ES&,- WWW!****'"* 'i y&,j£Z NLM 0055M571 T SURGEON GENERAL'S OFFICE LIBRARY Section Form 113c No. \V. D.,S. G.O. .JJA3.Z3. NMENT PRINTING OFFICE ■/✓••■s ••- NLM005545719 A PRACTICAL TREATISE SURGICAL DIAGNOSIS DESIGNED AS A MANUAL FOR PRACTITIONERS AND STUDENTS IN MEDICINE AMBROSE L. RANNEY, A.M., M.D. / > t Peofessob of Pbactical Anatomy in the N. Y. Pobt-Geaduate Medical School; Late Adjunct Pbofessok of Anatomy and Lectubeb on the Subgical Diseases of the Genito - Ubinaby Obgans and on MlNOE StTBGEBY IN THE MEDICAL DEPARTMENT OF THE UN1VEB8ITY OF THE ClTY OF NEW YoBK ; late subgeon to the northwestern and nobthebn dispensaries.; resident fellow of the New Yoek Academy of Medicine ; Membeb of the Medical Society of the County of New Yobk ; Authob of "The Applied Anatomy of the Nebvotts System," " Pbactical Medical Anatomy." etc. THIRD EDITION-THOROUGHLY REVISED, ENLARGED, AND PRO- FUSELY ILLUSTRATED. '■.....T .•, -' NEW YORK WILLIAM WOOD & COMPANY 1884 1684- COPYRIGHT 1884, By William Wood & Co. TO THOSE PROFESSIONAL FRIENDS WHO HAVE SPRUNG UP AROUND ME DURING MY EARLY LITERARY EFFORTS, AND WHO HAVE KINDLY AIDED ME IN MY LATER CONTRIBUTIONS BY THEIR VALUABLE COUNSEL, SUPPORT AND ENCOURAGEMENT &jjis Moxk xb g&ieafeb BY THE AUTHOR. PEEFACE 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 THE 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 him 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. 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, tor perspicuity, have been forced to frequently duplicate the symptoms of many of them. In this volume all questions of etiology, pathology and treatment have been purposely omitted, as they have no direct bearing upon diagnosis, and therefore do not properly appertain to it. Each differentiation is, in most instances, so arranged as to allow the symptoms of each to be reviewed separately by reading from above, downwards; while by reading across the page the points of contrast become prominent. The "Common Symptoms" written below each differentiation explain, in general, the possible causes of error in diagnosis. At the close of this volume will be found enumerated under the head of bibliography those authors to whom I am indebted for many statements advanced and from whom occasional extracts have been given. I have adopted this method of acknowledgment since the arrangement of disease in a tabulated form precludes the frequent interpolation of authorities. Confusion would thus often result un- less explanatory paragraphs were also inserted and the object of marked contrast in symptoms would be thus thwarted. If I succeed in placing before students and the medical profession at large a work whose system and arrangement will probably be its chief recommendation, the object of this volume will have been ac- complished. loG Madison Avenue, ■ January, 1879. J Vll PREFACE TO THE THIRD EDITION. The adoption of this work by several medical colleges as a text- book, and the encouraging support which it has also received from the profession at large, have prompted the author to increase its scope, and, in addition, to eliminate all errors in the edition now ex- hausted, to which his attention has been called. The improvements which have been made comprise the addition of two chapters upon the diseases of the Brain and Spinal Cord and their Envelopes, and a most careful revision of the previous chapters. In the two new chapters, the desire of the author has been to present in an accessible form the chief points which are essential to an accurate diagnosis and localization of the more common lesions. The difficulties of the task have been greatly enhanced by the neces- sity of condensation. The author would refer those readers who desire more anatomical information upon these subjects to his work, "The Applied Anatomy of the Nervous System," and also to various articles which he has published in the Journal of Nervous and Mental Diseases, the Medical Record, the New York Medical Journal, and the Archives of MediAne. The author takes pleasure in expressing his deep obligation to those medical instructors who have made suggestions, from time to time, regarding additions to, or modifications of his work, which a continued use of it as a text-book in their classes had brought to their minds. The publishers have kindly granted the author the privilege of illustrating this edition. Some of the cuts are original, but the majority have been selected from the later works upon surgery and nervous diseases. They have been arranged to suit the descriptive text, as far as it was possible, without destroying the plates of the previous edition. It is hoped that they will add to the value of the work. Dr. J. Lee Richmond has kindly assisted the author in the revision of the proof and the preparation of the index. 156 Madison Avenue, N. Y. City, December, 1883. 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 intrathoracic 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 naevi, 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. Gonorrhceal synovitis (gonorrhceal rheumatism), its causes and symp- IX X 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, beaded 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, Cvstic tumors of the antrum, Malignant tumors of the antrum, Extra-cranial tumors Intra-cranial tumors, Exostoses of the cranium.......... p Q7 1Q~ CONTENTS XI 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 anklo and a severe sprain, Dislocation at ankle and a previous deformity associated with injury............................................Pages 133-186 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 onlv, Fracture of outer and inner tables only, Fracture of inner table only, and apoplexy with complicating injury, Fracture of the base of xii CONTENTS the skull and cerebral concussion. Cerebral compression and cerebral concussion II. Fractures of the upper jaw. Ill 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. Differentia] 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 condyles of 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 ulna, Transverse fracture of humerus and dislocation at elbow joint. VI. Fractures near the wrist joint. Varieties of, and their location. Differential diagnoses between Colles' fracture and dislocation of the wrist, Fracture of both bones near wrist and dislocation of carpus, Separation of the epiphyses and dislocation of the carpus, Colles' fracture and transverse 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 genera] 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. Hamiatocele 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. Atrophy of testis. Incomplete descent of testis. Calcareous deposit of testis. Differential diagnoses between acute orchitis and neuralgia of the testis, Syphilitic orchitis and tubercular orchitis, Malignant orchitis and syphilitic orchitis, Cysts of testicle and hydrocele, Benign fungus of testis and cancer of testicle with fungous growth Orchi tis and epididymitis. Diagnostic table of the four principal enlargements'of the testicle. II. Diseases of Hie tunica vaginalis and the spermatic cord Simple hydro CONTENTS. xm 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 hamiatocele. 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 fistula?. 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, Fistula? 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- xiv CONTENTS. tive diagnosis. Table of diagnoses of inguinal hernia. Diagnoses of femoral hernia. Differential diagnoses between typhilitis and perityphlitis, External hemor- rhoids and internal hemorrhoids, External hemorrhoids and condylomata of anus, 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 hematocele, Incomplete in- guinal hernia and bubo, Bubonocele and undescended testicle, Inguinal hernia ar.d 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, Congenital 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 cephalsematoma, 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 mamma?, Scirrhus of the breast and innocent tumors of the breast. Tumors of the Uterus : Classification. Differential CONTENTS. XV diagnoses between congestive uterine hyperemia 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 hsematocele and extra-uterine pregnancy, Vaginal polypus and inversion of the uterus, Pelvic hematocele 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 PAET IX. DISEASES OF THE BEAJN AND ITS EN- VELOPES. Table of the more important conditions. The chief symptoms of brain diseases. Con- genital malformations of the Brain. Diseased conditions of the Cerebral vascular apparatus : Aneurismal dilatations; Atheroma, Spontaneous perforation, Cerebral thrombosis, Cerebral Embolism, Infarction. Inflammatory conditions of the Brain and its Envelopes: Pachymeningitis, Arachnitis, Hydrocephalus, Encephalitis. Degenerations of the Brain substance : Cerebral softening, white, red, and yellow; Sclerosis of the Brain, Cerebral atrophy. Tumors of the Brain and its Envelopes. Special symptoms indicative of Brain lesions. Motor paralysis : Cortical paralysis, from irritation and destructive lesions, Hemiplegia, Crossed paralysis, its various types, Complete paralysis, sensory paralysis: Affecting cranial nerves, Affecting spinal nerves, General symptoms, Hemianesthesia, Numbness, Formication, Hyper- esthesia, Hemianopsia, Aphasia, its varieties and tests. Practical, clinical, and physiological deductions concerning lesions of the Brain and the cranial nerves. Lesions of the Olfactory nerve : Anosmia and crossed paralysis. Lesions of the optic nerve : Amblyopia, Hemianopsia, Crossed paralysis, Choked disc, with hemianesthesia, facial paralysis, hemiplegia, and aphasia. Lesions of the Motor oculi nerve: Ptosis, internal squint, crossed paralysis. Lesions of the fourth cranial nerve. Lesions of the Trigeminal nerve, axioms of diagnosis pertaining to them. Lesions of the Facial nerve : Axioms pertaining to the diag- nosis of Facial paralysis. Lesions affecting the cranial nerves and nerve-tracts of the medulla oblongata: Duchenne's disease, Cheyne-Stokes respiration, general symp- tomotology. Lesions of the Cerebral cortex : Motor area of brain, monoplegia, early rigidity, pain, convulsions, aphasia. Lesions of the internal capsule of the Brain : hemiplegia, hemianesthesia, impairment of special senses, choked disc, con- jugate deviation of eyes, choreiform movements, rise in temperature, late rigidity of muscles. Lesions of the Optic Thalamus : Its four centres, Effects upon smell, Effects upon sight, Effects upon hearing, Effects upon general sensation, Effects upon hallucinations. Rules governing the use of the trephine. Differential diag- noses: Cortical paralysis and non-cortical paralysis, Irritative and destructive lesions of the cerebral cortex, Crossed paralysis of olfactory nerve and trigeminus nerve, Crossed paralysis of the motor oculi and the facial nerves, Bilateral facial paralysis, and Unilateral facial paralysis, Cerebral motor paralysis and Tabes dorsalis, Cerebral embolism and Cerebral thrombosis, Aphasia and Glosso-labio-laryngeal paralysis, xvi CONTENTS. Cerebral softening and Cerebral abscess, Internal pachymeningitis and Externa. pachymeningitis, Cerebral tumors and Cerebral softening, Cerebral hemiplegia and Spinal hemiplegia, Cerebral sclerosis and Paralysis agitans : Auditory vertigo and Epilepsy, Chronic hydrocephalus and Congenital hydrocephalus___Pages 461 to 539 PAET X. DISEASES OF THE SPINAL COED AND ITS ENVELOPES. Table of the more important diseases of the spinal cord. Systematic lesions. Focal lesions. General axioms of spinal symptomotology. Physiological axioms pertaining to the spinal cord. Spinal paralysis, its varieties. Sensory phenomena due to spinal lesions. General symptomotology. Sclerosis of Tiirck's columns. Sclerosis of the lateral columns, its primary and secondary varieties. Myelitis of the Anterior Horns, Poliomyelitis of infants and adults, Infantile spinal paralysis, Acute spinal paralysis, Subacute poliomyelitis, Chronic poliomyelitis. Amyotrophic lateral sclerosis. Progressive muscular atrophy. Pseudo-hypertrophic paralysis. Central myelitis, Sclerosis of the posterior columns: Progressive locomotor ataxia, Tabes dorsalis, The pains, abnormalities of sensation, symptoms of incoordination, various complications, spinal reflexes, etc. : Focal lesions of the spinal cord, Gen- eral symptomotology, The superficial spinal reflexes, The deep or tendon-spinal re- flexes, Knee-jerk, ankle-jerk, foot-clonus, peroneal reflex, front-tap contraction, axioms of the clinical value of the spinal reflexes. Sensory phenomena in focal le- sions, rigidity and spasm of muscles, bodily temperature and sweating, nutrition of the tissues, effects upon the special centres of the spinal cord, Guides to the different levels of the spinal cord. Focal lesions of the upper cervical region. Focal lesions of the cervical enlargement of the cord. Focal lesions of the mid-dorsal region of the cord. Focal lesions of the spinal cord above its lumbar enlargement. Focal lesions of the lumbar enlargement of the spinal cord. Focal lesions confined to one lateral half of the spinal cord. Spinal hemiplegia, Hemi-paraplegia, Differential diagnoses. Lateral spinal sclerosis, of cerebral and spinal origin ; Lateral sclerosis, primary and secondary; Poliomyelitis, acute and subacute; Poliomyelitis and Progressive muscular atrophy, Progressive muscular atrophy and Lesion of the ulnar nerve, Tetanoid paraplegia and Locomotor ataxia, Locomotor ataxia and the general paralysis of the Insane, Pseudo-hypertrophic paralysis and Locomotor ataxia, Paralysis agitans and Cerebro-spiual sclerosis, Organic paraplegia and Func- tional paraplegia, Myelitis and spinal meningitis, Spinal meningitis and Tetanus, Reflex paraplegia and Myelitis, General paralysis and Syphilitic general paraly- sis............................................................Pages 539 to 593 Bibliography Pages 593-596 LIST OF ILLUSTRATIONS. PLATE I.—Page 8. Original Source. Varicose aneurism........................................ Chas. Bell Aneurism by anastomosis..................................... Erichsen Aneurism at elbow........................................ Hamilton Subclavian aneurism........................................ " Limits of pulsation in early stages of innominate aneurism....... Barwell Subclavian aneurism. ....................................... " Plate II.—Page 14. Aneurism of thorax..........................................Barwell Popliteal aneurism ...................................... .. " Thoracic aneurism involving vertebre .... Charing Cross Hospital Museum Plate III.—Page 52. Ostitis of knee with luxation................................. Barwell Hydrarthrosis of knee........................,.............. " Arthritis of knee with ostitis......................... ........ " Knock-knee or genu-valgum.................................. " Housemaid's knee (double)................................... " Arthritis of ankle.................................••......... Enchondroma of phalanges.................................. Hamilton Plate IV.—Page 60. Caries and necrosis of tibia....................................Barwell Bow-legs.................................................... Strumous arthritis of elbow................................... Spinal curvatures (four cuts).................................Hamilton Plate V.