exudative process is excessive. Suppuration is frequent. Organization of the infiammatory products is rare. In Chronic Inflammation, The irritation is usually slight. The duration is usually prolonged. The changes in tissues are slower and less extensive. The injury to the affected tissues is less severe. The vascular phenomena are less prominent. The exudative processes are less abundant. Suppuration is rare. Organization of the infiammatory products is the rule. Etiology. The causes of inflammation may be either predisposing or exciting. 'Chronic Inanition (produced by poverty, bad at- mosphere, etc.). Old Age (chiefly on account of defective heart power, and altered capillaries). Exhaustive Diseases (bed-sores are an example of its results). PREDISPOSING CAUSES. \ Local Arterial Dis- ease Local Obstruction of Veins (by causing imperfect nutri- tion to the tissues). Previous Inflammation (by weakening the reac- tive power of tissues). Abuse of Alcohol. Climate. Temperature (extreme heat or cold). Atmospheric Poisons (poisons of malaria, sewer gases, chemical vapors, etc.). Bad Hygienic Conditions. 382 S URGICAL DIA GNOSIS. EXCITING CAUSES. r Heat. (1.) Direct Irritation Cold. from chemical agents, " Acids. viz.: Caustics. r Introduction of foreign bodies (splinters bullets, etc.). Stabs. Gun-shot wounds. (2.) Mechanical Injury. - Lacerations. Contusions. Fractures. Dislocations. r Liver. Kidney. Salivary glands. Calculi in the - Prostate gland. Lachrymal glands. Joints. (3.) Influence of Mor- - Serous cavities. bid Products gener- - ' In the bladder. ated within the body. In the rectum. Retained putre- In the intestine. factive ex- -cretions. Blood clots. Tubercle. Gangrene. - Sequestra, (4.) Altered State of Local Nerves. ' Injury to the brain substance. " " cranial nerves. " " spinal cord and nerves. " " sympathetic. (5.) Abnormal Proper- ties in Blood. Deficiencies in Abnormal in- gredients. Nitrogenized food. Salts (chiefly those of 'potash). Arterial supply. Poisons. Purgatives. Diuretics. Emmenagogues. Cathartics. Uric acid. Urea. [ Lactic acid. (6.) Direct Contagion _ arising from Gonorrhoeal poison. Chancroidal " Syphilitic " Vaccine virus. Decomposing pus. _ Contagious ophthalmia. DISEASES OF TISSUES. 383 Results of Inflammatory Processes. These may be divided into two great classes, viz: Local changes within the inflamed part. Constitutional changes. Local Changes within the in- flamed part. ' Impaired function. A. Pain. Rational Symp- • Heat. toms. Redness. _ Swelling. ■ Momentary contraction. Dilatation with fluxion (the blood current being more rapid than normal). ' Changes in Dilatation with congestion (the Vessels. blood current being slower than normal). Transudation of plasma. Transudation of leucocytes and red corpuscles. B. Stasis. Microscopical Changes. " Sero-albuminous. Sero-fibrinous. ' Exudation. - Hemorrhagic. Pus. Catarrhal. Changes in __ .. Diphtheritic. - Tissues. Due to altered - nutrition. Cell-growth. Organization. Degeneration. Death. Constitutional Changes. Changes in Temperature (modified by the severity of the inflam- mation and also by its type). Changes in Pulse. . Changes in Blood. Increase of fibrin. " of albumen. " of white globules. Slow coagulation (causing the buffy coat). Decrease in chlorides. Increased cohesiveness of the red blood globules. 384 SURGICAL DIAGNOSIS. Theories Advanced as to the Causes of the Local Inflammatory Changes. The results of inflammatory processes, as indicated in the table on the preceding page, have been, to the different observers, a sub- ject for inquiry and investigation. It may not be out of place, therefore, to enumerate some of the more important theories which have, at different times, been advanced to explain them, since, by so doing, the student may be better able to appreciate them, and to realize the importance of their bearing upon the long list of dis- eases which are of inflammatory origin. Each of the more important headings in the preceding table will, therefore, be separately considered where any theories have been advanced to explain them ; the different theories being simply enu- merated without elaboration or discussion. Other points of inter- est, which are not purely theoretical, will also be here and there inserted, when they seem to have a special bearing upon the subject. A. Microscopical Changes. (1.) Cause of momentary contraction of the capillary vessels. 1st Theory. " Capillaries contract when irritated." (This stage of inflammation is denied by some authors.) (2.) Cause of dilatation of the capillaries. 1st Theory. " Direct paralysis of vessel." 2d Theory. " Extension of contraction (the first condi- tion of the capillary vessel) to larger trunks, thus dilating the capillaries." 3d Theory. " Cell influence demanding increased nu- trition." 4th Theory. " Reflex act through the sympathetic sys- tem." (3.) Cause of retardation of tJie blood current (Ryneck's ex- periments). 1st Theory. This phenomenon is probably due to changes in the capillary wall, as shown by the two fol- lowing experiments: No stasis occurs in vessels whose vitality has been destroyed by poisonous metallic substances. Stasis is produced by injections of milk or de- fibrinated blood. 2d Theory. It is possibly due to obstruction produced by the white globules adhering to the walls of the capillary vessel. DISEASES OF TISSUES. 385 (4.) Cause of transudation of plasma elements. The walls of the blood-vessel become thin and altered in their character by being dilated, and thus allow of easy transudation. (5.) The transudation of white corpuscles. Discoverers, Addison—1842. Cohnheim, of Berlin—1867. The white globules are observed at first to become stationary, and subsequently to protrude themselves through the wall of the blood-vessel, without leav- ing an apparent orifice. It is possibly due to the power of amoeboid movement possessed by the white blood-corpuscle. (6.) Cause of nutritive cell activity. 1st Theory. (Strieker.) " Stimidation of the cells by liquor sanguinis." Strieker excised a piece of the cornea and inserted it under the membrane covering the opposite cornea, and thus produced inflammation of both. 2d Theory. " Nervous irritation " of the cells. 3d Theory. Transmission of irritation from tlie ad- jacent elements to the cell elements. (7.) The transudation of red blood-corpuscles. Occurs in mechanical hyperaemia, but in less quantities than the white. Is often associated with either a rupture of the vessel or some alteration in its coats. B. Rational Symptoms (localized in the inflamed part). (1.) Cause of pain. Pressure upon, or stretching of the nerve filaments by the hyperaemia and exudation. (2.) Causes of heat. (1.) Hypercemia of the affected pari (2.) Increased chemical action. (3.) Causes of redness. (1.) Hypercemia of the affected part. (2.) Hemorrhage into the tissues. (4.) Causes of swelling. Effusions of serum or white corpuscles into the tissues. Increased cell-growth. Variations in the Rational Symptoms of Inflammation. The redness may vary both in degree and in tint. The intensity of red indicates the amount of blood in the part. 386 SURGICAL DIAGNOSIS. The tint of red indicates the rate of circulation. Redness need not necessarily indicate inflammation, since it may exist independently of inflammatory processes. It is not well marked in non-vascular tissues, as in car- tilage, the cornea, etc. The swelling varies, With the ability of the tissue to hold exudation or to allow of cell-growth. Is most marked, therefore, in loose areolar tissue or in tissues adjacent to it, in synovial sacs, and in the lungs and the kidneys. The PAIN is modified in degree, (1.) By the anatomical seat of the inflamed part. (2.) By the density of the tissues surrounding the seat of inflammation. (3.) By the character of the inflammation. The pain during inflammatory process may also vary in its charac- ter. It may be of the following types : Throbbing or pulsatile. Burning (chiefly in surface inflammations). Prickling. Tingling. Growing. Starting (chiefly present in inflamed joints). Sensitiveness to pressure. Superficial desquamative inflammations are generally comparatively painless, as in catarrhal inflamma- tions, nephritis, etc. Organs of special senses, when inflamed, give special symptoms which are equivalent to pain. Bitterness in throat exists in posterior faucial catarrh. Unnatural sounds exist when the ear is affected. Sparks or flashes of light exist when the eye is in- flamed. The pain of inflammation may not be felt alone in the inflamed part. Ophthalmic tension is often felt in the brow. Hip-joint disease is often felt in the knee. Renal inflammation is often felt in the bladder and penis. The pain produced by inflammation of the liver is often felt in the right shoulder. DISEASES OF TISSUES. 