—Page 74. Strumous synovitis of knee....................................Barwell Anchylosis of knee............ ............................. Varieties of talipes (four cuts)..................... Sayre and Hamilton Plate VI.—I Flat-foot..................................................... Clarke Double talipes (two cuts)........................................fayre Arthritis deformans (two cuts)................................ Canton Scrofulous synovitis of ankle................................... Barwell Arthritis of wrist, with ostitis................................. Medio-tarsal deformity......................................... 8ayre xvii xviii LIST OF ILLUSTRATIONS. PLATE VII.—Page 102. Original Source Necrosis of skull-cap (two cuts).....................Army Med. Museum Puncture of skull-cap............................. " " " Caries of vertebre...........................................Hamilton Articular disease folltrwing fracture............................ Barwell Caries of acetabulum and femur.............................. " Plate VIII.—Page 114. Necrosis of skull................................. Army Med. Museum Malignant tumors of femur and tibia...........................Bennett Sequestrum............................................ ... Hamilton Necrosis with osteo-myelitis................................. " Malacesteon (two cuts)...................................... " Central necrosis, with an involucrum........................ " Plate IX.—Page 134. Osseous growths after fracture............................... Hamilton Osteophytes of femur............................,.......... " Rachitic pelves (three cuts).................................. " Chronic rheumatic arthritis of hip-joint........................ Barwell Fracture of neck of femur with bony union.................... Hamilton Fracture of neck of femur with cartilaginous union............ " Plate X.—Page 140. Sub-glenoid dislocation...................................... Hamilton Sub-coracoid dislocation..................................... " Dislocation of acromial end of clavicle........................ " Dislocation of sternal end of clavicle......................... " Sub-spinous dislocation of humerus.......................... " Plate XL—Page 146. Dislocation of clavicle.................... .................. Andrews Dislocation of jaw........................................... Hamilton Dislocations of humerus at shoulder.......................... " Colles' fracture............................................. " Dislocation of the phalanges................................. " Plate XII.—Page 162. Dislocations of carpus (two cuts)........ .................... Andrews Dislocation at elbow........................................ Hamilton Dislocation at hip (two cuts)................................. " Dislocation at knee..........................,............... Andrews Plate XIII.—Page 174. Attitudes of hip-joint disease (two cuts)........................ Barwell Dislocations of femur at the hip (three cuts)................... Hamilton Plate XIV.—Page 194. Varieties of fracture of the skull (six cuts).......... Army Med. Museum Hernia cerebri.............................................. Hamilton LIST OF ILLUSTRATIONS. XIX Plate XV.—Page 220. Ortgtsal Source. Fractures at shoulder (two cuts)..................... Hamilton and Cray Fractures at elbow (two cuts)................................Hamilton Fractures in region of ankle (two cuts)........................Andrews Plate XVI.—Page 268. Enlarged lobe of prostate gland.............................. Hamilton Stone in the bladder (three cuts)............................... Coulson Rectal fistulae (three cuts).........................Molliere and Oosselin Plate XVII.—Page 292. Urethral stricture (five cuts)................................... Oouley Hypertrophy of bladder....................................... Coulson Medullary tumor of bladder................................... " Sounding for stone in the bladder...........................Hamilton Plate XVIII.—Page 338. Rectal polypi (two cuts).......................;.............. Esmarch Prolapse of rectum ..........................................Molliere Internal hemorrhoids........................................ Hamilton Plate XIX.—Page 348. Hernia (four cuts)........................................... Hamilton Spina bifida............................................... Plate XX.—Page 392. Gangrene.................................................... Bennett Contents of a sebaceous cyst................................... Microscopical appearance of tumors (six cuts)................... Plate XXL—Page 468. Diagram of the subdivisions of the motor area of the brain....... Ranney Plate XXII.—Page 478. Diagram of the centres of the convolutions of the brain of man........................Modified slightly from Ferrier Diagram of a spinal segment, showing its subdivisions and the construction of each spinal nerve.............................Ranney Plate XXIII. — Page 482. Diagram explicative of hemiopia............................... begum Diagrammatic representation of the skin-symptoms produced by a uni- lateral lesion of the spinal cord.................................. Erb Disease of the anterior horns of the spinal gray matter.............Roth XX LIST OF ILLUSTRATIONS. PLATE XXIV.-Page 486. Original Source. Diagram of the course of fibres within the nerve of sight.........Ranney Diagram to show the relations of the nerve of sight to adjacent structures within the cavity of the skull...................... « Plate XXV.—Page 496. Diagram to show the course of nerve fibres within the substance of the brain................................................Ranney Diagram to show the important structures situated at the base of the brain.................................................. " Plate XXVI.—Page 540. Diagram showing the effects of a transverse myelitis................ Erb Diagram showing multiple sclerosis of the spinal cord.............. " Diagram showing changes in the spinal cord in locomotor ataxia..... " Diagram showing secondary descending degeneration of the spinal cord.......*.................................................. " Plate XXVII.—Page 544. Diagram of the nerve-tracts of the medulla........................ Erb Diagram of the nuclei within the substance of the medulla.......... " Diagram of the physiological subdivisions of the spinal cord in man...................................................... Ranney Plate XXVIII.—Page 548. Diagram of the course of the principal tracts of nerves within the spinal cord....................................................Erb Diagram of the decussation of the motor fibres within the substance of the medulla................................................ " Diagram of the sensory tracts of the spinal cord.................... " Plate XXIX.—Page 552. Bell's paralysis............................................... Ranney Attitude of hand in paralysis...............................Rosenthal Progressive muscular atrophy.......................... ___ << Cross-legged progression..................................Med% Record Plate XXX.—Page 556. Attitudes assumed in pseudo-hypertrophic paralysis............ Duchenne Infantile paralysis.........................................* Unknown Plate XXXI.—Page 560. Pseudo-hypertrophic paralysis confined to calves alone.........Duchenne Pseudo-hypertrophic paralysis affecting legs but not the trunk.. Erect attitude of spinal caries................................Aanew Stooping attitude of spinal caries.................... << DISEASES OF THE BLOOD-VESSELS. DISEASES OF THE BLOOD-VESSELS. The Diseases of the Arteries to which surgical attention is most frequently directed, are of two classes : A. Diseases of the Arterial Coats, under which will be con- sidered : 1. Atheroma. 2. Fatty Degeneration of the Arterial Coats. B. Diseases affecting the Calibre of Vessels, comprising: 1. Aneurism. 2. Occlusion of Arteries from Pressure. 3. " " " " Emboli. L " " " " 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 AKTEEIAL COATS. ATHEEOMA. 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. Diminished 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 THE 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 DEGENEKATION 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, cedema, 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 THE BLOOD-VESSELS. 7 B. DISEASES AFFECTING THE CALIBKE 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.EVUS, where the capillary vessels are ab- normally dilated, and extensive anasto- mosis exists. Arterial Varix, where a single vessel is uniformly dilated for some distance along its course. Aneurism classi- fied on a path- ological basis. 2 great types. A. Where all the coats of the vessel are intact. 5 varieties. Cirsoid Aneurism, where a collection dilated and tortuous vessels exists. of B. Where one or more of the ar- terial coats is rup- tured. 6 varieties. 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 tumc" 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 "Arteriovenous 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. f Thoracic. Abdominal. . Pelvic. i '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. PLATE I. 5 6 1. Varicose aneurism. 2. Aneurism by anastomosis. 3. Aneurism at elbow. 4. Subclavian aneurism of large size. 5. Usual limits of pulsation of innominate aneurism. 6 Subelayian aneurism. DISEASES OF THE BLOOD-VESSELS. 9 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 coeliac 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 THE BLOOD- VESSELS. 11 The former indicates a transmission of the throb from the centre of the tumor m every direction; the latter the transmission of a force externat 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-lst, 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.aUpossible positions hoth. 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 be 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 may be 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 may be 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 upivard 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 It 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. PLATE II. 3— 2 4 1. Aneurism of innominate, arch of aorta, and left carotid. (1, Arch of aorta; 2, Laminated fibrin from interior of aneurism; 3, Cavity of aneurism; 4, Right carotid; 5, Right subclavian* d, Left carotid; 7, Left subclavian.) 2. Popliteal aneurism causing deformity of knee. 3. Aneurism of the thorax causing caries of the vertebrae. DISEASES OF THE BLOOD-VESSELS. 15 OCCLUSION OF AETEBIES. 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 this 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 THE 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. ATEOPHY 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 S URGICAL D1A GNOSIS. 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 THE 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 ivith 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. (Edema 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 THE 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 THE 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 IJV COMMON. Both may pulsate and yield a bruit on auscultation. " " produce shooting pains along the course of nerves. " " " stiffness in muscles, and muscular weariness. "■' " " impaired motion in joints, if so situated. " " " absorption of bone, caries, or necrosis. 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 THE BLOOD-VESSELS. Xb 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 eel- 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 pain 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 cedema- 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. " " pain. (< (( it DISEASES OF THE BLOOD-VESSELS. 2"! 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. " i( " " 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. 11 may be apparently unassociated with a tumor. Pulsation and bruit may be undetected possibly in both. DISEASES OF THE 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-THORACIC TUMORS. Location of Tumor. The tumor is always located in The tumor may possibly be situ- the course of the aorta. ated away from the direct track of large vessels. Density of Tumor. Tumor is only moderately resis- The tumor is usually hard and tant to pressure. markedly resistant to pressure. Auscultatory Signs. A bruit is heard over the tumor, No bruit is present, unless the on auscultation. tumor is in close relation to some large vessel. Percussion. The area of dulness on percussion The 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 THE 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 dulness 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 THE 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 THE 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- torn. 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. " " " " pulsation. " " " " 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 THE 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. a << " « « " " 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 THE BLOOD-VESSELS. 39 CIRSOID ANEURISM. N^EVI. Origin of Tumor. The tumor is seldom congenital. The tumor is usually congenital, but may develop even after puberty. Location of Tumor. The tumor is seldom sub-mu- The tumor may be either sub- cous in situation. mucous, or sub-cutaneous in char- acter. The tumor is most frequent upon The tumor is most frequent upon the scalp. the face. Appearance of Tumor. The tumor is knotty and irregu- The tumor may be markedly ele- lar in shape. vated or flattened, but is uniform in appearance. Auscultatory Sounds. A "bruit" is detected, but has A peculiar "cooing noise" is simply a blowing quality. often detected in auscultation. Pulsation. Pulsation is usually detected on Palpation often perceives a pecu- palpation. liar " vibratory thrill." SYMPTOMS IN COMMON. Both are associated with a tumor. " " pulsation. " " bruit. " " altered color of skin. " " elasticity and soft consistence. " " alteration in the appearance of tumor on im- peding venous return. 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 cedematous from a rule. pressure on the vena cava. Appearance of Thorax. The bulging of the chest wall The bulging of the chest wall, if over the tumor is often located on present, is confined to the right side the left side, 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 THE 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" \s harsh in charac- The pathognomonic "buzzing ter, and is heard most distinctly fremitus" exists, and is widely dif- over the intervening sac. fused. It is seldom carried into the vein. It is equally detected in both vein and artery. SYMPTOMS IN COMMON. Both yield a "vibratory thrill" on palpation. " " " venous pulsation. " are associated with change in the color of adjacent skin. a « « " defective venous return (often). tt « tt <( 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 prcs- 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. " " " of ten with pain over seat of tumor. " " " " " impaired usefulness of limb. " " " " " " venous return. DISEASES OF THE 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. a c< a tt a dilatation of vessel at the affected portion. a a a a « tortuosity of the vessel. a a tt a a impaired nutrition to tissues when excessive arterial supply is de- manded, as in inflammation. it a it tt (i local gangrene. a tt a n tt local oedema. a a a f " 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 THE 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. " " " " " oedema. a a a a a prominence of neighboring veins. DISEASES OF THE JOINTS. DISEASES OF THE JOINTS. The surgical Diseases of the Joints may be thus enumerated A. Inflammatory Diseases. 1st. Of the synovial membrane : " Syno- - vitis." 9 varieties. Acute. Subacute. Chronic. Scrofulous. Rheumatic. Gouty. Pyaemic. Gonorrhceal. Syphilitic. Acute. Chronic. Rheumatic. _ Syphilitic. 2d. Of the general structures entering into the formation of a joint: "Arthritis." 4 varieties. ■~ . . ,. (1. Fibrous. B. Anchylosis—varieties, < 0 ^ ' ( 2. Osseous. 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 acide 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, pyo?mia, as occurs often after operations, severe injuries, parturition, etc.; 5th, syphilis ; and 6th, urethral inflammation of an acute gonorrhceal 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, pycemic, gonorrheal, and syphilitic. DISEASES OF THE 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 sufficiently 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 wave 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 superficfally 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 DIAGNOSIS. 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, to over-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. PLATE III. 1. Ostitis of condyles with posterior luxation. 2. Hydrarthrosis of knee. 3. Arthritis with ostitis. 4. Knock-knee or genu-valgum. 5. Housemaid's knee (double). 6. Arthritis of ankle-joint, with ostitis of astragalus, as compared with the healthy ankle. 7. Enohondroma of the phalanges. DISEASES OF THE 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 rather 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. Bheumatic 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 THE 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. Gonorrhceal Synovitis. Sir Benj. Brodie first described this disease under the name of gonorrhceal 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 the 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 being most apparent where the erosion of the cartilages has occurred. All the DISEASES OF THE JOINTS. 57 ligaments and surrounding tissues are liable to participate in the destructive process, and to become either thickened by plastic mate- rial or infiltrated with pus. Arthritis may be either acute ; chronic ; rheumatic in its origin; or dependent upon syphilis. It may result from wounds of joints, from sprains, from fractures in the vicinity of joints, from diseases of the bone (as in caries or necrosis), from extension of inflam- mation from outside tissues, from the progressive development of an acute synovitis, and from pyaemic and scrofulous conditions. It may also occur in certain blood conditions which favor the de- velopment of inflammation, as in renal disease, certain fevers, and when poisons are present in the circulation. The diagnostic symptoms of arthritic inflammation are : (1.) Pain.—In the acute form, this pain is often excruciating. It is throbbing in character, is greatly increased by movement, and, in many cases, examination of the limb without the aid of anaesthetics is impossible. The pain is usually associated with nocturnal exacer- bations, and is often confined to one special locality within the affected joint. All attempts to approximate the diseased articular extremi- ties increases the pain, while extension of the parts sufficient to separate the bony surfaces of the joint often affords the greatest relief. Spasms, or startings of the limb, which are of a very painful and distressing character, occur at times, chiefly in the night, and are created by a reflex muscular act, causing a close approximation of the diseased surfaces of the joint. (2.) Local heat within the joint.—Arthritic disease is usually asso- ciated with a marked increase in the local, and possibly in the gen- eral temperature; and is accompanied, as a rule, by a superficial reddening of the integument. This elevation of temperature is most marked in the acute form, and least of all in the rheumatic type. (3.) Swelling.—The swelling in arthritic disease is uniform over the affected joint, and differs, in this respect, from all forms of synovitis, save the scrofulous variety; since, in them, the synovial pouches alone are prominent. It is seldom excessive until suppu- ration is in active progress, and usually gives to the touch a soft, doughy sensation without much elasticity or fluctuation. As pus forms, or when the synovial fluid is rapidly augmented, the joint may increase in size with great rapidity and yield distinct fluctuation over the points where the fluid approaches the integu- ment. (4.) Position of the limb.—-In arthritic disease, as in synovial in- 5S SURGICAL DIAGNOSIS. flammation, the position of the limb is altered from its normal atti- tude in such a way as to afford the greatest ease to the inflamed joint. Thus the knee, if affected, is usually semiflexed and turned outward; the thigh is adducted, in case the hip be diseased and the capsule not perforated; and the forearm is bent upon the arm, if the elbow be involved. (5.) Constitutional disturbance.—A marked increase in the tempera- ture and pulse is usually present in the acute form of arthritic in- flammation. As suppuration develops, rigors are frequent, and symptoms of exhaustion from pain and loss of rest may, in some cases, rapidly ensue. Hectic, and symptoms of general nervous irritation, may precede or accompany those of exhaustion; and death has not infrequently relieved the sufferer, if surgical assist- ance has failed to successfully combat the disease. (6.) Local Symptoms.—In addition to pain, heat, and redness of the part, local swelling, and an abnormal attitude of the limb, arthritis, in its severer forms, is gradually followed by symptoms indicating a rapid disorganization of the joint. The accumulated pus at length finds escape externally, and sinuses remain to drain the open joint. The bones grate upon each other, giving great suffering to the pa- tient ; the ligaments no longer retain the bones in their proper posi- tion, and an excessive mobility is perceived. Caries and necrosis attack the bony structures; ulceration enlarges the openings formed by the escape of pus; and the imperfect return of venous blood causes extensive cedematous infiltration of the soft tissues, and gives to them a dark purplish color. In this condition, anchylosis is in many cases the best prognosis which can be extended by the surgeon. CHRONIC RHEUMATIC ARTHRITIS. This condition has been described under the terms " nodosity of joints," " rheumatic gout," " chronic rheumatism," " morbus coxae senilis," and " chronic osteo-arthritis." It may affect both the large and the small joints of the body. It probably commences as a chronic inflammation of the synovial mem- brane, and may be produced either by a constitutional condition following rheumatic fever or exposure, or as a local affection attrib- uted to over-exertion, or some injury. The larger joints are more frequently affected in males ; while, in the female sex, the smaller joints, especially those of the fingers, are more often implicated. It is more frequently met with in advanced DISEASES OF THE JOINTS. 59 life, although it is occasionally present in youth. It affects all con- ditions of life, but has a more gouty character when present among the opulent and indolent classes. It is essentially chronic in its course, and, as a rule, progresses steadily when once developed, until the affected joints become to a greater or less extent useless and disorganized. This disease occasionally exhibits periods of temporary quies- cence, and may remain stationary for an indefinite length of time ; but it is seldom permanently arrested in its progress. It is manifested during life by pain, which is chiefly experienced at night or upon attempts at motion after long intervals of rest to the affected joint, and which is of an aching character; by enlarge- ment and ultimate deformity of the joint; by rigidity and stiffness in the articulation; and by a peculiar crackling noise, which is occasionally heard when the affected joints are used. Cold and dampness increase the symptoms, especially the pain, and often render rest almost impossible. There is little or no tendency toward suppuration, nor does ab- solute anchylosis often occur; although the affected joints may sim- ulate that condition. Bony outgrowths frequently develop upon the articular surfaces of the joint, and, by their mechanical impedi- ment, often greatly impair its function. In cases where the motion of the joints affected is greatly inter- fered with, the muscles of that region may undergo atrophy from disuse. The peculiar crackling noise which often follows attempts at motion, especially after the joint has been in a state of rest, is often audible both to the patient and the surgeon, and is produced by the rubbing together of the altered bony surfaces. This symp- tom is most frequently well marked in the hip-joint, and can be best perceived in the morning on the patient attempting to arise. Chronic rheumatic arthritis does not appear to shorten the actual duration of life, but in severe cases it frequently renders the person afflicted incapable of support, and even in a state of utter helpless- ness. It is very frequently developed in the hip and knee joints to a marked degree; and, in the joints of the fingers, it is by no means uncommon. When the affected joint is superficially situated, the peculiar bony growths, having the appearance of irregular knots, are hardly to be confounded with any other known affection. GO SURGICAL DIAGNOSIS. ANCHYLOSIS OF JOINTS. By Anchylosis is meant an abnormal rigidity of a joint. Anchy- losis may be of two varieties, true and/afee. True anchylosis, which is also called synostosis, includes all varieties of fixation of joints where union of the contiguous surfaces occurs through bone-tissue. Ealse anchylosis may be either of the intra-capsular or the extra- capsular variety, and signifies a fixation of a joint through the inter- vention of fibrous bands or adhesions. In true or osseous anchylosis, the joint is, as a rule, permanently destroyed ; although, in rare cases, the bony deposit is found to lie entirely outside of the articulation. Impaired mobility of a joint may, however, be occasionally inde- pendent of either true or false anchylosis. Thus, in chronic rheu- matic arthritis, the bony growths upon the articular surfaces of the joint may act as mechanical impediments to its normal power of movement; old cicatrices may also so impair the motion of a joint as to simulate an anchylosed condition; and muscular contraction may produce the condition of "articular rigidity," which is to be differentiated from anchylosis. Anchylosis, whether it be of the true or false variety, usually re- sults from an inflammation within the affected joint, which has to a greater or less extent led to a destruction of its component parts, and which has subsequently been followed by a reparative process. In a few isolated cases, however, anchylosis of some of the minor joints may be met with in advanced life without any such obvious cause being discovered to account for its presence. When the hip or shoulder joints are apparently affected with anchylosis, care should be exercised lest the increased mobility which may occur in the pelvis, or at the scapula, be not mistaken for motion in the articulation. In subsequent pages, at the close of this chapter, will be found enumerated the points of distinction between osseous and fibrous anchylosis of joints, arranged in contrast as an aid to memory and reference. DROPSY OF JOINTS. (Hydrarthrosis.) This condition consists of an increase in the synovial fluid of a joint, without symptoms of inflammatory processes being present. It has been described under the name of " hydrops articuli," and has been compared to those conditions of serous membranes, where a PLATE IV 1. Caries and necrosis of tibia. 2. Bow-legs. 3. Strumous arthritis of elbow. 4. Lordosis. 5. Double lateral curvature. 6. Kyphosis. 7. Quadruple lateral curvature. DISEASES OF THE JOINTS. 61 deposit of fluid is present without apparent cause or marked symp- toms, as in hydrocele. It is in reality, however, associated with some structural changes within the lining membrane of the joint, and the fluid, when drawn by an aspirator, differs markedly from the normal synovial secretion, resembling rather that of ascites or hydro- cele. This disease is most frequently found in the knee and elbow joints. It is usually the result either of a previous synovitis, or of a weakened and depressed vital condition when exposed to some ex- citing cause, as cold, exposure, or slight violence. The fluid usually forms with considerable rapidity, and the joint presents the peculiar deformity produced by distention of its synovial pouches. Pain may be entirely absent, motion may be normal or only slightly impaired, and the skin may exhibit no redness or oedema. Fluctuation is usually a well-marked and diagnostic symptom, and can be, as a rule, most positively perceived by placing the hands upon the anterior and posterior of the joint, thus avoiding any mistakes of sensation through displacement of muscles or ten- dons. Dropsy of joints should be differentiated from abscess of joints, and from scrofulous synovitis. ARTICULAR NEURALGIA. This condition may occur in conditions of general nervous de- pression ; from sympathy with some abnormal condition of organs; from injury to, pressure on, or irritation of nerves, or degenera- tions of nerve trunks; from concentrated attention to a part, with imaginary or real anxiety concerning it (as occurs often in those of a hysterical temperament); from local causes; and from cer- tain blood conditions, as in rheumatism, gout, pyaemia, etc. In this condition, the pain is out of proportion, as a rule, to the apparent lesion at the affected joint. This pain may be distinctly circumscribed, or, possibly, diffused over a large area. It may be periodical or exacerbating; and may often be absent during sleep or when the attention is diverted from the seat of disease. This pain is not usually increased by firm pressure exerted from a distance upon the articular surfaces of the joint, although oc- casionally a fine crepitation may be detected, which is situated near the surface, and which differs markedly from the grating crepitus perceived when the cartilages of a joint are eroded. 