387 Inflammation of the pelvic viscera is often felt in the thigh. The LOCAL heat in inflammation is modified, (1.) By the activity of the inflammatory process. (2.) By the variety of inflammation present (least in the necrotic type). (3.) By the constitutional condition of the patient. The function of the inflamed part is usually impaired. As examples of this fact, the bladder cannot retain urine, the eye cannot bear light, a joint cannot be moved, the ear loses its normal function or abnormal noises are present. The Constitutional Effects of Inflammation. (1.) Elevated Temperature. If sudden in its rise, it is accompanied by chiU or rigors. It is greatly modified by the state of the blood, the state of the nervous system, the seat of inflammation. It is usually associated with diminished or arrested secretion, as evidenced by the following conditions : High-colored urine. Confined bowels. Coated tongue. Marked thirst. Theories of causation of inflammatory fever. (1.) Increased elimination of nitrogenous, sulphurized, and phosphorized products. (2.) General systemic infection. (3.) Nervous influence on the capillaries. (2.) Pulse of Inflammation. The pulse is usually accelerated and fuU in inflammation, and is, as a rule, hard, tense, and wiry if serous mem- branes be inflamed. (3.) Blood Conditions in inflammation. The fibrin is increased from 2 parts as high as 10 parts in 1000. (Andral's researches.) The existence of fibrin as a distinct element is now questioned by some authorities. Slow coagulation, producing the "buff" and "cup"con- dition in from 8 to 40 minutes, is present in inflam- matory blood. 388 SURGICAL DIAGNOSIS. A buffed condition may, however, also occur in pregnancy, plethora, or after severe exercise. If due to inflammation, it is greatest when fibrous or serous structures are inflamed, and least when the mucous or tegumentary structures are involved. The clot of inflammatory blood is shaped like a trun- cated cone, and is less firm in texture at its base than in healthy blood. White globules are increased in their proportion to the red blood-globules during inflammation; the albumen is usually increased ; a marked decrease in the chloride salts of the blood and secretions may exist; the water of the blood is diminished ; and the blood-globules exhibit an unnatural cohesiveness. Exudation, in inflammation, may be of six varieties, as follows: (1.) Sero-fibrinous (water, fibrin, and salts). (2.) Sero-albuminous (water, albumen, and salts). (3.) Hemorrhagic. (4.) Pus. (5.) Catarrhal (consists of pus-corpuscles, mucus, des- quamated epithelium, and a sero-albuminous fluid). (6.) Diphtheritic. Both varieties of serous exudations contain an excess of the chlorides, phosphates, and carbonates over other salts. Exudation differs with the variety of tissue affected. It is least abundant in dense organs and non-vascular tis- sues, and most abundant in organs with a lax structure and in inflammations of a free surface (mucous or serous). SPECIAL TYPES OF INFLAMMATION. A. Inflammation of mucous membranes may be of two types, (1.) Catarrhal, (2.) Croupous or Fibrinous. (1.) Catarrhal Inflammations. In the milder forms of catarrhal inflammation, the changes which result are as follows : (1.) Hyperaemia. (2.) Increased secretion of mucus. (3.) Proliferation of epithelium. (4.) Slight transudation of leucocytes. DISEASES OF TISSUES. 389 In the severer forms of catarrhal inflammation, there exists, in addition to the above, (1.) Desquamation of the epithelium, leaving abrasions on the surface. (2.) Infiltration of the submucous tissues with the products of cell-growth. (3.) Follicular ulceration, from hyperplasia of the lymphatic structures. (4.) The glands become obstructed with epi- thelium, and ulcerate or atrophy. In the chronic types of catarrhal inflammation, the following changes may be noticed: (1.) The vascularity is not as great as in the acute type. (2) Proliferation of cells takes place, both in the epithelial and subepithelial struct- ures (causing thickening). (3.) The lymphatics become permanently en- larged. (4.) Abrasion or ulceration may ensue. (2.) Fibrinous or Croupous Inflammation. This is a more severe type than the catarrhal variety, and is characterized by an excess of fibrin exuded. This fibrin may be within or upon the mucous membrane, and, if upon the free surface, may result in the for- mation of complete casts of the inflamed surfaces. Fibrinous inflammations may exist in Croup. Diphtheria. Dysentery. Severe irritation of mucous membranes. It is usually a catarrhal process in its commencement. It may result in "false membranes" when the fibrin is very large in amount. In diphtheria, the exudation is largely within the sub- mucous tissue. B. Inflammation of Serous Membranes. Steps: (1.) Hyperaemia. (2.) Endogenous growth in epithelial cells. (3.) Loss of lustre in membrane. 390 SURGICAL DIAGNOSIS. (4.) Opacity and roughening in membrane. (5.) Fibrinous exudation. If serum be pres- ent it is always turbid, thus indicating its inflammatory character. Pus occurs in the specific types of disease. (6.) Absorption of the fluid exudation. (7.) Adhesive inflammation (hyperplastic), Due either to fibrillation of the fibrin and elongation and union of cells, or to irregular papillary outgrowths from the inflamed surfaces. C. Inflammation of Lymphatic Structures. This form of the inflammatory process includes the following conditions: (1.) Acute inflammation of lymphatic glands and vessels. (2.) Chronic inflammation of lymphatic glands and vessels. (3.) Typhoid intestinal lesions. Acute inflammation of lymphatic structures may result from Wounds. Extension of inflammation. Sympathy. (As occurs during attacks of gonorrhoea.) p . j Putrefactive matters. ( Snake bites. Chronic inflammation of lymphatic structures may result from Scrofula. Prolonged irritation. The symptoms by which the acute form of inflammation of the lymphatics is manifested may be enumerated as follows : (1.) Redness of the skin along the course of the lym- phatic vessels. (2.) Swelling of the inflamed part and tenderness to pressure. (3.) Yiolent pain. (4.) Enlarged glands. (5.) Frequent suppuration of the glands or in the connect- ive tissue surrounding them. In the chronic type of disease, where the lymphatics are affected, the glands undergo either (1.) Fatty degeneration. DISEASES OF TISSUES. 391 (2.) Caseous degeneration. (3.) Calcareous degeneration. In typhoid fever the solitary glands and Peyer's patches, and often the mesenteric glands, undergo special changes pecul- iar to the blood condition of that disease, which, however, do not pertain to a surgical treatise, and must, therefore, be found by reference to works on pathology. I shall consider diseases of tissues in the following order: A. INFLAMMATORY CONDITIONS OF TISSUE. Under which 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, as a rule, with local pain and tender- ness to the touch, 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. SURGICAL DIAGNOSIS. Circumscribed pus may exist as acute or chronic abscess, furuncle, anthrax, suppurative inflammation of glands and organs, and as a symptom of pyaemia. It frequently results in the formation of sinuses and fistidce, 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 cidaneous 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. 393 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 phagce- 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 phagaedena. 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 phagaedenic process commences within a wound and symptoms of pyaemia often rapidly follow. It is markedly contagious and usually fatal. 394 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 with 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 with a chill, rise in tem- perature to 103°-104°, nausea or vomiting, and frequent stupor or delirium. The face becomes reddened and oedematous, 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 within 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 with 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. 395 fissures. The chorium 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 with an oedematous 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 view. The disease exerts little, if any, influence upon the general health. Patients live for years, burdened with the weight of the growing 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. 396 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; and 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 with 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. 397 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 with vessels. It is chiefly developed on the posterior surface of the trunk, and is seldom present upon the extremities. Shape of Tumor. 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. 398 SURGICAL DIAGNOSIS. ABSCESS. LOCAL (EDEMA, 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. Both may be associated with pain. " " " " redness of the skin. " " " " marked local swelling. " " " " elevation of local temperature. " " " " constitutional disturbance. DISEASES OF TISSUES. 399 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 with an abnormal tumor. " " " " fluctuation. tt tt a ft a detection of pus by the aspirator or exploring needle. tt a tt ft pointing. 400 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 Tumor. The tumor lies deep in the iliac The tumor is superficially lo- fossa. cated. Integument. The skin is involved late, if ever. The skin is involved early in the disease. Mobility of Tumor. The tumor is immovable and hard The tumor allows of slight move- at its commencement. ment with the abdominal walls. 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. 401 PSOAS ABSCESS. FEMORAL HERNIA. Situation of the Tumor. 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 development 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 pelvic muscular strain, as a rule. affection. Bowel. No intestinal embarrassment is The intestinal function is often present. interfered with. 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, backwards 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. rille> as lonS as a recumbent position is maintained. 403 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. Temperature and Pulse. The temperature and the pulse are usually increased. The skin is usually involved and becomes red and cedematous, as pointing takes place. The temperature and pulse may he affected if malarial enlargement exists. The integument is normal in its appearance. Rigors. Chills may be present. Chills are absent, save in malaria. History. A history of contusion, or of some The tumor develops without any exciting cause exists. apparent causation. Integument. DISEASES OF TISSUES. 403 MOIST GANGRENE. DRY GANGRENE. Etiology. A condition of obstructed venous A condition of impaired arterial return is present, as a rule, although supply exists, which 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 with 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. ft a a tt diminished sensibility " " a tt n tt altered color " " " " « « " spontaneous separation of the 404 SURGICAL DIAGNOSIS. CUTANEOUS ERYSIPELAS. PHLEGMONOUS ERYSIPELAS. Origin. Is usually of idiopathic origin. Is generally the result of injuries penetrating to the cellular 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 which 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- which lasts till the tension is re- acter. lieved. Suppuration. Suppuration is seldom produced, Suppuration forms on the seventh the attack subsiding with 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 fol- duced. lows unless the tension is relieved and the pus evacuated. The wound being afterwards 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. 405 TUMORS. Tumors may be of two great classes, fluid 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 adivity, 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 may be 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: 406 SURGICAL DIAGNOSIS. Fully developed connective ) ««jv5r0WIO.»» tissue. ) SOLID TUMORS. Tumors of the connective tissue + type: Tumors of the higher tissue type: Tumors of the epithelial type: Embryonic connective tissue (Sarcoma). Granulation tissue. Mucous tissue. Adipose tissue. Cartilage tissue. Lymphatic tissue. Bone tissue. Type of muscle. " " nerve. " " blood-vessels. Papillomata; growing from Adenoma. Carcinoma. Fibro-Plastic. " Recurrent. " Nucleated. Myeloid. Glioma. Psammoma. Gummata. Lupus. Glanders. Myxoma. Lipoma. Enchondroma. Lymphoma. Leukaemia. Tubercle. Osteoma. Myoma. Neuroma. Angioma. Cutaneous surface. Mucous " Serous " 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. 407 CYSTIC TUMORS. A. Cysts formed in preexisting cavities. Retention Cysts ; (due to obstructed escape H of secretion). B. Cysts formed in sacs of inde- pendent ori- gin. 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 sublin- gual 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 ("Bursa?. Cysts ; (due to J Ganglia. excessive seere- 1 Hydrocele. tion). 1 Cysts of broad ligament. Extravasation Cysts ; (due to hemorrhage into closed cavi- ties). Haematocele. Sanguineous tumors. 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. Cysts formed t Parasites. around foreign \ Extravasated blood. (Bullets, etc., etc. Lipoma. Enchondroma. Sarcoma. New bursse. Serous cysts of the neck. Compound ovarian cysts. Congenital j Frequently resulting from a blighted ovum. They Cysts. ( often contain hair, bones, teeth, etc., etc. 408 SURGICAL DIAGNOSIS. Tumors may be again classified on the basis of location as follows Cysts. Glioma. Myxoma. Lipoma. Carcinoma. Psammoma. Gummata. Cholesteatoma. Tubercle. Hydatids. A. TUMORS OF THE HEAD. Brain. Scalp. Orbit. Antrum. Gums. Lips. Tongue. „ Jaws. { Lipoma. ■< Sebaceous. ( Vascular. Glioma. Myxoma. Cystic. Osteoma. Medullary Cancer. Cystic. Erectile. Osseous. Fibroid. Enchondroma. Lipoma. Encephaloid. Cystic. Fibrous. Carcinoma. Myeloid. [ Cystic. < Epithelioma. ( Lupus. Cystic. ^W4 Fibroid. Gummata. Epithelioma. . Encephaloid. Cystic. Fibroid. Myeloid. . Osteoma. DISEASES OF TISSUES. 409 B. TUMORS OF NECK. THE Vessels. j Encysted Aneurism. ( Diffuse Muscles. f Cystic. \ Lipoma. \ Myoma. Parotid Gland. Cystic. Fibrous. Enchondroma. c*u~r&i-Hypertrophy. —-***-£t<\* Abscess. . Cancer. Thyroid Gland. f Cystic. 1 Hypertrophy. 1 Encephaloid. -Lymphatic Glands. - ' Lipoma. Hypertrophy. Abscess. Syphilitic Induration. Tuberculous " _ Cancer. Integument. r Fibroid. Serous Cysts. Moles. Warts. Keloid. Eloid : (coil-like tu-mor). Mucous Membranes of Pharynx, (E-sophagus, and Larynx. ' Cystic. Myxoma. Fibroma. Adenoma. Sarcoma. Papillomata. Carcinoma. 410 SURGICAL DIAGNOSIS. Mammce. Labia. C. TUMORS OF THE TRUNK. Uterus. Rectum. Prostate. Testicle. Cysts. Fibroma. Adenoma. Enchondroma. Lipoma. Scirrhus. . Encephaloid. ' Cysts. Abscess. Haematocele. Epithelioma. Cystic. Fibroid. Myoma. Enchondroma. Pulsatile. Carcinoma. Fibrous. Fatty. Carcinoma. Hypertrophy. Abscess. Scirrhus. Encephaloid. Cysts. Tubercular deposits. Gumma. Enchondroma. Benign fungus. Carcinoma. DISEASES OF TISSUES. 411 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 of humerus in frac- ture. 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. .Drnatnton}He™aoftiieiu^ 412 SURGICAL DIAGNOSIS. Abscess of lo- cal origin. TUMORS OF THE GROIN. In the iliac fossae. In region of in- guinal canal. In the region of femoral canal. Due to perityphlitis. " empyema, the pus burrow- 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 now 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. 413 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. Epitlidioma. 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. SYMPTOMS OF CANCER. SCIERHUS. The scirrhus variety, called also the chronic or fibrous form of can- cer, is usually a primary type of disease. It is characterized chiefly by its slow development, its stony hardness, and by a tendency to pucker and depress the adjacent tissues before the disease reaches the stage of ulceration. It is most frequently present in the breast of females, and is oc- casionally present in the alimentary canal and its accessory organs. If present in the breast, it seldom reproduces its own type elsewhere. In this form of cancer, the ulcerative process is slow, and is de- veloped late in the disease. It is seldom associated with severe hemorrhage. As seen by the microscope, scirrhus is characterized by an ex- cess of the fibrous stroma over the cellular elements, which ac- counts for its solidity; and its tendency to pucker and depress adjacent tissues is explained as a result of the contraction of its newly formed connective tissue. Encephaloid. This form of cancer, called also acute or medullary, is usually a secondary disease, some other form having first developed. It is extremely malignant in its progress, grows rapidly, invades 411 SURGICAL DIAGNOSIS. all surrounding tissues, ulcerates early in its course, is associated often with early and profuse hemorrhages, and is rapidly fatal. To the touch, this form is soft, lobulated, and often elastic. It is most commonly present in the various organs, and in glandular structures. On inspection it resembles brain tissue, from which resemblance it gains its name; and it is characterized under the microscope by the remarkable excess of the cellular elements over the stroma. Epithelioma. To this form, the terms "epithelial cancer," "clay-pipe cancer," and " chimney-sweep cancer " are often applied, since it occurs from irritation, such as soot or the heat of a pipe, and affects epithelial structures. It is usually, in all its forms, a primary disease of a cutaneous or mucous surface, and is rarely found in the viscera. It begins, as a rule, either as a nodule or as a small indolent ulcer, which steadily advances, in spite of ordinary forms of treat- ment. It is most common upon the lips, tongue, anus or scrotum, and penis. If the ulcerating surface, or an incision into the tumor be com- pressed, a thick, crumbling, curdy mass is often exuded in a worm-like form, which, if placed in water, does not tend to diffuse itself, and which the microscope shows to consist of epithelial cells closely packed together. Under the microscope, a section of the tumor reveals epithelial cells arranged as eggs in a nest, or in the form of concentric spheres. It is clinically of comparatively long duration, unless some other form of cancer be simultaneously present in other regions of the body. Colloid. This form of cancer, called also the alveolar or gelatinous, variety, is most frequently met with in the stomach, peritoneum, and the intestine. It has a tendency to spread rapidly to adjacent tissues, and is a frequent associate of other forms of cancer. It is questionable if it properly deserves to be classed as a separate type of disease, as it is more properly a degenerative process of other forms of cancer or sarcoma. To the eye, colloid deposits have a glistening, jelly-like, and translucent appearance. DISEASES OF TISSUES. 415 The microscope shows the existence of large spherical cells, which often present distinct lamince, and which contain within their in- terior drops of colloid material. I shall defer the full description of the symptoms of each of the four varieties of cancer, as they are to be found enumerated in the diagnostic 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. 