62 SURGICAL DIAGNOSIS. Exaggerated tenderness of the joint, especially in the integumentary structures, is a frequent symptom of this affection. The swelling about the affected joint is usually limited in amount, and is rather superficial to the joint than within its cavity. It is due, as a rule, either to the increased amount of blood in the capil- lary vessels, or to a slight infiltration of serum into the subcutaneous areolar tissue. Spasmodic or convulsive action of the muscles is sometimes de- veloped in the course of this disease, if movement be attempted; and a rigid condition of the joint may, occasionally, be found to exist, in which case the affected joint is usually in an abnormal attitude. This rigidity is due to muscular contraction however, as can be easily demonstrated by the administration of an an- aesthetic, when the joint will admit of free and perfect motion. LOOSE CARTILAGES IN JOINTS. These bodies are more frequently met with in adult life than in youth. They consist of white or yellowish bodies, and may be either of soft consistence, or hard and glistening in character on removal. They are usually attached to some portion of the joint, and are probably developed in the vascular processes of the syno- vial membrane. They vary greatly in their size ; some being no larger than a small kernel of corn, while, in rare cases, they may nearly equal the patella in size. They are either round, oval, flattened, or nodulated in form, and vary in number from one to twenty or thirty in a sin- gle articulation. They are most frequently present in the knee-joint; and least in frequency, of all the large joints, in the hip. They contain a few cartilage cells, are often covered with epithelium, and, occasionally, are partly osseous in character; but, in the majority of cases, they are chiefly fibrinous. Loose cartilages do not always occasion symptoms. When caught between the articular ends of the bones by some sudden movement, a violent pain is generally produced, and an inability to control the limb results until dislodgement either spontaneously takes place or is effected by mechanical means. Syncope often occurs from the severity of the pain which accom- panies such a condition. This pain is due, in all probability, rather to the stretching of the ligaments by the wedge-like action of the DISEASES OF THE JOINTS. 63 foreign body between the bones than to compression of the loose cartilage. After one such attack has occurred, repeated attacks are liable to follow without any apparent exciting cause. In the following pages will be found contrasted the prominent points of diagnosis pertaining to acute synovitis, scrofulous synovitis, hydrarthrosis, acute arthritis, chronic rheumatic arthritis, syphilitic periostitis in the vicinity of joints, suppuration external to joints, fibrous anchylosis, bony anchylosis, and articular neuralgia. 61 SURGICAL DIAGNOSIS. I. DISEASES OF JOINTS IN GENERAL. SYNOVITIS. RHEUMATISM. Is usually a purely local inflam- Is a disease dependent on an ab- mation independent of any blood normal state of the blood. condition. Locality. Is a unilateral affection as a rule. Is generally a bilateral affection. One joint only is affected. Several joints are usually involved simultaneously. Swelling. The swelling about the joint is The swelling about the joint is irregular, and due to the distension uniform, if severe. of the synovial pouches. Integument. The integument over the affected The integument over the affected joint is usually normal. joints is usually reddened. Secretions. The secretions are normal in re- The secretions are usually strong- action, ly acid in reaction. Pain. The pain is only of moderate se- The pain in the affected joints is verity. often excessive. Heart. Heart complications are seldom Heart complications are frequent- present ; if present they are of in- ly the result of the abnormal blood- dependent origin. condition. Temp, and Pulse. The constitutional disturbance is The constitutional disturbance is generally slight, unless the acute often alarmingly severe. variety exists. DISEASES OF THE JOINTS. Go SCROFULOUS SYNOVITIS. HYDRARTHROSIS. Age Affected. Is usually a disease of youth. May occur at any age. Pain. The pain is at first slight and Pain may be present in the early often remote from the seat of ac- stages, if the disease is of inflam- tual disease. matory origin, but is often absent. In the latter stages, however, the A sense of distension within the pain becomes local and severe; is joint is, in the advanced stages, worse at night, and is increased by more often the only source of dis- impinging the articular surfaces of comfort. the joint. Appearance of Joint. The normal bony prominences of The normal bony prominences of the joint are concealed, and the the joint are still apparent, but the hollows normal to the joint are ef- synovial pouches are distended, faced. rendering them prominent. Motion. The normal movements of the Motion of the affected joint is joint are impaired. only slightly embarrassed. Skin. The skin over the affected joint The integument over the joint is is milky-white in color, shiny in of normal appearance. appearance, and the blue veins on the surface are apparent. Sinuses. Sinuses form in the latter stages. Sinuses seldom, if ever, exist. Crepitation. Crepitation appears as the joint Crepitation is absent, if no corn- undergoes disorganization. plications are present. Palpation of Tumor. The tumor is soft, doughy and The tumor is fluctuant, and elas- fluctuant before sinuses form. tic to the touch. History of Patient. History of scrofulous diathesis History of traumatism, rheuma- exists. tism, syphilis, etc. 66 SURGICAL DIAGNOSIS. ACUTE ARTHRITIS. CHRONIC RHEUMATIC ARTHRITIS. (Rheumatic Gout.) Pain. The pain is severe and acute in The pain is slight at first and in- the early stages. creases with the development of the disease. The pain is localized at the joint. The pain is not local, but follows the course of nerve-trunks. The pain is steady and constant. The pain is paroxysmal and usu- ally worse at night. Deformity. The deformity of the affected The deformity is marked and pro- joint is at first due only to a serous gressive, resulting in the distortion effusion within it; but in latter of bony prominences, relaxed liga- stages structural changes occur. ments, atrophied muscles, etc., etc. Motion. The motion of the joint is fre- The motion of the joint is usu- quently destroyed by suppuration. ally only impaired, and a stiffness is experienced. Crepitation. Crepitation occurs from necrotic Crepitation, when present, is due or carious changes within the joint, to denuded cartilages, or a deposit as the result of suppurative inflam- of osteophytes. mation. Age. This disease may occur at any age. Occurs most frequently about 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 THE JOINTS. Ql 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 THE 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 startings No symptoms referable to mus- in the sleep are prominent and cular irritability are present. severe. Termination. Frequently amputation is de- Seldom of serious import. manded. SYMPTOMS IN COMMON. Chills, pain on motion, unnatural attitude of joint, local heat, and swelling and tenderness on pressure are present in both. 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 Anaesthetics. 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 THE 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 DIA GNOSIS. 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. Suppuration may possibly be absent. 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. 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. FEMORAL. ST. •e- Pain is referred to ;a, the knee joint in the i\- early stages of the dis- ease, and is often slight is- at the onset. This •e, symptom is produced ir- by irritation of the ob- to turator nerve; which passes in close relation ill to the capsular liga- of ment of the hip-joint, of and which is, further- er more, distributed to it. Pus, when formed, a- burrows either under the glutei muscles, and it, points behind, or on i- the outer aspect of the r, thigh ; or ;h 2d, it burrows under at the pectineus muscle, ;k and points on the inner aspect of thigh. Anchylosis often oc- curs in some abnormal position, following a dislocation of the fe- mur. 3d Symptom : Dislocation. Dislocation is rare. Dislocation into the Dislocation is fre- When present, it is due pelvic cavity occasion- quent, and is due either either to rupture of the ally occurs from caries to caries of the head capsule, or caries of the of the acetabulum. of the femur, or new head of the bone. growth in the cavity of the acetabulum. 4th Symptom : Anchylosis. Not infrequent; usu- Anchylosis is rare. ally occurs within the acetabulum. 2d Symptom : Suppuration. DISEASES OF THE 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, however, be restored to the normal position by manual pressure, or, possibly, by a muscular effort on the part of the patient. 3d. On placing the patient in the dorsal position upon the table, all attempts to straighten the affected limb until the popliteal space touches the table, will tend to elevate the back at the lumbar region from the same plane, so that frequently the hand can be placed be- tween the table and the spinal column. 4th. In the same position on the table the two anterior superior spines of the ilium will be seen not to be on the same level as they are in health, when the limb is extended; the affected side being elevated above the healthy side. 5th. Flexion of the thigh and leg, and an altered relation of the affected thigh to the pelvis will remove the pelvic inclination, will bring the spines of the ilium to the same level, and will cause the lumbar region of the spinal column to lie in contact with the couch. When these points are perfectly accomplished the normal relations are restored, and the actual existing deformity of the hip is made manifest. 6th. Extension of the affected limb will usually relieve the pain by separating the inflamed surfaces of the joint. 7th. Concussion upon the end of the affected femur with the palm of the hand, when the knee is flexed, will increase the pain by ap- proximating the inflamed surfaces. 8th. Pressure over the trochanter of the affected side will like- wise, as a rule, increase the sufferings of the patient. 9th. Motion of the affected limb at the hip joint will usually give pain, and especially will this be marked when motion in some par- ticular direction is attempted. Great credit is 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. PLATE V. rf\y 5 6 1. Strumous synovitis. 2. Anchylosis with deformity. 3. Talipes calcaneus. 4. Talipes equi- nus. 5. Talipes varus. 6. Talipes valgus. DISEASES OF THE 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 wiU 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 THE JOINTS. ?7 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 inlate 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. DISEASES OF THE 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 THE 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. a a tt tt a tt pressure over trochanter. tt tt a 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. tt a a tt a Spine, "' " diseases of childhood. DISEASES OF THE 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. << " " li possible immobility. tt tt a a a crepitus. tt a tt ti pam on pressure. a tt a a a a 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 THE JOINTS. 8<3 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. " " " " pain on motion of the limb. a a tt 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 an antero-posterior character, as it 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. " tt a a a spinal curvature. " " " " " atrophy of the limb. The spinal curvature which often exists is of the lateral variety. DISEASES OF THE 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 either side of the patella. " " Ankle. In front of the joint, slightly above the malleoli. " " Shoulder. The anterior aspect of the joint, pressure being made through the axillary coverings. " " Elbow. In front of the joint, over the head of the radius. III. DEFORMITIES OF JOINTS. The various deformities of joints which are liable to be met with in a surgical practice, may be divided into, 1st, those of congenital origin; and, 2d, those acquired after the date of birth. Under the first type, viz.: " Those deformities which are con- genital," may be enumerated A. Congenital Distortions ; under which I include 1. Club Foot, in all its varieties. 2. Club Hand, in all its varieties. 3. Sub-Luxation, in all its varieties. 4. Distortions, dependent on paralysis. 5. " " " contracted muscles. B. Congenital Malformations; under which head may be enumerated 1. Atrophy of limb, with malformation of long bones. 2. Hypertrophy of phalanges. 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. PLATE VI. 1. Splay- or flat-foot. 2. Severe form of double Talipes varus. 3. Arthritis deformans (early stage). . 4. Same in advanced stage. 5. Medio-tarsal deformity in contrast with the normal atti- tude. 6. Scrofulous synovitis of ankle. 7. Arthritis of wrist and ostitis. 8. Mild form of double Talipes varus. DISEASES OF THE JOINTS. 89 4. Talipes. 8 distinct types. 6. 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. Valgus...........where the sole of the foot is turned outward. Equino-Varus.... where a combination of the equinus and varus deformities exists. Equino-Valgus.... where a combination of the equinus and val- gus deformities exists. Calcaneo-Valgus.. where a combination of the calcanean and val- gus deformities exists. Spurio-Valgus.. . .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. 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 THE 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. " " « " increased width of the foot, from separation of the metatarsal bones. a 't a tt projection forward of the astragalus. " " " " elevation of the heel. « " " " contraction of the muscles of the calf. Both may occur in the young, and, possibly, in the adult. 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 THE 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- Eversion of the toes, and actual ished, and the toes are often flexed, elongation of the foot occur. 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. The outer margin of the foot is The outer margin of the foot be- affected early in the disease, and comes raised late in the disease, and locomotion is performed on the side locomotion is mostly effected upon of instep. the heel, in the later stages. 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 oases 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 THE JOINTS. 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. a a << « pain on standing or walking. " mav be " " .a history of excessive exertion or debility. " t) - a long duration and progressive symptoms. I DISEASES OE BONE. 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, PLATE VII. 6 5 1 and 6. Necrosis of skull-cap. 2. Puncture of skull-cap. 3. Caries of vertebrae. 4. Articular disease following fracture. 5. Caries of acetabulum and femur. 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 tenderness 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 the 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 disturl ance, 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 iissue, 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 lower 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 utility; 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 Kachitic 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, hyperaesthesia, 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 granidations 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 heal 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 the 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 cloacae. 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 bono 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 involucrum 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 involucrum 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 centred 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-ANETTRISM. 