416 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 own 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 with great ra- rule, and, when 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 well marked in the later stages of the disease. DISEASES OF TISSUES. 417 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 Growth. 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. 418 SURGICAL DIAGNOSIS. EPITHELIOMA SCIRRHUS (Epithelial Cancer ; Clay-pipe (Fibrous or Chronic Cancer). Cancer ; Chimney - sweep'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 which 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 worm-like 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 water, 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. 419 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- which 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. 420 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. Termination. 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 within the tumor. Effects of Removal. A return of the disease, after re- The disease shows no tendency moval of the tumor, within two towards a return after removal. years is frequently present. DISEASES OF TISSUES. 421 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 always conveyed backwards. Location of Tumor. It never ascends behind the ribs. It frequently ascends behind the ribs. Surface of Tumor. 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. 422 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. 423 SEBACEOUS TUMORS OF THE FATTY TUMORS OF THE SCALP. SCALP. Comparative 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 Tumor. 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. with an offensive odor, from an es- cape of its contents. 424 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 black 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 offensive odor is occasionally The tumor is odorless. associated with 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. 425 EXTRA-CRANIAL TUMORS. INTRA-CRANIAL TUMORS. Respiratory Movements. 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 Tumor. 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 Cranium. The bony walls 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 with an absence of cerebral disturbance. a a a a similarity in feel and consistence. tt ft tt tt rapid or slow formation. tt tt a ft an absence of apparent causation or a knowl- edge on the part of patient or friends of a congenital defect or deformity. 426 SURGICAL DLAGNOSIS. 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 between the also be apparent at any of the two halves of the frontal bone. cranial sutures. Contents of Tumor. The protrusion consists chiefly of The tumor is due to an excessive brain substance. amount of fluid within the mem- branes of the cerebrum, and the pro- trusion of the membranes. Appearance of Tumor. 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 within the cranium. " " often associated with respiratory movements. " " " " " pulsation. DISEASES OF TISSUES. 427 ENCEPHALOCELE. CEPHALHEMATOMA. History of Tumor. 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 within the tumor is within the tumor. rare. Respiratory Movements. 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. Integument. 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. 428 SURGICAL DIAGNOSIS. 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 present, such as Chills, Great pain, " sensitiveness to touch, (Edema of face, Increased pulse, and " temperature. No acute inflammatory symp- toms are present, (such as pain, oedema, great sensitiveness, and con- stitutional disturbance). Fluctuation. Fluctuation is absent, as a rule. Fluctuation often appears in ad- 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 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 be- comes thin. DISEASES OF TISSUES. 429 EPITHELIOMA. LUPUS. Locations Affected. Affects principally the lips, Affects the face, nose, ears, cheeks, nose, forehead, and scro- cheeks, buttocks, and extremities. turn. It is also found frequently It also affects the mucous mem- on the mucous membranes of the brane of the lips, hard palate, and tongue, prepuce, labia, uterus, and throat. bladder. Development. Begins either as a subcutaneous Begins as a brownish-red spot, movable nodule, which undergoes which subsequently becomes a pa- ulceration, or as a small, foul ulcer pule and then ulcerates. with 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, Its ravages are often terribly se- and is often unassociated with any vere, and the part affected under- very marked deformity. goes, in some cases, marked and rapid deformity. Surface of Ulcer. The surface of the ulcer is fre- The ulcer may often be " serpigi- quently papillated and villous, from nous" in character. It may be an irregular growth of the corium. scabbed, and, on removal of the The surface is often friable, and on scab, the surface may present irreg- pressure frequently exudes a thick, ular elevations and depressions on crumbling and curdy material in a its surface. The skin, hair, seba- worm-like form. In some cases the ceous follicles and sweat glands, are ulcer is scabbed. often destroyed. Repair. Seldom, if ever, tends towards The ulcer frequently heals with a spontaneous recovery. depressed and puckered cicatrix. 430 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. 431 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 lower margin. Origin. Follows traumatism or lactation. Occurs after a period of uterine activity as in menstrual derange- ment, miscarriage, abortion, or normal confinement. Tumor. 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. ble, 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 involved. Integument. The skin becomes involved early. Tbe skin becomes involved late. Number of Tumors. 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 milk is often de- Pus is withdrawn by the needle, tected by the exploring needle. but no evidences of milk are present. 432 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- developed 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. 433 GLANDULAR TUMOR OF HYPERTROPHY OF MAMMJS. THE BREAST. Origin. Occurs most frequently in maid- ens between twenty and forty years of age, and is often associated with 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 Both breasts are simultaneously one breast is usually affected. 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. " tt tt 0f siow growth. " " " unassociated with tegumentary changes. " " " associated with normal health. " tt tt free frora enlargement of neighboring glands. " " " characterized by a normal position and appearance of the nipple. 434 SURGICAL DIAGNOSIS. SCIRRHUS OF THE BREAST. INNOCENT TUMORS OF THE BREAST. Outline of Tumor. 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 slowly and is often stationary for years. DISEASES OF TISSUES. 435 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. Complications. Cancerous tumors develop in other Complications are infrequent. organs and tissues. 436 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 following 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. 437 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. ed. 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. Foetal 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 with absence of the menses. tt ft a (t tt vomiting. tt tt a tt tt i0Cal uterine disturbance. tt tt tt n ft vesical and rectal irritability. 438 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 Tumor. The duration of the tumor is in- The duration is limited. definite. Location of Tumor. The tumor may not always be The tumor usually lies in the median in location. median line. DISEASES OF TISSUES. 439 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 Symptoms. The retention and decomposition No constitutional disturbance, of menstrual products create con- save from exhaustive vomiting, is stitutional disturbances, which are perceived if the foetus be alive, and often severely marked. no maternal disease exists. Fcstal Manifestations. No evidences of foetal life are de- Foetal life is clearly indicated af- tected. ter the fifth month. SYMPTOMS IN COMMON. Both are usually associated with amenorrhoea. " " (i a "a uterine tumor. tt a tt tt tt frequent local pains. " " " " " vesical irritation. tt tt tt a tt rectal " 440 SURGICAL DIAGNOSIS. UTERINE HYDATIDS. PREGNANCY. Development. The tumor develops with 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. Fostal Manifestations. Foetal manifestations are absent. Foetal movements and quickening are apparent, if the child be alive. DISEASES OF TISSUES. 441 UTERINE FIBROID. SOLID OVARIAN TUMOR. Menstruation. The tumor is usually accompanied The menstrual function is often by menorrhagia. unaffected. Movements of Tumor. The uterus always participates in The uterus is usually independent movements communicated to the of motions of the tumor. tumor. Movements 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. 442 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. Movement of Tumor. The tumor, if moved, 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 within 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 Tumors. The fluid, if withdrawn, coagu- The fluid, if withdrawn, 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. 443 UTERINE POLYPUS. UTERINE FIBROID. Mobility of Tumor. After the cervix has been dilated The tumor may often be felt ex- a movable tumor is perceived within 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. " " (t a a leucorrhoea. " " " " " pain in the back and in the loins. " " " " " dysmenorrhcea. 444 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. 445 OVARIAN DROPSY. ASCITES. Situation of Tumor. 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 bowel 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. 446 SURGICAL DIAGNOSIS. OVARIAN DROPSY ASCITES (continued). (continued). (Edema of Limbs. If present, oedema of the limbs It often precedes the ascites. follows 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 drawn by aspirator, The fluid, if drawn by aspirator, may reveal the following character- may reveal the following 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, which 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. 447 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 Tumor. The tumor rises gradually above The tumor rarely extends to the the umbilicus. umbilicus. Mobility of Tumor. 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 Tumor. The tumor is distinct in outline. The outline of the tumor is ob- scure. Development. The tumor develops 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 Symptoms. 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 withdrawn when the ex- ploring needle or aspirator is used. \ 448 SURGICAL DIAGNOSIS. UNILOCULAR OVARIAN RENAL CYST, (Dropsy or CYST. Hydatids). Intestinal Displacement. The tumor displaces the intes- The tumor displaces the intes- tine backwards, 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. Development. The tumor grows from below up- The tumor grows from above wards. downwards. 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 never crossed by The tumor is often crossed by the the colon, as shown 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 Tumor. The tumor involves both sides, if The tumor is unilateral. of large dimensions. DISEASES OF TISSUES. 449 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. Growth. 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. Foetal Manifestations. No quickening or foetal move- Foetal manifestations are a promi- ments are detected. nent symptom. Duration. Indefinite. Limited. SYMPTOMS IN COMMON. Both may produce enlargement of the breasts. a ti a pain jn the breasts. a a i( areola " " ft tt a morning sickness. 450 8 URGICA L DIA GNOSIS. 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 Hematocele. 4. Extra-uterine Pregnancy. 5. Uterine 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. 451 PELVIC CELLULITIS. PELVIC PERITONITIS. Tumor. The tumor will be felt low 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. Tympanites. Tympanites is absent. Tympanites 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. 452 SURGICAL DIAGNOSIS. PELVIC HEMATOCELE. EXTRA-UTERINE PREG- NANCY. Development. A tumor develops 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 Symptoms. 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. Termination. 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. 453 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 down wards towards 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 vagina, 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 va- 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. 454 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 wdiole or greater portion of the spinal column. The sac DISEASES OF TISSUES. 455 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- noidean 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 will 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. 456 SURGICAL DIAGNOSIS. SPINA BIFIDA. CONGENITAL FATTY TUMOR (connected with the Mem- 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. Number 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- file 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 when 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. 457 SPINA BIFIDA CONGENITAL FATTY TUMOR (continued). (connected wrrn the Mem- branes of the Spinal Cord) (continued). Transmitted Lioni. 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 however it is normal in appearance. SYMPTOMS IN COMMON. Both may be associated with other congenital deformities such as hare- lip, cleft palate, imperforate anus, cra- nial protrusions, etc., etc. a ti a tt imperfect development of the lower limls. Both are rare in the cervical region of the spine. '' reveal a long axis parallel with that of the spine. " are usually broad at the base, but they may be pedunculated. " may result in atrophy of the lower limbs. ft a a a paraplegia or extreme muscular weakness and reten- tion or incontinence of urine if the tumor be situated above the second lumbar vertebra. BIBLIOGRAPHY. Acton, William. The Functions and Disorders of the Reproductive Organs in Youth, Adult Age, and Advanced Life. Philadelphia, 1865. * Allingham, W. Diseases of the Rectum, their Diagnosis and Treatment. London, 1871. Ashton, T. J. A Treatise on Diseases, Injuries, and Malformations of the Rectum and Anus. London, 1854. / Prolapsus, Fistula in Ano, and other Diseases of the Rectum, their - Pathology and Treatment. London, 1870. 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Seidillot, C. Contributions a la Chirurgie. Paris, 1$08. Phlebite traumatique. Paris, 1832. Shaw, A. Diseases of the Spine. (Article in Holmes' Surgery.) Skey, F. C. Operative Surgery. Philadelphia, 1857. Smith, Henry. The Surgery of the Rectum. London, 1871. Smith, R. W. Treatise on Fractures in the Immediate Vicinity of Joints. Dublin, 1847. Stanley, Edward. Treatise on Diseases of Bone. London, 1849. Stromeyer, Louis. Gunshot Fractures. (S. F. Statham.) Philadelphia, 1862. Syme, James. Observations in Clinical Surgery. Edinburgh, 1861. Spence, J. Lectures on Surgery. Edinburgh, 1871. Thomas, T. G. Treatise on Diseases of Women. Philadelphia, 1876. Thompson, Sir Henry. Clinical Lectures on Diseases of the Urinary Organs. Phil- adelphia, 1869. Todd, Robert Bentley. Clinical Lectures on Certain Diseases of the Urinary Organs. London, 1857. Travers, Benj. Monograph on Injury to the Intestines. London, 1812. ■Van Buren, W. H. Monograph on Diseases of the Rectum. New York, 1873. Van Buren and Keyes. Genito-Urinary Diseases and Syphilis. New York, 1874. Velpeau, A. L. M. Elements of Operative Surgery. (Mott.) 1847. Monograph on Cancer. 1840. Virchow, R. Cellular Pathology. Philadelphia, 1863. Wardrop, James. Essay on Aneurism. London, 1828. Year-Book of Surgery. Sydenham Society Trans., 1861. Ziemssen. Article on Diseases of the Vessels. Cyclopaedia of Practice of Medicine. New York, 1874. INDEX. A. Abdomen, Aneurism of, 29. Contusions of the, 335. Injuries of the, 335. Wounds of the, 335. Abdominal Aneurism, 25, 27, 28. Cavity, Surgical Diseases of the, 335. Diseases, painful, 28. Tumors, 2iA Wall, abscess of, 400, 402. Abrasion, Balanitic, 332. Abscess, 398. Acute, 399. Acute Articular, 52. Chronic, 399. Cold, 399. Mammary, Acute, 431. Chronic, 431. Iliac, 400. of Abdominal Wall, 400, 402. of Antrum, 1:9, 428. of Bone, 99, 102, 110, 123. cause of, 102. symptoms of, 103. over a ve'ssel, 26. Pelvic, 447. Perineal, 320. Periosteal, 99. Prostatic, 307. Psoas, 29, 78, 349, 368, 401. Secondary, simultaneous appearance of, 16. Urethral, 317. Adenoma, 406. Anchylosis, 49. Bony, 70. Fibrous, 70. of Joints, 60, 105. varieties of, 60. Aneurism, 3, 7, 23, 24, 26. 35. 36, 128, 411. Abdominal, 25, 27. 28. Anatomical locations of, 8. Arterio-venous, 8. by Anastomosis (Noevus), 7. Cau-es of, 9. Cirsoid, 7, 34, 38, 39. ClassiCitation of, 8. classified on basis of location, 8. Common, 8. Cystogenic, 8. Diffuse, 7, 8. differential Diagnosis, 14. Dissecting, 7, 8. Encysted, 8. External, 8. False, 7, 8. Fusiform, 7, 8. Hernial, ~. internal, 8. in general, 22. Osteo-, 113. of Abdomen, 29. of Arch of Aorta, 4. of Bone, 32. Aneurism of Innominate Artery, 40. Table of, 7. Thoracic, 8, 30, 31. ascending portion, 12. symptoms of, 12. Traumatic, 9. True, 7, 8. Varicose, 7, 8, 41, 42. Various types of, 22. Aneurismal Diathesis, 9. Tumor, effects of pressure upon, 11. growth of, 10. in general, symptoms of, 10. situation of, 10. Aneurismal Varix, 7, 36. Angioma, 406. Anthrax, 397. Antrum, Abscess of, 129. 428. Cystic Tumor of, 130. Malignant Tumor of, 130. Solid Tumors of, 129, 428. Tumors of the, 408. Anus. Condylomata of the, 353. Fissure of the, 357. Ulcer of the, 339. Aorta, Aneurism of Arch of the, 40. relaxed pulsation of, 25. Apoplexy with injury, 198. Arterial Coats, Diseases of, 3, 4. Pnatty Degeneration of, 3. Weakening of, 9. Arteries, Disease* of, 3. Fatty Degeneration of, 9, 22. Occlusion of, 15. from Emboli, 3. from Foreign Bodies, 3. from Pressure, 3. from Thrombi, 3. Arterio-venous Aneurism, 8. Artery, Innominate. Aneurism of, 40. Arthritis, 56, 103, 123. Acute, 57, 66, 68, 69, 122. Chronic. 57. Chronic Osteo-, 58. general symptoms of, 57. local symptoms of, 58. Rheumatic, 57. acute, 66. chronic, 58. Rheumatic, chronic, of Tempero-Maxil- lary articulation, 139. Rheumatic, chronic, with contusion, 236. Syphilitic, 57. Ascites, 445. Atheroma, 3. 4. Atrophy of Prostate Gland. 308 Axilla, Glands of, Cancer of, 420. Axillary Glands, Tubercular Disease of, 420. Tumors of, 411. B. Balanitic Abrasion, 332. Balanitis, 325. 463 4!] 4 INDEX. Barton's Fracture, 226. Biliary Colic, 28. Bladder, Atony of the, 305. Bar at neck of, 288. Conditions of the, not necessarily associ- ated with structural changes in the Organ. 