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. ENCHONDROMA. 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,t 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 PLATE VIII. 1. Necrosis of skull. 2. Malignant tumors of the femur and tibia. 3. Large sequestrum. 4. Deformity of malacosteon. 5. Central necrosis and involucrum. 6. Deformity of malacosteon! I-. Necrosis with osteo-myelitis. 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.) Cysrs 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 DIA GNOSIS. 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. It may result from disease, or Is always traumatic in origin; from traumatism. follows amputations, fractures, etc. It occurs in scrofula, syphilis, It occurs, as a rule, where the me- rheumatism, and follows exposure, 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; The pain is first perceived at the is worse at night if syphilitic in seat of injury, or in the stump in origin, or is increased by dampness cases where amputation has been if of rheumatic origin. performed, and is accompanied by rigors. Changes in the Bone. The affected bone gradually en- Pyaemic symptoms often rapidly larges in circumference. 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 becomes hard, irregu- The bone undergoes necrotic lar in contour and incompressible, changes and becomes infiltrated with pus. Termination. The disease often terminates in Recovery is rare. recovery. SYMPTOMS IN COMMON. Both may be associated with a traumatic history. elvis. " " " leg " " thigh. tl If t tt i i tl tt . tt ft .. ■ > 11 it '•• tt .. ft it tt 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 difiicult, but permanent when ef- easy by simple extension of the fected. limb, but is transient if the force be not maintained. No crepitus is present. Crepitation. Crepitus is present, unless ex- treme impaction exists. Shortening. The shortening is well marked. Slight shortening of the limb is 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, and is associated with direct vio- lence. If intra-capsular in variety, it may occur in the old, and from slight and indirect violence. Inversion of Foot. Inversion of the foot is perma- nent until reduction of the disloca- tion is accomplished. The foot may become everted after extension of the limb, if the inversion be due to impaction of the fragments. SYMPTOMS IN COMMON. Both are associated with inversion of the foot. shortening of the limb. an abnormal tumor. a history of an accident, (as a rule). impaired function. a normal position of the trunk. DISLOCATIONS. 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. Ioav the groin, and almost iri 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 eArerted. 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 difiicult, but per- The reduction is easy under sim- manent when effected. pie extension, but is transient if tke 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 flexion of Slight flexion of Leg extended, ab- Limb is abducted the thigh and leg. the thigh and leg. ducted and brought and extended, or The femur points The femur points forwards. slightly flexed. inwards. inwards. The femur points The femur points downwards and out- downwards and wards. slightly outwards. Marked shorten- Lengthening. ing. Position op the Foot. Toe on opposite Foot straight. instep. Position of the Limb. Slight flexion of Leg extended the thigh and leg. ducted and bro The femur points forwards. inwards. The femur pi downwards and wards. Position of the Trunk. Slight shortening. Toe on opposite toe. Little affected. Behind acetabu- lum. Hip is prominent. Looks forwards. Is less prominent. Little affected. Behind and above acetabulum. Bent forwards. Psoas and iliacus tense. Below the groin. Abduction and flexion easy. Adduction, ex- tension and int. ro- tation impossible. Slight shortening. Foot everted. Bent forwards. The psoas and ilia- cus are tense. At upper part of the groin. and Abduction and rotation out. easy. ex- Adduction and ro- rotation inwards im- le. possible. Flattened. Is carried forwards and inwards. Is nearer the me- dian line. Is less prominent. Fold of the Nates. Raised. Raised and car- Lower than nor- Raised. ried backwards. mal. Effects upon Motion. Adduction and ro- tation easy. Abduction and outward rotation impossible. Adduction and int. rotation easy. Abduction and ext. rotation impos- sible. Is approximated Is approximated Is removed from to ant. spine of to the ant. spine of ant. spine of ilium. ilium. ilium. Appearance of Hip. Prominent and Flattened and sun- raised, ken. Position of Trochanter. Looks forwards. Is inclined back- wards. Is less prominent. Is less prominent. Location of Head of Femur. PLATE XIII. 1. Attitude of nip-joint disease. 2. Same with leg straightened, 3. " Dorsum ilii " dislocation of femur. 4. " Pubic " dislocation of femur. 5. " Sciatic notch " dislocation of femur in recum- bent posture. 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 Eemur and the Tibia,—called the "Botary 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 j^dclla 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. 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 anteroposterior 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. ' 178 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 anteroposterior 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. SYMPTOMS IN COMMON. Both are associated with increased breadth of the knee. tt tt it a slight flexion. a tt tt a fixation of the joint. a " marked pain on communicated attempts at mo- tion. a tt a tt abnormal anterior aspect of joint. a tt a a 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. Lengtii 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. " '• " marked and rapid swelling. " crepitus, as a rule. " " history of an accident. n it 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 f rac- 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. " " i: " 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. Tlie 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 Tlie 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. •• 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. FRACTURES. 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 vicinitv 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 Ldib. It is not infrequent in both dislocation and fracture, that alteration does occur both in the nor- mal length and in the ai 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. tt it Face. C a it Shouldei f« D. n a Humerus AT ShOULDEB. E. (< AT THE Elbow Jotnt. F. a a Wrist a G. f. u Hip (< H. a a Knee C( I. n a Ankle a J. it u 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 the br~ain 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 contrc-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. PLATE XIV. V. 1, 2. Depression of inner table of skull. 3. Fissure of outer table of skull. 4. Fracture and de- pression of outer table of skull. 5. Hernia cerebri. 6. Punctured gun-shot fracture from a pistol ball. 7. Inner plate, showing the extensive depression. 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. 19G 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 tlie sur- edge of bone in the healthy or un- rounding parts; no free or well-do- 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 sym ptoms 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 s"ome time after the injury, or of injury from falling, and will Symptoms also of simple local pres- usually exist from the commence- sure on special nerves may exist. ment of the attack. Skin. The skin may not be markedly The skin is usually flushed, es- altered. pecially in the region of the head. Age. May occur at any age. Occurs usually after 40th year of age. SYMPTOMS IN COMMON. Both may be associated with injury of the scalp. " " " absence of external evidences of depression of bone. " " " " cerebral symptoms, such as convulsions, coma, paralysis, etc. FRACTURES. 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. " '"' " " alteration in temperature. " << <' " impairment of special senses. 200 SURGICAL DIAGNOSIS. CEREBRAL COMPRESSION. CEREBRAL CONCUSSION. Insensibility. The coma is profound. The coma is incomplete. tt a a it 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 full and The pulse is feeble, rapid and in- slow, termittent. Respiration. The breathing is slow and ster- The breathing is feeble and sigh- torous. ing in character. Eyelids. The eyelids are usually closed and The eyelids are usually open and immovable. movable. Pupils. The pupils are either natural, di- The pupils are usually contract- lated, or irregular ; but they are al- ed ; but they act feebly, and are 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. SYMPTOMS IN COMMON. Both may be associated with coma. " " abnormal temperature. " " abnormal pulse. " abnormal respiration. " " abnormal pupils. " " history of an injury. 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 deforfnity, 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. If the fracture occur at the ramus, slight deformity will exist. If at the condyle, the chin will be deflected towards the injured side, in which respect it differs from dislocation of the bone, and an abnormal hollow will exist behind the ear. If the coronoid process be fractured, displacement of the fragment FRACTURES. 203 by the temporal muscle will ensue, and the separated portion of the bone wdll 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 it a FRACTURES. 205 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. v 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. 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. Both are associated tt tt a a tt tt tt tt tt FRACTURES. 20? 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. " " " " easy reduction and crepitus. a "a marked tendency towards return of the de- formity. n n tt a severe pain in shoulder, and often in the hand. a n tt tt marked swelling in shoulder, and often in the hand. n it n -" 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. Reducibility. The reduction is easy and is The reduction is difficult and is effected by simply raising the elbow, effected by extension and manipu- lation. The reduction is transient when The reduction is permanent if the force is not maintained. once accomplished. 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 clue 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 from 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. 11 " " " crepitus. a " " " altered appearance of shoulder. " " " " pain and swelling. FRACTURES. 215 IMPACTED INTRA-CAPSULAR IMPACTED EXTRA-CAPSULAR FRACTURE OF THE HU- FRACTURE OF THE HU- MERUS AT SHOULDER. MERUS AT SHOULDER. Acromion. The acromion process is quite The acromion process is normal, prominent. or very slightly prominent. Hollow at Shoulder. The 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. " impaired function of limb. " local pain and swelling. " crepitation, in some instances. " 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. 2B 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 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 EprrROCHLEAR Process of the Humerus, which can often be detected as a small, detached and movable fragment. Fractures of the humerus near the elbow are to be diagnosed 1st. From each other. 2d. " dislocation at the elbow. 3d. " fracture of the ulna or radius. 4th. " severe sprain or contusion of the joint. 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 difiicult 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. PLATE XV. 1 Fracture of anatomical neck of humerus. 8. Fracture of surgical neck of same. 3. Frac- ture of same above its condyles. 4. Fracture of coronoid process of ulna with dislocation. 5. Fracture of olecranon process of same. 6. Fracture of leg bones with dislocation of tarsus. 7. Deformity of Pott's fracture. 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 a Jove 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 tt "an anterior and posterior tumor. a a tt a impairment of function. << << " " a history of an accident. an << " possible crepitus. a a tt a \0qq\ 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 Avith 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- location of the ulna or of both bones ment of the ulna, or the ulna may backwards. be dislocated forwards. Displacement. The displacement is often very The amount of displacement va- slight if dislocation be absent. A ries with the extent of injury done simple fulness in front of the joint to the triceps expansion over the and a small, hard, movable body olecranon. are all that are discovered. If dislocation is present, a special deformity will be produced which will be characteristic. Deformity. The condyles and the projecting The point of the elboAv is gone olecranon are normal and preserve and the arm is usually semi-flexed, the shape of the joint. though the fragments are often closely approximated on extension of the forearm. Crepitus. Crepitation is often absent, but Crepitation is detected by exten- 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. i( '• " " possible dislocation. tt a a tt impaired function. i: a a a crepitus. a a tt a history of an accident. " " *'•' " local pain and sAvelling. 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. " " " "an empty space behind the elbow. " " " "a tumor high up behind the joint. " " " "a history of traumatism. " " " " local pain. " " " " local swelling. FRACTURES. 225 FRACTURE OF THE UPPER FRACTURE OF THE UPPER END OF THE RADIUS. END OF THE ULNA. Deformity. No displacement of the upper A displacement will be easily de- fragment will exist, if the seat of tected, as a rule, on the posterior fracture be above the tubercle of part of the forearm, on account of the radius ; but if below it, a marked the superficial position of the bone displacement is apparent on exten- in that locality, although it may sion of the forearm, from tension of not be discovered on the anterior the biceps tendon. surface. Crepitus. Crepitation can be detected by Crepitus will be detected on ro- fixation of the condyle, and rota- tation of the lower fragment, and tion of the lower fragment of the possibly on flexion and extension of radius. the forearm. Motion. Flexion is difficult, or incom- The motions of the forearm may plete. be only slightly impaired if the fracture be transverse. Position of the Hand. The hand is pronated. The hand has no fixed position. SYMPTOMS IN COMMON. Both are associated with a history of traumatism. " " " " marked swelling. " " " " seATere local pain. " a i. frequent ecchymosis. a t- " a crepitus. " •* " " impaired function and motion. tt a a a 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 Arariety 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 clown 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 Avrist. 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 Colics' Fracture and from dislocation of the carpal bones. D. Separation of the Epiphyses at the Wtrist. 