297. Deficiency of, 287. Diseases associated with structural changes within the, 288. Diseases of the, 287. varieties of, 287 Extroversion of, 287. Gangrene of, 288. Hern a of, 288. Hypertrophy of the walls, 288. Inflammatory condition of, 288. Inversion of the, 288. Malformations of the, 287. Multiplicity of, 287. Paralysis of the, 305. Rupture of the, 288, 301. symptoms of, 289. Stone in the, 291, 300, 301. Etiology of, 291. Physical signs of, 294. Rational symptoms of, 293. Suppuration of Vesical Walls, 288. Tumors of the, 288. Blood-vessels, diseases of, 3. Bone, Abscess of, 99, 102, 110, 123. cause of, 102. symptoms of, 103. Aneurism of, 32. Atrophy of, 99, 105. Cancer of, 32, 100, 112, 126, 300. Caries of, 99, 109. symptoms of, 110. Colloid Tumor of, 100. Cystic Tumor of. 100, 106. Cysts of, 125. Death of, 111. Diseases of, 99. special types, 129. Encephaloid Tumor of, 100. Entozoa of, 118. Exostoses of, 125. Fibrous Tumors of, 100, 118. Fibro-cystic Tumors of, 100. Fracttires of, of the leg in the vicinity of the knee, 241. Gangrene of, 99, 111. gradual chancres in, or abnormal deviations from healthy type of structure, 99. Hvrlatids of, 118. Hypertrophy of. 99, 104. Inflammation of the coverings of, 99. Inflammatory diseases of. 99. Internal Malleolus, Fracture of, 244. Malignant Cysts of, 100 Tumors of, 100, 114. Necrosis of, 99. changes in, 111. Non-malignant Tumors, 99. Patella, Fracture of, 242. Pulsatile Tumors of, 34, 100, 113, 126, 128. Rachitic condition of, 99, 106. Scirrhous Tumor of, 100. Spontaneous Fracture of, 99. Tumors of, 99. Ulceration of, 99. Bowel, condition of, in hernia, 346. Brain, Dropsy of, 426. Tumors of the, 408. Breast, Cvsts of th--, 432. Glandular Tumor of, 432, 438. Inrocent Tumors of the, 434. Scirrhous Cancer of the, 434. Tumors of the, 430. varieties of, 430. Bruit, 11. Bubo, 342. 348, 363. Bnbonocele, 342, 364 Bursa1, 407. C. Calculi, Prostatic, 309. Urethral, 318. Vesical, consistency and appearance of, 292. Etiology of. 291. Shape of, 293. Canal, Femoral, Lipoma or, 349, 371. Tumors in region of, 412. Inguinal, Tumors in region of, 412. Cancer, 405, 412. Acute, 417. Alveolar, 419. '■ Chimney-sweep," 418. Chronic, 417, 418. "Cluy-pipe," 418. Colloid, 419. svmptoms of, 414. Encephaloid, 35, 417. symptoms of, 413. Epithelial, 418. Epithelioma, symptoms of, 414. Fibrous, 417, 418. Gelatinous, 419. Medullary, 417. of Axillary Glands, 420. of Bladder, 300. of Bone, 32, 100, 112, 126. of Omentum. 421. of Prostate Gland, 308. of Rectum, 3M9. 356. of Testicle, with fungus, 267. Scirrhous, 417, 418. of the Breast, 434. of organs, 419. symptoms of, 413. varieties of, 413. Carbuncle, 397. Carcinoma, 406, 412. Cardiac Hypertrophy, 9. Caries, 120. Chancre, 326. 330. Chancroid, 326, 330. Chancroidal ulcers. 313. Clavicle, Fractures of the, 209. Fracture of, inside of Coracoid Process, 211. Fracture of, outside of the Coracoid Pro- cess near the Conoid Ligament, 211. Fracture of, symptoms of, 209. Cranio-tabes, 107. Cranium, Exostoses of, 116, 132, 424. Tumors of the, 422. Cellulitis. Pelvic, 451. Cephahematonia, 427. Cerebral Hernia, 340, 341, 345. Cirsocele, 277. Cloacae, 112. Chordee. 328. Colic, Biliarv, 28. Intestinal, 28. Renal, 28. Colles' fracture, 226. Comedones, 407. Compression, Cerebral, 200. Concussion, Cerebral, 199, 200. Contusions of the Abdomen, 335. over the Trochanter of the Femur, 173. Cord, Hydrocele of the, 285. Corpora Cavernosa, chronic circumscribed in- flammation of, 328. Diseases of the, 327. Inflammation of the, 327. Condylomata. 353. Cowperitis, 317. Cryptorehidi-m, 261. Cystic disease of Prostate, 308. Sarcoma, 258. Cystitis, Acute, 288, 304. Chronic, 2SS, 306. Cystocele, 341, 315 Cysts, Congenital, 407. Extravasation, 407. INDEX. 405 Cysts, Exudative, 407. Fibro-uterine, 442. Mucous, 407. of Antrum, 130. of the Breast, 432. of Broad Ligament, 407. of Kidney, 40i. of Liver, 407. of Testes, 266, 283. Ovarian, 442. compound, 407. unilocular, 448. Renal, 448. retention, 407. Sebaceous, 407. Serous, of Neck, 407. D. Deformities, Urethral, 317. Degeneration, fatty, of arteries, 22. of vessels, 43. Diaphragmatic Hernia, 374. Diathesis, Aneurismal, 9. Disease, Cystic, of Prostate, 308. Diseases affecting Calibre of Vessels, 3, 7. of Arterial Coats, 4. of Bladder, 287. of Bladder, associated with structural changes, 288. of Bladder, varieties of, 287. of Bone, 99. special types, 129. of Corpora Cavernosa, 327. of Crest of Ilium, 84. of Glans Penis, 325. of Intestine, 337. of Joints, 49. classification of, 49. in general, 50, 64. of Male Genitals, 257. varieties of, 257. of Penis, 325. of Prepuce, 326. of Prostate Gland, 307. of Rectum, 338. of Testicle, 257. Table for the diagnosis of, 270. Varieties of, with enlarge ment, 257. Varieties of, without enlarge- ment, 261. Of Tissues, 379. of Trochanter of Femur, 81. of Tunica Vaginalis and Spermatic Cord, 273. of Urethra, 313. of Urethra, affecting structure of its coats, 313. Sacro-iliac, 75, 79. Special, of Joints, 70. Surgical, of Abdominal Cavity, 335. Tubercular, of Axillary Glands, 420. Dislocations, 135, 253. causes of, 135. classification of varieties, 135. congenital, of Jaw, 138. general symptoms of, 135. special, 136. at Ankle Joint, 181, 185, 186. of Astragalus, backward, 182. externally. 184. forward, 182. internally, 184. upward, 183. of Carpus. 16?, 163, 164, 165. of Clavicle, 148. varieties of, 148. of Elbow Joint, 149. Table of, 159 of Femur, " Dorsum Ilii," 169. "Pubic," 171, 172, 240. "Sciatic notch," 169,170, 239. 30 Dislocation of Femur, "Thyroid," 171. of Forearm, both bones, backward, 151, 153, 154, 156, 221. both bones, forward, 154. of Hip-joint, 168, 173. Nelaton's guide, 168. Table of, 174. of Humerus, 208. Sub-clavicular. 143, 146. Sub-coracoid 145. Sub-glenoid, 141, 216. Sub-spinous, 143, 144, 218. Supra-coracoid, 145,146. of Jaw, 136, 139, 204. bilateral, 137. causes of, 136. unilateral, 137, 138. of Knee. 175. of Os Magnum, 167. of Patella, inward, 179. outward, 179. rotary, 180. upward, 180. of Radius, backward, 157. forward, 157. of Radius, forward, and Ulna, back- ward, 153. of Scapula, 149. of Shoulder Joint, 140. Ruler test, 140. Table of, 147. of Tibia, backward, 177. forward, 177. lateral, 178. rotary, 178. of Ulna, backward, 156, 158. forward, 158. lower end, backward, 166. lower end, forward, 166. of Wrist, 160, 228. 229, 230. Dropsy, Abdominal (Ascites), 445. of Brain, 426. of Joint, 49, 60. Ovarian, 445. Renal, 448. E. Elephantiasis Arabum, 394. Emboli in Veins, 3. Embolism, 15, 22. 44. Emphalocele, 426, 127. Enchondroma, 99,114, 406, 407. of Testicle, 260. Enterocele, 341. Entero-epiplocele, 341. Entozoa of Bone, 100, 118. Epididymitis, 268. Epigastric Hernia, 340. Epiphyses, Separation of the, of Radius and Ulna, 230. Epiplocele, 341. Entero-, 341. Epithelioma, 288, 326, 418, 429. Epulis, 118. Erysipelas, 393. Cutaneous, 394, 404. Interna], 384. Phlegmonous, 394, 404 Exomphalos, 340, 372. Exostoses, 99, 115. causes of, 116. of Cranium, 116, 132, 424. Face, Tumors of the, 422. Fatty degeneration of Arterial Coats, 3. of Vessels, 5. Flatfoot, 89, 92. 93, 95. Fracture, at the Elbow, 219. varieties of, 219. at the Hip, 232. 460 INDEX. Fracture, at the Knee and Ankle, 241. Shoulder, 205. Wrist, 226. Barton's, 226. Colles', 162, 226, 228, 231. Compound, of Ankle Joint. 245. in general, in the vicinity of Joints, 253. near the Wrist Joint, 22(> varieties of, 226. of the Ankle, 243. varieties of, 243. of the Clavicle, 209. inside of Coracoid Pro- cess, 211. outside of Coracoid Pro- cess near the Conoid Ligament, 211. symptoms of, 209. of the Femur, neck of, 172. 240. with inversion of foot, 170. of the Hip, 232. Extra-capsnlar. 235. Extra-capsular. simple, 237. Extra-capsular, with impac- tion, 23li. Intra-capsular, 236. Intra-capsular, simple, 237. Intra-capsular, with impac- tion, 235. with inversion of the foot, 239. distinct types of, 232. of the Humerus above the Condyles. 151. above the Condyles (transverse), 221. Extra-capsular, simple, 213. Impacted Extra-capsu- lar, at Shoulder, 215. Impacted Intra-capsu- lar, at Shoulder, 215. Inner Condyle of, 2.12. Intra-capsular, simple, 213. near Shoulder, 212. near Shoulder, varie- ties of, 212. Neck of, 141, 207, 216, 217. Outer Condyle of, 222. of the Jaw, Lower, 202, 204 of the .1 aw, Upper. 202. of the LeLr, in vicinitv of Knee, 241. of the Malleolus, Internal, 244. of the Patella, 242. of the Penis, 322, 328. of the Radius, upper end. 225. of the Radius and Ulna near the Wrist, 229. of the Ribs, 248. 250, 251, 252. of the Scapula, Body of, 206. Neck of. 207, 208, 217. Spine of, 206. of the Skull, 193. Base of, 199. complete, 193. Inner Table of, 197, 198. Outer Table of, 193, 197. of the Sternum, 2-16. of the Tibia and Fibula in region of Ankle Joint. 183. of the Trunk, 246. of the Ulna, Coracoid Process, 223. at Elbow, 220. Olecranon Process, 223, 224. Upper End of, 225. of the Vertebrae, 246. of the Wrist Joint, transverse, of both Bones, 164, 231. Pott's, 244. Separation of the Epiphyses of Radius and Ulna, 165. Separation of the Great Trochanter of the Humerus, 218. Special, 192. Spontaneous, 99. Symptoms of, in general, 190. Fracture, Varieties of, 189. Fragilitas Ossium, 108. Faces, Impacted, 348, 365. Femoral Canal, Lipoma of, 371. Tumors in region of, 412. Femoral Hernia, 340, 349, 307, 3iJH, 369, 370, 371, 401. Femur, Disease of the Trochanter, 81. Femur, "Dorsum Ilii," Dislocation of, 169. Fractures of. 232. " Pubic," Dislocation of. 240. "Sciatic Notch," Dislocation of,239. "Thyroid " Dislocation, 171. Fibroma, 406. Fissure of the Anus, 339, 357. Fistula of the Rectum, 338, 357. Fistulas, Urethral, 317. Foot, Fracture of the Femur, with inversion of the, 170, 230. Fosene, Iliac, Tumors in, 412. Furuncle, 307. G. Ganglia, 407. Gangrene, Dry, 403. Hospital, 403. Moist. 