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. Avhich 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 is lower than that of the radius. higher than that of the radius. The styloid process of the ulna is The styloid process of the ulna is markedly prominent from displace- not markedly prominent. ment of the carpus. SYMPTOMS IN COMMON. Both are associated with an alteration in the length of the limb. " " " " an abnormal tumor. " " " " local pain and SAvelling. " " " " impaired function. " " " "a history of an accident. FRACTURES. 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 ro- 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 tt tt it impaired function. a tt tt tt ioca] pajn and swelling. a a a "a history of an accident, a n tt tt shortening of the limb (as a whole). 230 SURGICAL DIAGNOSIS. SEPARATION OF THE DISLOCATION AT THE EPIPHYSES. WRIST. Age Affected. Occurs only in the young. Occurs at any age. Bony Tumor. The bony projections are often The bony projection is distinct indistinct and can be felt as two and can be felt as a rounded mass. smooth tumors. Seat of Displacement. The displacement occurs above The displacement occurs below the styloid processes of the radius the styloid processes of the radius and the ulna. and the ulna. Tendons of the Forearm. The tendons are relaxed upon The tendons are tense upon one both surfaces of the forearm. side of the forearm. Length of Forearm. The bones of the forearm are The bones of the forearm are nor- shortened, on measurement from mal in length. condyles at elboAv to styloid pro- cesses. Styloid Processes. The styloid processes of the ulna The styloid processes of the radius and the radius are not prominent, and ulna are prominent. but are normal in their relation to the carpus. SYMPTOMS IN COMMON. Both are associated with the absence of crepitus. " shortening of the upper extremity. " smoothness of the tumor at the wrist. " " " " impaired function. " " local pain and swelling. " " " " easy reduction. " " a history of an accident. FRACTURES. 231 COLLES' FRACTURE. TRANSVERSE FRACTURE OF BOTH BONES ABOVE WRIST. Deformity. The deformity is apparent upon The deformity is apparent on both the radial side, and has the charac- sides of the forearm. teristic "silver-fork" appearance. Length of Bones of Forearm. The ulna is normal in length, Both sides of the forearm reveal but the radius is shortened. shortening. Length of Limb. The limb is shortened on the The limb is shortened on both radial side, if measured from the sides, if measured from the acro- acromion to the styloid process. mion to the styloid processes. Styloid Processes. The styloid process of the ulna is The styloid processes are both prominent. normal in their appearance and re- lations. Crepitus. Crepitus is often absent from im- Crepitus is almost invariably pres- paction of the fragments. ent, as impaction is rare. Mobility. The mobility is not markedly in- Excessive mobility exists at the creased at the seat of fracture. seat of fracture. Relation of Carpus. The carpus is usually displaced The carpus is normal in its rela- outwards. tion to the inferior fragments. Reducibility. The reduction is sometimes diffi- The reduction is always easy, if cult. simple extension is applied. SYMPTOMS IN COMMON. Both are associated with deformity at wrist. " impairment of function. " alteration in the length of bones. " crepitus. " local pain and swelling. " history of an accident. 232 SURGICAL DIAGNOSIS. FRACTURES OF THE HIP. The femur is the bone most frequently involved in injury to the hip joint. The pelvic bones are too heavy and solid in their structure to often become implicated, save when the violence is terribly severe and so directed as to impinge upon the ossa innominata. The femur may exhibit the following five distinct types of frac- ture in the upper third of that bone : A. Simple Intra-capsular Fracture of the Femur. This form of fracture occurs at the anatomical junction of the head of the bone to its neck, inside of the attachment of the capsular ligament of the hip joint. It is most com- monly present in the aged, and is usually the result of indirect and slight violence. It is seldom followed by osseous union, and is often a permanent source of impairment to the usefulness of the limb. B. Impacted Intra-capsular Fracture of the Femur. In this form of fracture the location is identical with the frac- ture preceding, but the condition of the bone is altered by the lower fragment being driven forcibly into the can- cellous tissue of the head of the femur. Impaction of the fragments in intra-capsular fracture of the hip is of great surgical importance. Upon its existence depends greatly the hope of osseous union, and the prognosis is proportionately favorable when im- paction can be clearly and positively diagnosed. R. W. Smith, of Dublin, in his great essay upon fractures in the vicinity of joints, questions if osseous union is possible in any other condition save impaction, provided the frac- ture of the femur be located within the capsule of the hip joint. C. Simple Extra-capsular Fracture of the Femur. This form of fracture of the femur is usually the result of a direct form of violence which is generally severe in FRACTURES. 233 character. It is most common in middle or adult life. Its location varies from a point immediately in relation with the capsular attachment, to a line corresponding to the junction of the middle and lower third of the bone. It is associated, as a rule, with marked deformity, great impairment of function of the injured limb, and severe local manifestations. D. Impacted Extra-capsular Fracture of the Femur. This form of fracture differs but little from the preceding variety in its origin or its location. It may possibly present equal deformity in case the impaction is oblique or in- complete ; and may also be associated with severe local manifestations. It is, however, characterized by the absence of a false point of motion, and the general impairment of function may be less marked. In case of rotary impaction of the fragments, an ab- normal position of the foot may ensue, which will fre- quently disappear after firm extension has loosened the impacted fragments. E. Fracture of the Great Trochanter of the Femur. This variety of fracture occurs as a separate type in cases of falls upon the hip, and also more frequently as a com- plication of extra-capsular fracture of the neck of the femur. So frequently does the trochanter become involved in this latter accident that it is considered an almost uni- versal rule, that more or less comminution of the trochan- ter accompanies every fracture of the neck, from an impaction which primarily occurs, and is subsequently loosened by a continuation of the violence producing the original impaction. Should the violence, however, be slight in amount, this impaction may remain permanent and the trochanter thus escape comminution. We may safely exclude all fractures of the pelvic bones from the causes of error in diagnosis of injuries received in the region of the hip joint, provided no evidences of previous disease of these bones are present, since if the fracture of these bones be severe and extensive, the location of the crepitus and symptoms referable to the pelvic viscera will easily remove all doubt. Should the fracture be of a local 234 SURGICAL DIAGNOSIS. character, however, and not of the comminuted variety, it is often impossible to either positively diagnose the existence of a fracture, or, provided even that crepitus be obtained, to locate its situation. Fractures of the upper third of the femur are to be diagnosed chiefly from each other, and also from 1. The "pubic" dislocation of the hip. 2. The " sciatic notch " dislocation of the hip. 3. Chronic rheumatic arthritis with contusion. 4. Severe contusion over the trochanter, in the aged. In the following pages will be found enumerated the chief points of diagnosis in a condensed form. FRACTURES. 235 INTRA-CAPSULAR FRAC- EXTRA-CAPSULAR IMPACT- TURE OF THE HIP, WITH ED FRACTURE OF THE IMPACTION. HIP. History of Accident. A history of slight violence and A history of severe violence, di- usually of the indirect character is rectly applied, exists. present, in the majority of cases. Position of Foot. The foot is markedly everted. The foot is slightly everted, or normal in its attitude. Crepitus. Crepitus is frequently detected, as Crepitus is either absent, or is the fragments may overlap and rub very obscure. upon the acetabulum. Effect of Extension. Extension relieves the shortening Extension, when moderately ap- of the limb. plied, fails to relieve the deformity. Age. Is most frequent in old age. Is most frequent in adult life. SYMPTOMS IN COMMON. Both are associated with shortening of the limb. eversion of the foot. local pain near seat of fracture. swelling and possible ecchymosis. a history of an accident. a possible crepitus. 236 SURGICAL DIAGNOSIS. INTRA-CAPSULAR FRAC- CHRONIC RHEUMATIC AR- TURE OF THE HIP. THRITIS WITH CONTUSION. History. No previous history of disease of A previous history of pain, de- the hip, or impairment of the func- formity about the joint, and im- tion of that joint is present. pairment of function, precedes the accident. Subsequent Power. The patient slowly, if ever, re- The patient regains the amount gains the power present within the of power and motion which he pos- joint pievious to fracture. sessed within the hip previous to the accident, as soon as the effects of the contusion disappear. SYMPTOMS IN COMMON. Both are associated with crepitus. " loss of power and loss of voluntary motion. '*' *' " " local pain in the region of the hip. " " " " swelling and possible ecchymosis. '' " " "a history of an accident. " " " " advanced years. " " " " eversion of the foot. FRACTURES. 237 SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HIP. FRACTURE OF THE HIP. Age Affected. Is rarely present in patients under May occur at all ages. fifty years of age. Sex Affected. Is most frequent in females. Both sexes are equally affected. History. Is the result of slight and indi- Is usually associated with severe rect violence. and direct violence. Shortening. The shortening of the limb is at The shortening of the limb is first not severe, but it steadily tends markedly apparent immediately af- to increase, from absorption of ter the occurrence of fracture, but bone. is stationary. False Point of Motion. A false point of motion is ob- A false point of motion is ap- scure. parent. Crepitus. Crepitation is obscurely detected. Crepitation is well marked. Poaver of Motion. The power of motion of the limb The power of motion within the is always impaired, but not always limb is usually lost. destroyed. Arc of Rotation. The trochanter rotates in nearly The arc of rotation of the tro- its normal arc. chanter is diminished, as the femur is detached from its neck. Pain. Pain of a slight but deep charac- Pain of a severe and superficial ter is present. character is present. 238 SURGICAL DIAGNOSIS. SIMPLE INTRA-CAPSULAR SIMPLE EXTRA-CAPSULAR FRACTURE OF THE HIP FRACTURE OF THE HIP (continued). (continued). Ecchymosis. Ecchymosis is usually slight or Ecchymosis is usually extensive. absent. Swelling. Swelling is not markedly appa- Swelling is frequently severe. rent. Rapidity of Union. Union occurs slowly, if at all. Union occurs rapidly and per- fectly, as a rule. SYMPTOMS IN COMMON. Both are associated with the history of an accident. " " " " impairment of function. " " " " shortening of the limb. " " " " crepitus. " " " " pain and possible ecchymosis. FRACTURES. 239 FRACTURE OF THE HIP WITH " SCIATIC NOTCH " DISLOCA- INVERSION OF THE FOOT. TION OF THE FEMUR. Mobility of Limb. The mobility of the injured mem- The mobility of the limb is great- ber is increased, ly decreased. Crepitus. Crepitus is present. Crepitus is absent. Shortening. Shortening of the limb is well Shortening of the limb exists only marked. to a slight degree. Inversion of the Foot. The inversion of the foot is often The inversion of the foot is per- changed to eversion, after extension manent, and is only restored to a of the limb has loosened the im- normal position by reduction of the paction of fragments, to which the dislocation. inversion is most frequently due. Abnormal Tumor. The separated trochanter often The abnormal tumor produced fails to participate in the motions by the displaced head of the femur of the shaft of the femur. rotates with motion communicated to it through the shaft of that bone. Reducibility. The reduction of the deformity The reduction of the deformity is easily effected by extension, but is difficult, but when once accom- is transient if the force be not main- plished no tendency to return is tamed. manifested. History of Accident. Is often produced by indirect Is usually produced by direct violence. violence. SYMPTOMS IN COMMON. Both are associated with shortening of the limb. a a " " inversion of the foot. tt a a a local pain in the region of the hip. ft ft ff " impairment of function. tt ft ft f( swelling, and possible ecchymosis. a ft << " history of an accident. 240 SURGICAL DIAGNOSIS. FRACTURE OF THE NECK "PUBIC" DISLOCATION OF OF THE FEMUR. THE FEMUR. Position of the Trochanter, The trochanter of the femur is The trochanter of the femur is normally prominent, and is not dis- carried forwards, and is much les.s placed towards the median line of prominent than normal. the body. Position of the Head of Femur. The head of the bone is felt to The head of the femur is felt as be in the acetabulum. an abnormal tumor in the groin, at its upper portion. Crepitus. Crepitus can easily be detected. No crepitus is present. Mobility of Limb. The mobility of the injured limb The mobility of the limb in the is increased, but its power of motion movements of adduction and rota- is greatly impaired or entirely de- tion inwards is greatly impaired. stroyed. Reducibility. The reduction of the deformity is The reduction of the deformity is easily accomplished by direct exten- difficult, but if once effected no ten- sion, but is transient if the force be dency towards a return is apparent. discontinued. SYMPTOMS IN COMMON. Both are associated with eversion of the foot. " " " " shortening of the limb. " " " " impaired function. " " " " severe local pain. " history of traumatism. FRACTURES. 