403. of Bladder, 288. fJionrt Axillary, Cancer of, 420. Tubercular disease of, 420. Enlarged, 349, 367. Lymphatic, Tumors of, 409. Parotid. Tumors of, 409. Prostate, Atrophy of, 308. Cancer of, 308. Cystic disease of, 308. Diseases of I he, 3i>7. Hypertrophy of, 307. Tubercle of, 308. Tumors of. 410. Wounds of the, 309. Thyroid, Tumors of, 409. Glanders, 406. Glans Penis, Diseases of the, 325. Gonorrhoeal Inflammation, 313. Gout, 50. Rheumatic, 58, 66. Groin, Tumors of. 412. Gummata, 327, 406. Gums, Tumors of the, 408. II. Head, Tumors of the, 408, 422. Haematocele, 272, 286, 348, 407, 411. of Testicle, 259, 362. Pelvic, 452. Hemorrhage, Prostatic, 309. Hemorrhoids, 338. External, 352. Internal, 352, 354. Hernia, 340. anatomical classification of, 340. classified as to contents of sac, 341. cerebral, 340, 341, 345. condition of Bowel in, 846. conditions of sac of, 341. congenital, 284, 341, 346, 375, 376. "cough impulse" of, 345. Diaphragmatic, 340, 345. 347, 374. differential diagnosis of, 348. Direct, 342. Epigastric, 340. External, 342. Femoral, 340, 345, 349,367,368, 369, 371,401 Gluteal, 345. Incarcerated, 341. Infantile, 341, 376. Internal, 342. Indirect, 342. Incomplete, 341. Inguinal, 285, 340, 365, 366, 370. direct, 358. indirect, 358. INDEX. 4G7 Hernia, Inguinal, incomplete, 363. nomenclature of, 342. region. 348. Ingnino-labial, 340. -scrotal, 340. In Pelvic region, 340. Irreducible. 341. Ischiatic, 340. Lumbar, 340. Obturator, 340, 345. of Abdominal Viscera, causes of, 342. exciting causes of, 344. predisposing causes of, 342. of Bladder, 288. of Kidney, 341. of Liver, 341. of Lung, 341, 411. of Spleen, 341. of Stomach, 341. of Testis, 341. pain as a symptom of, 346. Perineal, 340, 345, 373. Poupart's Ligament (above), 340. (below), 340. Pudendal. 340. reducible, .'141. reducibility of. 346. special types of, 342. Sciatic, 345. strangulated, 341. Scrotal, 280, 281, 359, 360, 361, 362. symptoms in geueral, 344. Testis, 260. 267. Thyroid, 373. Umbilical, 340, 372. Vaginal, 340. Ventral, 340, 346, 372. Herpes, 332. Progenitalis, 325. Humerus, Dislocation of, 208. Extra-capsular Fracture of, at shoulder (impacted). 215. Extra-capsular Fracture of (simple), 213. Intra-capsular Fracture of, at shoulder (impacted), 215. Intra-capsular Fracture of (simple), 213. Condyle of (inner). Fracture of, 222. Condyle of (outer), Fracture of, 222. Fracture of the, near Shoulder Joint, 212. Fracture of the, near Shoulder, varieties of, 212. Fracture of the Neck of the, 207, 216, 217. Separation of Great Tubercle of, 218. Sub-clavicular dislocation of, 143, 145. Sub-coracoid dislocation of, 145. Sub-glenoid dislocation of, 141, 216. Sub-spinous dislocation of, 218. Supra-coracoid dislocation of, 145, 146. transverse Fracture above the Condyles, 221. Hydatids, 118, 448. uterine, 440. Hydrarthrosis, 49, 60, 65. Hydrocele, 266, 272, 280. 284, 286, 375, 407. congenital, 274. diffuse of the Spermatic Cord, 275. encysted, 283. of the Spermatic Cord, 276. of the Testicle, 274. of the Cord, 285, 348, 366. of the Testicle, 348,360. Hydrops Articuli, 00. Hydro-Sarcocele, 274. Hypertrophy of Prostate Gland, 307. Ichthyosis, 394. Ilium, diseases of the crest of, 84. Inflammation, 379. acute, 380, 381. symptoms of, 390. catarrhal, 388. Inflammation, causes of (exciting), 382. (predisposing), 381. classification of, 379. cellular, 380. constitutional effect* of, 387. chronic, 380, 3si, 390. chronic circumscribed, of Corpora Cavernosa, :!2S. constitutional symptoms of crou- pous, in general, 389. etiology of, 381. Exudation in, varieties of, 388. Fibrinous, 389. Gonorrhoeal, 313. Heat of, its causes, 385. Hyperplastic, 380. Idiopathic, 330. Infective, 380. microscopical changes in, 384. Necrotic, 380. Necrotic-reparative, 380. non-specific, 313. of the Corpora Cavernosa, 327. of larger Joints, diagnostic points of tenderness on pressure, 87. of Lymphatic Structures, 390. of Psoas Bursa. 85. of Serous Membranes, 389. pain of, its causes, 385. pleuritic, 250. rational symptoms of, 385. redness of, its causes, 3S5. results of inflammatory process (table), 383. special types of (table), 388. specific, 380. swelling in, its causes, 385. traumatic, 380. theories as to causes of local in- flammatory changes, 384. Tubercular, 380. Urethral, 50. Vascular, 380. Inguinal Canal, Tumors in region of, 412. Hernia. 340, 370. region, Hernia of the, 348. Ingnino-labial Hernia, 34». -scrotal Hernia. 340. Injuries of Abdomen, 335. Intestinal Canal, foreign bodies in, 336. Intestinal Colic, 28. Intestinal Obstruction, &37, 349, 351. causes of, 337. symptoms of, 337. varieties of, 351. Intestine, diseases of the, 337. Involucrum, 112. Ischiatic Hernia, 340. J. Jaw, dislocation of, 136. 139, 204. Bilateral, 137. causes of, 136. Congenital, 138. Unilateral, 137, 138. Lower, Fracture of. 202, 204. Upper, Fracture of, 202. Tumors of the, 4'i8. Joint, Anchylosis of, 60, 105. varieties of, 60. Ankle, deformity of, with injury acquired or congenital, 186. diagnostic points of tenderness on pressure, 87. Dislocation at, 181, 185, 186. Fracture of, 243. (compound), 245. (varieties of), 243. Sprain of, 95. Ankle and Knee, Fractures at, 241. Deformities of, 87. acquired, 88. or congenital, 49. 468 INDEX. Joints, Diseases of, 49. classification of, 49. in general, 50, 64. special, 70. Dislocations of, special, 136. Distortions of, congenital, 87. Dropsy of, 49, 60. Elbow, diagnostic points of tenderness on pressure, 87. dislocation of, 149. Table of, 159. Fracture at, 219. (varieties of), 219. Elbow, Fracture of Ulna, 220. Fractures in general in the vicinity of, 253. Hip, Deformity of (Rheumatic), 83. diagnostic points of tenderness on pressure, 87. diseases of, 70. Dislocation at, 168, 173. congenital, 74, 77. Nelaton's guide, 168. Table of, 174. Fracture of, 232. (extra-capsular), 235. (simple extra-capsular), 237. (intra-capsular), 236. (impacted intra-capsular), 235. (simple intra-capsular), 237. (with inversion of the f oot),239. Knee, diagnostic points of tenderness on pressure, 87. Dislocations at, 175. Fracture of bones of the leg in the vicinity of the, 241. Knee and Ankle, Fractures at, 241. loose Cartilage in, 49, 62. Malformations (congenital), 87. Nodosity of, 58. Periostitis near a, 122. Shoulder, diagnostic points of tenderness on pressure, 87. Dislocations at, 140. Dislocation of, Table of, 147. Fracture at, 205. impacted extra-capsu- lar of Humerus. 215. impacted intra-capsu- lar of Humerus, 215. of the Humerus near the, 212. of the Humerus,varie- ties of, 212. Suppuration, external to a, 69. Wrist, Dislocation of, 160, 228, 229, 230. Fracture near, 226. varieties of, 226. of both bones near, 229. transverse, of both bones near, 164. Ganglion at, 167. Sprain at, 163. K. Kidney, Hernia of, 341. L. Labia, Tumors of, 410. Larynx, Tumors of Mucous Membrane of, 409. Leg, Barbadoes, 394. Leukaemia, 406. Ligament, Conoid. Fracture of the Clavicle outside of Coracoid Process near the, 211. Poupart's, Hernia above, 340. below, 340. Triangular, Rupture of the Urethra in front of, 321. Rupture of the Urethra within the, 320. Lipoma, 406, 407. of Femoral Canal, 349, 371. of Spermatic Cord, 278. of Testicle, 2.59. Lips, Tumors of, 408. Liver, Hernia of, 341. Lumbar Hernia, 340. Lung, consolidation at apex of, 81. Hernia of, 340, 341, 411. Lupus, 395, 406. 429. Iaipus Vulgaris, 395. Lymphatic Gland, Tumors of, 409. Lymphoma, 406. ra. Malacosteon, 108, 124. Malformations, acquired and congenital, 49. Mammae, Hypertrophy of, 433. Tumors of, 410. Merocele, 310. Mollities Ossium, 99, 108, 124. Monopodia, 186. Monorchidism, 262. Morbus Coxarius, 70, 77, 78, 79, 81 to 86. Acetabular, 72. symptoms of, 72. Arthritic, 72. symptoms of, 72. differentia] diagnosis of, 74. Femoral, 72. symptoms of, 73. symptoms of, 71. Morbus Coxa? Senilis, 58. Mouth, Tumors of the, 422. Muscle, Cremaster, Spasm of, 279. Muscles. Tumors of, 409. Myoma, 406. Myxoma, 406. N. Naevi, 39. Nasvus, 7. Neck, Tumors of the, 409. Necrosis, 111, 120. changes in, 111. Nerve, Recurrent Laryngeal, result of pressure upon, 13. Neuralgia, Articular, 49, 61. of Intestine, 28. of Rectum. 340. of Testis, 263. Neuroma, 406. O. Omphalocele, 340, 372. Ovarian Cyst, 442. compound, 407. unilocular, 448. Dropsy, 445. Tumor, 449. solid, 441. Ovary, Tumor of the, 444. (fluid), 447. Omentum. Cancer of, 421. Osteitis, 99, 100,102, 119,121. symptoms of, 101. Osteo-Aneurism. 113. Osteo-Arthritis, chronic, 58. Osteo-Cystoma, 116. Osteo-Malacia, 108, 124. Osteo-Myelitis, 99, 101, 119. symptoms of, 102. Osteo-Sarcoma, 117. Osteoma, 406. Orbit, Tumors of the, 408. Orchitis. 268'. Acute, 263. Chronic, 261. Inflammatory (simple), 257. Malignant, 258. 265. Syphilitic, 258, 264, 265. Tubercular, 258, 264 Obturator Hernia, 340. INDEX. 469 (Edema, local, 398. ffisophagas, Tumors of Mucous Membrane of, 409. P. Pachydermia, 394. Papillomata, 405, 406. Paralysis, infantile, 86. of Bladder, 305. Paraphimosis, 327. Parasites. 