241 FRACTURES AT THE KNEE AND ANKLE. The fractures which may occur at the region of the knee may be confined either to the femur in its lower third, to the tibia and fibula at the upper portion of both bones, or to the patella. The femur if fractured either in its middle or lower third is gene- rally broken by some form of direct violence. In its lower third, it is liable to present the following types of fracture : A. Fracture of the outer condyle. B. " " inner C. Transverse fracture above the condyles. D. "T-shaped" fracture. These fractures of the femur in this region are generally easily detected by the deformity and the location of the crepitus. It is not infrequent that fractures of the femur in this vicinity are complicated by wounds of the knee joint, and amputation is often required provided extensive comminution exists, or the symptoms of the patient seem to demand it. Impaction in these fractures is occasionally present, and, provided comminution of the lower fragment does not ensue, this impaction may not be associated with any serious deformity. FRACTURES OF THE BONES OF THE LEG IN THE VICINITY OF THE KNEE. The tibia, although the stronger and larger bone of the leg, is by far the more frequently fractured. This is partly due to its exposed position, but chiefly to the fact that the fibula is extensively protected by muscles. The tibia, also, is much more liable to receive injury from violence transmitted through the heel and the tarsus, than the fibula. The variety of fracture which is most frequently present at the upper third of the tibia is the transverse, and this seldom, if ever, occurs except from the application of direct violence. If both bones are simultaneously involved, the presence of crepi- tus, marked deformity, false point of motion, and shortening renders the diagnosis easy; but if either is fractured singly, the opposite 242 SURGICAL DIAGNOSIS. bone acts as a splint, and prevents displacement and shortening. In this case an irregularity in the line of the tibia can easily be de- tected by the finger, if that bone be fractured ; but if the fibula be broken, the investing muscles render the diagnosis obscure, pro- vided the seat of fracture be above the middle third of the bone. A deep-seated crepitus can, however, be often detected by care- ful manipulation, and the seat and presence of fracture be thus dis- covered. Fractures of the bones of the leg in the region of the knee can hardly be mistaken for any other existing surgical affection. Con- tusion may possibly so mask the symptoms of fracture by its ac- companying swelling as to leave doubt as to whether the bone is broken, but it could hardly be mistaken for it. FRACTURES OF THE PATELLA. Fractures of the patella most frequently occur from muscular action in an effort being made by the patient to save himself from falling when slipping, or in falls when the knee is bent. It may, however, also occur from falls directly upon the knee, or from any other form of violence directly applied. Fractures of the patella may be transverse, longitudinal, or ob- lique in direction; and simple, or comminuted in variety. The transverse fracture is usually the form met with when due to mus- cular action, and is by far the one most frequently present in sur- gical practice. The fractures of the patella can hardly be mistaken for other forms of injury, when they are well defined. The two portions of the bone, in case of transverse fracture, are separated by the action of the quadriceps extensor muscle, and the space between the frag- ments is increased by flexion of the knee. All power to extend the leg upon the thigh is lost, and endeavors to stand upon the in- jured leg are fruitless. In the comminuted variety local crepitus can usually be discerned, but in the transverse form, the fragments can hardly be sufficiently approximated to yield marked crepitus, except the position of the thigh be so modified as to relax the rectus muscle, and extension be applied to the upper fragment of the bone. Fractures of the patella are more common among males than females, and are seldom present in youth. This is explained on the theory of previous structural change within the bone substance, FRACTURES. 243 (Malgaignc), but it can hardly be considered as proven. A better explanation of the frequency of fracture of this bone seems to be the lack of support which the upper half of the patella receives when the knee is in a state of flexion, as in this position the upper edge is projected forwards, and the posterior surface of the upper half of the bone is totally separated from contact with the femur. FRACTURES AT THE ANKLE. The fractures which may occur in the bones of the leg at their lower third, or in the immediate vicinity of the ankle joint are more common than those occurring in the immediate vicinity of the knee. This is partly due to the bones gradually diminishing in size as they approach the ankle, and partly to the greater frequency of in- direct violence occurring in the vicinity of that joint from trans- mission through the bones of the foot, and from the leverage exerted by the astragalus upon the malleoli of the leg bones, in case of its displacement. Fractures of the leg in the vicinity of the ankle may be thus enumerated: A. Transverse Fracture of Both Bones. This form of injury is perhaps less common than the oblique variety of frac- ture which is so frequently present in the shafts of the leg bones, since a natural tendency seems to exist in fractures occurring in the tibia or fibula beloAV their upper third to approach a longitudinal direction, and thus to cause a greater or less obliquity, eATen if the force be so applied as to tend towards a directly trans- verse separation of the fragments. Still, in speaking of transverse fracture I include all those forms which more nearly approach the horizontal than the perpendicular plane, without entering into too many fine distinctions as to the absolute direction of the line of fracture. In this type of fracture near the ankle, we may have either slight or marked displacement existing. The degree of this displacement is the most extensive when the fracture is obliquely directed across the bone, since in this condition the fragments glide more easily upon each other; and it is the least apparent in that form of fracture where an absolutely transverse separation is present, in which case the bones may often be retained 244 SURGICAL DIAGNOSIS. in almost their normal position, and the line of the frac- ture may for that reason be more clearly discerned by the location of the crepitus than from any evidence per- ceived by the careful inspection and examination of bhe contour of the injured member. B. "Pott's Fracture" of the Fibula. This type of fracture is located in the shaft of the fibula, at a point usually about three inches above the external malleolus. The seat of the fracture may, however, vary someAvhat in its location, as it is often much nearer the malleolus. It is associated, as a rule, with an outward dislocation of the astragalus, and the internal malleolus is fre- quently broken. The internal lateral, or deltoid ligament, of the ankle is usually severely stretched or ruptured, and the deformity due to the displacement of the astra- galus, is aggravated often by marked local swelling. This form of fracture of the leg is extremely frequent, probably the most frequent of any fracture of the leg bones. It is produced by twisting of the foot, by catch- ing of the foot in a hole Avhile running, by jumping from a height upon the feet, or from a carriage while in motion. It may also result from violence directly ap- plied. The deformity which characterizes Pott's Fracture, is one of ordinary fracture combined with that of an exter- nal dislocation of the foot. A depression is perceived on the external border of the leg opposite the seat of fracture, and the sole of the foot is either directed out- wards, or the external border of the foot is elevated. The internal malleolus is either prominent, or can be felt as a detached and movable fragment; and crepitus can often be detected on extension of the leg and inver- sion of the foot, thus bringing the fragments into ap- proximation. C. Fracture of the Internal Malleolus. This form of frac- ture at the ankle may be associated with a normal position of the foot, or with a partial dislocation of the astragalus inwards, resulting either in severe stretching, or rupture of the external lateral ligament of the joint. It is complicated, as a rule, with marked swelling at the external portion of the joint, and is not infrequently FRACTURES. 245 associated Avith a partial or complete fracture of the fibula. D. Compound Fractures of the Ankle Joint. This form of accident is one of serious import, commonly requiring amputation if associated with dislocation or severe lace- ration of the soft tissues. The tibial arteries are not infrequently involved, and serious hemorrhage may exist. Gangrene of the parts supplied by these arteries may also follow the arrest of the hemorrhage, from the defec- tive nutrition which is liable to result in consequence of the impaired blood supply, and thus additional danger to the patient may ensue. It is always important therefore in the diagnosis of this accident to investigate the condition of the supply- ing vessels to the foot, before deciding as to the methods of treatment Avhich are best indicated, or expressing an opinion as to the general prognosis. Fractures in general in the vicinity of the ankle joint can hardly admit of great confusion in diagnosis. Ob- scure injuries to the astragalus, or tarsal bones will often fail to give positive evidence of fracture, even when such exists; but the history of the accident, the general de- formity, the presence of some of the prominent symptoms of fracture, and the length of duration required for re- covery will, in time, remove doubt, in cases where an early and positive diagnosis is impossible. I shall not attempt therefore to arrange all the pos- sible fractures of the bones of the leg and foot in the vi- cinity of the ankle joint, in a form of contrast, since many of the most positiA~e symptoms of each are capable of great variations, and in the majority of cases, the bones themselves Avill disclose from their superficial location the seat and extent of the injury received. I should suggest, however, in case the deformity were slight, and the other symptoms so obscure as to create doubt as to the existing condition of the parts injured, that the opposite member be always used in comparison with the one injured, before deciding as to the actual de- formity present, and that repeated examinations under anaesthetics and without them be employed, till a satis- factory conclusion can be reached. 246 SURGICAL DIAGNOSIS. FRACTURES OF THE TRUNK. Fractures of the trunk may affect the vertebrae, ribs, sternum and pelvis; of these four, fractures of the sternum are extremely rare, and usually occur where a severe injury is received, which directly impinges upon the chest, or in cases where the body is suddenly bent backwards or forwards, as in a fall. It is of surgical impor- tance however, when present, since complication of the pericardium, heart, pleura, lungs, and injuries of the great vessels and fractures of the ribs, or spine, may be also thus produced, and greatly modify, when present, the prognosis as to life. As many of these complications, however, can also exist with frac- tures of the ribs, they will be specially considered under that head. Fractures of the sternum may be associated with most of the symptoms common to fracture in general. Crepitus may be de- tected possibly on palpation and on auscultation. FRACTURES OF THE STERNUM. Displacement of the fragments, abnormal mobility, localized pain at the seat of fracture, and dyspnoea may all be present, even with- out the existence of any serious complication of organs or the se- rous cavities, though subsequent inflammatory changes are always liable to follow any violence to the chest which is sufficient to pro- duce so serious an injury. It is therefore to be diagnosed chiefly from its complications, and especially from inflammatory changes in the pleura or pericardium. Fractures of the sternum have in several reported cases been pro- duced by muscular action. Chaussier reports two cases resulting from resting upon the head and heels only, during parturition. Faget and Gurlt report each a case resulting from attempting to lift weights with the teeth, with the body bent backwards. FRACTURES OF THE VERTEBRAE. Fractures of the vertebras may result from direct injuries to the spine, or from force indirectly applied, as in case of falls upon the feet, knees, pelvis, or head. In the first set of causes, viz. : those producing fracture from FRACTURES. 247 direct violence, the injury is, of necessity, received upon the back, since in front the spine is most thoroughly protected. This class of injury almost without exception results in a com- plicating dislocation of the vertebras in addition to the fracture re- ceived, since the anterior ligamentous attachments of the bodies to each other are ruptured by the direct force of the blow, altering the normal spinal curve, while at the same time the spinous pro- cesses and laminae of the vertebras are comminuted by the com- pression exerted in endeavoring to resist such an alteration in the spinal axes. In the second class, viz.: those dependent upon force indirectly applied to the spine, the fracture is found to be usually located at a distance from where the shock was first received. Dislocation of the vertebrae will, as a rule, be absent, but the articular surfaces will generally be comminuted, and the spinous and transverse pro- cesses frequently fractured. In very severe cases, however, where the force transmitted through the spinal column is of a violent character, the bodies of the vertebrae may be comminuted, and displacement from this cause will often be detected. In either variety, however, we can judge of the location of the fracture and its severity by the combined local and spinal symp- toms. The local symptoms will consist of probable crepitus, deformity, detached and movable fragments, local ecchymosis, and local pain. The spinal symptoms will vary with the seat of fracture and the portion of the cord compressed, or injured. Thus, if above the origin of the phrenic nerve, death may ensue from respiratory paralysis, provided both lateral halves of the spinal cord are in- jured. If aboATe the origin of the lumbar and sacral plexuses, symp- toms of paralysis of the limbs and pelvic organs will be apparent. The paralysis of muscles may be of the hemiplegic or paraplegic type, as the pressure on the cord is lateral or bilateral, or possibly eAren local paralysis may result, if special spinal nerves be affected, and the cord be not involved. In some cases where dislocation of the vertebrae exists in connec- tion with fracture, extension of the spine by suspension of the pa- tient, if practicable, if not, by ordinary means, will often reduce the dislocation, and possibly an audible click will be heard when the reduction is effected. Fractures of the spine are frequently fatal. The result of the injury depends more upon the severity of the 248 SURGICAL DIAGNOSIS. spinal symptoms produced by injury to the cord, than upon the location of the fracture or its extent. If dislocation be present, the immediate vertebra will usually reveal the seat and extent of the displacement by the altered relation of the displaced bone. Should the displacement be but slight, the spinal cord may possibly escape injury, and reduction may be followed by recovery without para- lysis. Fracture of the spine can hardly be mistaken for any other type of local injury, as the symptoms are usually unmistakable, and the history of the accident would probably warrant a most justifiable suspicion of fracture from its severity, even before the local mani- festations were determined. FRACTURES OF THE RIBS. Fractures of the ribs occur rarely among the young, as the elas- ticity of the ribs is great in youth, but are most frequent in elderly people, or in adult life. They occur as a rule from external injuries applied to the chest wall, as in blows, falls, the passage of wheels over the chest, or from pressure between two opposing forces. In rare instances fracture of the ribs has occurred from muscular effort, as in attacks of coughing; but in these cases a structural change had probably ensued within the bone, before the fracture occurred. The ribs may be broken in one of two ways : either by the direct force of the injury, in which case the seat of fracture will correspond probably with the seat of the external contusion, and one or two ribs only will be implicated, the fractured ends being driven in- wards ; or the ribs may be fractured at a point remote from the seat of injury by an indirect force, causing excessive bending of the bones. In these cases the ribs are usually broken at about their middle, and the fractured ends of two or three bones are simulta- neously displaced outwards. Fractures of the ribs may be also divided into the complete, and the incomplete. In the former variety, the separation of the frag- ments is such as to allow of displacement and marked crepitus. In the latter, either the.bone itself is imperfectly fractured, or the periosteal coverings still remain intact and prevent any displace- ment, and often conceal all symptoms of local injury to the bone. Fractures of the ribs may be unilateral or occasionally bilateral, FRACTURES. 