407. Parotid Gland, Tumors of, 409. Patella, Dislocation upward, 180. lateral, 180. rotary of, 180. Pharynx, Tumors of Mucous Membrane of, 409. Psammoma, 406. Pelvic region, Hernia in, 340. Pelvis, Cordiform, 107. Tumors of the, 450. various types of, 450. Penis, Anomalies of, 328. Calcification of, 327. Diseases of, 325. Fracture of. 322, 328. Perineal Abscess, 320. Hernia, 340, 373. Periosteal Abscess, 99. Thickenings and Nodes, 99. Periostitis, 99, 103, 121. near a Joint, 122. Syphilitic, near a Joint, 68. types of, 103. Peritonitis, Pelvic, 451. Perityphlitis, 340, 350. Phlebiectasis, 20. Phlebitis, Adhesive, 3, 18, 22, 45. Diffuse, 3, 19. Suppurative, 19, 22, 45. Phlebolites, 21, 309. Pneumo-thorax, 251. Pregnancy, 449. extra-uterine, 452. Tumor of, 438, 439, 440. Prepuce, Diseases of, 326. Phimosis. 326. Polypus, Fibrous. 118. Rectal, 339, 354, 355. Uterine, 443. Vaginal, 453. Posthitis, 325. Poupart's Ligament, Hernia above, 340. below, 340. Process, Coracoid, Fracture of Clavicle inside of, 211. Fracture of Clavicle outside of, near Conoid Ligament, 211. Coronoid, Fracture of, of Ulna, 223. Olecranon, Fracture of, of Ulna, 223, 224. Prolapse of Rectum, 338. Prostate Gland, Atrophy of, 308. Cancer of, 308. Diseases of, 307. (cystic), 308. (inflammatory . 307. Hypertrophy of, 307, 312, 323. Tubercle of, 308. Tumors of, 410. Wounds of, 309. Prostatic Enlargement. 307. Prostatitis, acute, 307, 311. chronic, 306, 307, 311. Psoas Abscess, 401. Pudendal Hernia, 340. Pruritus Ani, 339. Pyaemia, 50. R. Radius, Fracture of upper end of, 225. of (transverse, above the wrist), 231. Separation of the Epiphyses, 230. Ranula, 407. Rectal Prolapse, 355. Rectocele, 341, 345. Rectum, Cancer of, 339, 356. Disea-es of. 338. Fistula of, 33S, 357. Neuralgia ot, 340. Polypus of, 339. Prolapse of, 338. Stricture of, 339, 356. Tumors of, 410. Renal Colic, 28. Rheumatism, 50, 64. chronic, 58. Ribs, Fracture of. 248, 250, 251, 252. Rickets, 106, 124. Rickets, causes of, 106. symptoms of, 108. Rupture of Bladder, 288. of Triceps Tendon, 224. of Urethra in membranous portion, 321. in front of Scrotum, 322. in front of Triangular Liga- ment, 320. within the Triangular Liga- ment. 320. Urethral, 316. S. Sacro-iliac Disease, 75, 79. Sarcocele, 359. Hydro-, 274. of Testicle, 348. Sarcoma, 406, 407. Cystic, 258. of Testis, 270. Scalp, Tumors of, 408. (fatty), 423. (sebaceous), 423. Scapula, Fracture of the body of, 206. neck of, 207, 208, 217. spine of, 206. Spasm of Cremaster Muscle, 279. Spasm, Urethral, 318. Sprain, severe, 185. Sclerosis, 101. Separation of the Great Tubercle of Humerus, 144. Spermatic Chord, diseases of Tunica Vaginalis and the, 273. diffused Hydrocele of, 275. encysted Hydrocele of 276. Lipoma of, 278. Varicocle of, and Testicle, 277. Spleen, Enlargement of, 402, 421. Hernia of, 341. Sternum, Fractures of, 246. Spina Bifida, 454, 456. Spina Ventosa, 100,125. Spine, lateral curvature of, 82. Tumors of, 454. varieties of, 454. Stricture, Congestive, of Urethra, 318. of Rectum, 339, 356. Urethral organic, 312, 313, 323, 324. Sores, Venereal, 326. Scrofula, 50. Scrotal Hernia, 359 to 362. Hcrnia-inguino-, 340. Scrotum, Rupture of Urethra in front of, 322. Stomach, Hernia, of, 341. Stone in Bladder, 291, 300, 304. etiology of, 291. physical signs of, 294. rational symptoms of, 293. steps for sounding, 295. Skull, Fractures of, 193. at base, 199. complete, 193. of Inner Table of, 197, 198. of Outer Table of, 193,197. varieties of, 193. SympodK 186. Syndactylus, 186. 470 INDEX. Synostosis. 60. Synovitis, 49, 50, 60, 64, 103. acute, 51. chronic, 52. Gonorrhoeal, 55. Pyaemic, 55. Rheumatic, 54. Scrofulous, 53, 65. Suppurative, 52. symptoms of, 51. v Syphilitic, 56. Syphilis, 50. Syphilitic Orchitis, 264, 265. Testis, 270. Ulcers, 313. T. Talipes, 88. Calcaneus, 89. Calcaneo-valgus, 89, 92. Equinus, 9, 89. Equino-varus, 89. Spurio-valgus, 89, 92, 93, 95. Valgus, 89, 90, 93. Varus, 89, 90. Traumatic Aneurism, 9. Tendon, Rupture of the Triceps, 224. Testicle, (Ameer of, 267. Hematocele of, 362. Hydrocele of, 348, 360. encysted, 274. Retraction of, 279. Sarcocele of, 348. table for diagnosis of diseases of, 270. Tumors of, 410. undescended, 348, 364. Varicocele of Spermatic Cord, 277. Testis, Cy-ts of, 266, 283. Hernia, 207, 341. malignant, 270. Neuralgia of, 263. Sarcoma of, 270. Syphilitic, 270. Tubercular, 270. Tissues, Conditions of. inflammatory, 391. disea-es of. 379. Emphysema of, 252. Gangrene of, 392. Induration of, 391. Suppuration of, 391. Tumefaction of, 391. Ulceration of, 391. Tongue, Tumors of, 408. Thoracic Aneurism, 8, 30, 31. of Aortic Arch, symptoms of, 12. of ascending portion of Arch of Aorta, 12. Thromballosis. 18. Thrombi in Veins, 3. Thrombosis, 16, 22, 44. Tubercle, 406. of Prostate Gland, 308. Tubercular Testis, 270. Tumob or Tumors. Abdominal, 27. Aneurism, effects of, pressure upon, 11. Aneurismal, growth of, 10. in general, symptoms of, 10. situation of, 10. Atheromatous, 407. Benign, 416. classes of, 405. Congenita], fatty, 456. Cystic, 406, 407. classification of, 407. Erectile. 24, 38. External, sudden appearance of, 345. Extra-cranial, 131, 425. Fibro-cystic. 117. Glandular. 405. Hernial, character of, 345. surface of, 345. weight of, 345. Tumors in Iliac Fo=?rt, 412. in reg.on of 1A moral Canal, 412. of Inguinal Canal, 412. Intra-cranial, 131, 425. Intra-thoracic, 30. Malignant, 416 Mediastinal, 374. of Antrum, 4t>8. cystic, 130. malignant, 130. solid, 129, 428. of Axilla, 411. of Bladder, 288. of Brain, 408. of Breast, 430. glandular, 432, 433. innocent, 434. varieties of, 430. of Bone, 99. colloid, 100. cystic. 100, 116. Encephaloid, 100. fibrous, 100, 118. fibrocystic, 100. malignant, 100, 114. malignant cysts, 100. riou-malignant, 99. pulsatile, 34, 100, 113, 126, 128. Scirrhous, 100. of Cranium, 422. of Face, 422. of Groin, 412. of Gums, 408. of Head, 408. 422. of Integument, 409. of Jaws, 408. of Labia, 410. of Larnynx, Mucous Membrane of, 409. of Lips, 408. of Lymphatic Glands, 409. of Mammae, 410. of Mouth, 422. of Muscles, 409. of Neck, 409. of Orbit, 408. of Ovary, 444. (fluid), 447. (solid), 441. of OEsophagus, of Mucous Membrane of, 409. of Parotid Gland, 409. of Pharynx, of Mucous Membrane of, 409. of Pelvis, 450. varieties of, 450. of Pregnancy, 437, 439. of Prostate gland, 410. of Rectum, 410. of Scalp, 408. (fatty), 423. (sebaceous), 423. of Spine, 454. varieties of, 454. of Testicle, 410. (fibrous), 259. of Tongue, 408. of Trunk, 410. of Thyroid Gland, 409. of Uterus, 410, 436. fibroid, 438. of Veins, varicose, 3. of vessels, 409. on Artery. 23. Ovarian, 449. solid, 441. Sanguineous, 407. Sebaceous, 132, 424. (true), 407. solid, classification of types, 406. solid, types of, 405. Urethral, 317, 324. Uterine (fibroid), 441, 443. Tunica Vaginalis, diseases of the, and of Sper- matic Cord, 273. Trunk, Fractures of, 246. INDEX. 471 Trunk. Tumors of, 410. Typhi Lis, 84;i. 3.50. Thyroi 1 i.laiid, Tumors of, 409. Tuyroid Hernia, 3i3. U. Ulna, Fracture of the, at the elbow, 220. Fracture of the, at Conoid Process of, 223. Fracture of the Olecranon Process of, 223. 224. Fracture of the upper end of the, 225. Fracture (transverse) of, above the wrist, 231. separation of Epiphyses of, 230. Ulnar Aneurism, 18. Ulcer or IAlckhs. Chancroidal, 313. Local, 313. of the Amis, 339. Syphilitic, 313. \ enereal, 326. Ulceration, 288. Lupoid, 395. Urethra, diseases of the, 313. diseases of the, affecting structure of it3 Coats, 313. foreign bodies in the, 319. inflammatory diseases of, 313. Rupture of the, 316. Rupture of the, in membranous portion, 321. Rupture of the, in front of Scrotum, 322. Rupture of the, in front of Triangular Liga- ment, 321. Rupture of the. within the Triangular Lig- ament, 320. Stricture of, (organic), 312, 313, 323, 324. (congestive), 318. (spasmodic), 318. Urethral Abscess, 317. Calculi, 318. Deformities, 317. Dilatation, 316. Fistulae, 317. Inflammation, 50. Spasm, 318. I'u mors, 317, 324. Urethritis, 313. Uteru.-. Congestive Hyperaemia of, 437. Inversion of, 45-3. Tumors of, 410, 436. (fibrous), 438. (fibroidi, 439. Umbilical Hernia, 340. 372. Urine, conditions impeding the normal exit of, and independent of structural changes, 318. Incontinence of, 303 Retention of, 301, 302, 303. Suppression of, 302. V. Vaginal Hernia, 340. Varicocele, 277, 281, 348, 361. causes of, 278. of the Spermatic Cord and Testicle, 277. Varicose Aneurism, 8. Varix, 20. Aneurismal, 7, 8, 36, 41. Varix, Arterial, 7. of Saphenous Vein, 349, 369. Vegetations o enereal), 326. Via* or Vein.'. Atrophy of, 17. Calcification of, 17. Calculi of, 21. Degeneration of (amyloid). 18. (cancerous!, 18. (fatty), 17. diseases of, 3, 17. Inflammation of (adhesive), 3. (suppurative), 3. Innominate, resultol'pressureupon, 13. obstruction to, from Emboli, Thrombi, etc., 3. Parasites o1, 3, 21. Tumors of (varicose), 3. Varix of Saphenous, 349, 369. Vaiice.i of,22. Varicose, 20, 42. Venereal Sores, ,''26. Ulcers, ::2li. Venous Coats, Atrophy of, 3. Degeneration of, 3, 17. li, pei trophy of, 3, 17. Ventral Hernia, 340. 347. 372. Vertebras, Fractures of the. 246. Vesical Calculi, appearance and consistency of, 292. diagnosis of, 291. etiology of, 291. number of, 293. shape of, 293. sympti ms of, 293. Vesical Walls, Suppuration of, 288. Vessels, Atheroma of, 43. Degeneration of (cancerous), 43. (fatty),:., 43. diseases affecting calibre of, 3, 7. Exposure of. 9. Tumors of. 409. Viscera, Abdominal Hernia of, causes of, 342. Abdominal Hernia of, exciting causes of, 344. Abdominal Hernia of, predisposing causes of, 342. Volvulus, 337. W. Warts, Venereal, 326. Wounds of the Abdomen, 335. :&&.*■ NLM005545693