249 in situation; simple, comminuted, or compound, in variety. The middle ribs are the most frequently involved, and the first three ribs are seldom fractured. Fractures of the ribs may be uncomplicated, or complicated. If complicated, the integument may be lacerated, producing a com- pound variety of fracture. The bone may be shattered by gun-shot wounds, etc., resulting in the comminuted variety of fracture. The pleura may be involved, producing pleurisy, etc. The lung-tissue may be penetrated, thus inducing pneumo-thorax, pneumonia, pul- monary hemorrhage, emphysema, etc. The heart and pericardium may become implicated. The inter- costal vessels may be wounded, and finally the diaphragm and the abdominal viscera may be injured, provided the lower ribs be in- volved and greatly displaced. The proportion of uncomplicated cases of fractured ribs to the total number of recorded cases, is very large,—at least seATenty-five per cent. The balance usually recover, however, provided the com- plication is not of a markedly serious and severe type. Fractures of the ribs are to be diagnosed from many pulmonary affections, especially if connected with, or created by a severe con- tusion of the chest wall, or some variety of direct injury. Among the diseases which are liable to be confounded with a fracture of the rib, are pneumo-thorax if traumatic in origin, pleuritic inflamma- tion and emphysema of tissues. In the following pages will be enumerated the distinctive diag- nostic points of eadi in contrast, with those of fracture of the rib. In closing the subject of fracture I also append a differential diagnosis between Fracture and Dislocation of bone, as a general resume of the symptoms common to both. 250 SURGICAL DIAGNOSIS. FRACTURE OF THE RIBS. PLEURITIC INFLAMMATION, (in the dry stage associated with contusion). Appearance of Chest. The projecting edges of the frag- No projecting fragments can be ments of the fractured ribs can often discoA'ered, or any irregularity in be detected, or an irregularity in the course of the rib. the course of the rib may result from its displacement, in case no fragments can be discovered. The chest wall is often locally de- The chest wall is normal, until pressed in case of fracture. effusion into the pleural cavity pro- duces bulging of the affected side. Palpation. Crepitus may of ten be felt on pal- Palpation is negative in its re- pation. suits. Auscultation. Auscultation yields the fine grat- Auscultation perceives a harsh ing noise of crepitation. friction sound, before the fluid, separates the inflamed pleural sur- faces. Cough. Cough is absent, if no complica- Cough, without expectoration, is tion exist. usually present. SYMPTOMS IN COMMON. Both are associated with localized pain in the side. " " " " abnormal sounds on auscultation. " " " " diminished expansion of the chest. " " " " elevation of pulse and temperature. " " " " local ecchymosis. " " " "a history of an accident. FRACTURES. 251 FRACTURE OF THE RIBS. PNEUMO-THORAX, (of a traumatic origin). Appearance of Chest. The chest wall is often locally de- The chest wall is distended, and pressed at the seat of fracture. the intercostal spaces widened from air within the pleural cavity. Outline of Ribs. The fractured rib can often be The outline of the ribs is seen and felt to be irregular in outline, or felt to be normal. the fragments can be felt to overlap each other. Dyspncea. The dyspnoea present is due only The dyspncea is intense and is to the pain, and is not excessive. due to compression of the affected lung by atmospheric pressure. Palpation. A vocal fremitus can be perceived No vocal fremitus, or crepitus is on palpation of the chest Avhen the detected. patient speaks or counts, and crepi- tus may also be detected. Percussion. The percussion note is normal Pure " tympanitic" percussion over the affected side. resembling that of the abdomen, will be present. Inspection. The expansion of the affected side No expansion of the affected side is limited, but plainly perceptible. occurs on inspiration. Auscultation. Respiratory sounds are heard over No respiratory sounds are heard, the seat of fracture, though they provided the lung be not punctured, may be feeble. but if so, "amphoric breathing" may exist. SYMPTOMS IN COMMON. Both are associated with pain. " " " " dyspnoea. " " " " history of traumatism. 252 SURGICAL DIAGNOSIS. FRACTURE OF THE RIBS. EMPHYSEMA OF TISSUES. Appearance of the Chest. The chest wall is often depressed The tissues over the chest are in- at the immediate seat of fracture. flated with air, and the chest has, therefore, a puffy or distended ap- pearance, which is often extensively diffused. Abnormal Sounds. A fine, grating crepitus maybe A peculiar "crackling" noise and perceived during inspiration or ex- sensation to the touch may be per- piration, both on palpation and ceived on pressure over the em- auscultation, physematous tissues, irrespective of respiratory efforts. Outline of Ribs. The outline of the fractured ribs The ribs are felt to be normal in is felt often to be irregular ; or the their outline and position, if their overriding of the fragments may be contour can be detected through the detected. inflated tissues. Effects on Respiration. Pain is present in the side, and Pain may not be present to any the breathing is often restricted in serious degree, nor need the breath- consequence, ing be, of necessity, restricted. Duration of the Symptoms. The symptoms are continued for The symptoms may, in some some days after the accident. cases, rapidly subside. SYMPTOMS IN COMMON. Both are associated with abnormal auscultation. " " " " " palpation of the chest. " " " " deformity. FRACTURES. 253 FRACTURE IN GENERAL, IN . THE VICINITY OF JOINTS. " DISLOCATION. Deformity. The deformity is not in the joint, but near it, as is shoAvn by com- parison with the opposite side. It A-aries in its seat and in its de- gree, and is easily removed. The abnormal projections are usually felt to be small and irregu- lar in shape. The axis of the limb is not uni- form, but varies with changes in the relation of the fragments to each other. The deformity is great, and is lo- cated in the joint itself. It is stationary, and disappears only after reduction of the disloca- tion. The abnormal tumor, when per- ceived, is felt to be large, smooth, and rounded at its edges. The axis of the limb is abnormal, but is constantly the same and is of uniform direction throughout the whole length of the bone. Mobility of the Limb. The mobility of the limb is of an abnormal type. It is augmented in its degree. It is not always located at the region of a joint. All attempted voluntary move- ments are abnormal. The movements of the joint are greatly restricted, both in degree and direction. The movements are located in the immediate locality of the nor- mal joint, but not within it. All attempted voluntary move- ments are normal in direction, but restricted in amount. Crepitus. Appears at the time of the acci- dent, is easily obtained, and is of a grating character. If present, crepitus is a late symptom ; is obtained with diffi- culty, and is of a rubbing char- acter. Pain. Is seldom severe if the parts are at rest. It continues after reduction. Is usually severe even though the parts are at rest. Is ahvays relieved by reduction. 254 SURGICAL DIAGNOSIS. FRACTURE IN GENERAL, IN DISLOCATION, THE VICINITY OF JOINTS, (continued). (continued). Length of Limb. Shortening is often present, but Shortening and lengthening may lengthening never. both, at times, exist. Position of Limbs. Fractured limbs usually lie close Dislocated limbs usually stand to the median line of the body. out from the body, and cannot be made to lie parallel to its median line. Appearance of Joints. The bony prominences in the The relations of the bony promi- vicinity of joints are unaltered in nences normal to the joint are un- their relations to each other. altered. Sensibility. Numbness of the injured limb is Numbness is often a prominent often absent, but if present, is slight symptom ; it is usually present to a in amount. greater or less degree. Ecchymosis. Is often extensive, and is located Is usually slight and superficial, in a dependent part. if present. Reducibility. The deformity is easily reduced, The deformity is reduced often but shows a tendency to return. with difficulty, but Avhen accom- plished, no tendency towards a re- turn is manifest. No sound is perceived at the A distinct snap is often perceived moment of reduction. at the moment of reduction. DISEASES OF THE MALE GENITALS. DISEASES OF THE MALE GENITALS. The surgical diseases of the male genitals may be divided into A. Diseases of the Testicle. B- " " Tunica Vaginalis. C- " Spermatic Cord. D. " " Scrotum. E. " " Bladder. F- " Pkostate Gland and Urethra. G " " Penis. I shall consider the diseases of the male genitals in this order, enumerating under each of the separate divisions the various sur- gical conditions liable to exist, and the sources of error in diag- nosis which pertain to the various organs under consideration. °I shall endeavor in this chapter to elucidate as exhaustively as is compatible with conciseness, those diseases which are most com- mon in a general surgical practice, and shall be content with the enumeration only of such as are infrequent, referring those desirous of more extended information to the various monographs upon the special subjects. DISEASES OF THE TESTICLE. The testicles may become enlarged from the following named con- ditions : 1. Simple Inflammatory Orchitis which is a frequent sequek of injury, mumps by metastasis, and exten- sion of inflammation down the spermatic cord. It is largely due to an cedematous infiltration of the testi- cle, but may result in suppuration, and is associated with all the symptoms characteristic of inflamma- tory processes in general. 257 258 SURGICAL DIAGNOSIS. 2. Specific Deposit within the Testicle, or " Syphili- tic Orchitis." This type of disease is a sequela of the acquired A-ariety of syphilis, as a rule. It con- sists of circumscribed, or infiltrated deposits of gum- mata. It is a rare affection before the age of pu- berty, and is most frequently located at the period of its commencement, in the body of the testicle. It may, however, subsequently involve the epidi- dymis. 3. Cheesy Degeneration of the Testicle, or "Tuber- cular Orchitis." This variety of degeneration oc- curs in a tubercular diathesis, and exists in connec- tion with a similar condition of other organs in the large majority of cases. It is essentially a disease of early manhood, and is primarily located in the globus major of the epididymis. It is associated, as a rule, with impairment of the general health, and is frequently accompanied by suppuration in its ad- vanced stages, and in some cases by fungoid growth. 4. "Malignant Orchitis," or Cancerous Deposit in the Testicle. This variety of disease may occur in all ages. It is a frequent disease after the age of fifty. It is primarily a disease of the body of the testicle, but involves the epididymis and the cord in its ad- vanced stages. It is associated with impairment of the general health as the later cachexia is developed. It is chiefly of the encephaloid variety, although scirrhus may occur in this region, and occasionally melanoid cancer may be present. 5. Cysts of the Testicle, called also " Cystic Sar- coma." This is a rare affection, and consists of compound or proliferous cysts de\Teloped within the testicle. They vary usually in size from that of a millet seed to the dimensions of a pigeon's egg, and contain either a transparent, viscid, albumi- nous fluid, or a blood-stained fluid with coagula. The cysts are usually of an elongated form, and are primarily a disease of the body of the testis, although the epididymis may become involved. They are probably produced by an occlusion of the tubuli DISEASES OF THE MALE GENITALS. 259 seminiferi, or the ducts of the rete testis. They are sometimes associated with enchondroma. 6. Hematocele of the Testicle. This is frequently the result of a blow, as in riding on horseback, and being thrown upon the pommel of the saddle; or of violent muscular efforts, as in attempts to raise heavy weights. It may also occur from direct wounds of the testicle, and during scurvy and pur- pura. It is due to the rupture of a blood-vessel, and the blood is usually effused into the cavity of the tunica vaginalis. The testicle under these circumstances immediately enlarges, and symptoms referable to the escape of blood become manifest. Haematocele may occur when hydrocele has pre- ceded the exciting cause of hemorrhage. In this way tapping not infrequently creates a complica- tion, although a lancet, if used, is more liable to produce haematocele than a trochar. The source of hemorrhage in haematocele of the testicle may be the spermatic artery, or some of the branches either of the spermatic, or of the artery of the vas deferens. The testicle, as a rule, lies at the posterior portion of the tumor, but as this rule has exceptions, pressure upon the back of the tumor in doubtful cases will yield the peculiar " sickening sensation," usually associated with com- pression of the testicle, and thus decide its exact location. 7. Lipoma of the Testicle. Fatty tumors of the tes- ticle occasionally occur. They are to be diagnosed by their slow and painless growth, by the absence of an exciting cause, by the general health being unimpaired; and by the general characteristics of fatty deposits. 8. Fibrous Tumors of the Testicle. This type of dis- ease is frequently associated with the condition of atrophy of the testicle. It consists of a marked increase in the connective tissue of the organ. 260 SURGICAL DIAGNOSIS. It may also accompany cysts of the testicle, or it may occur as an independent process, resulting in a painless and marked enlargement of the organ, as is common in the so-called " chronic enlargement" of the testicle, which possesses no distinctive symp- toms. It is questionable if this state of chronic indura- tion is not, in the majority of cases, a direct sequela to a chronic orchitis, the products of the inflamma- tion having undergone organization into connective tissue, instead of becoming absorbed. 9. Enchondroma of the Testicle. Cartilaginous tumors of the testicle are seldom unassociated with other textural changes within that organ. Still, in rare cases, the deposit has been localized to so marked a degree as to constitute a separate or principal lesion. While this type of tumor is often associated with cancer of the testicle, yret it can doubtless be re- garded as in itself, non-malignant. 10. Benign Fungus of the Testicle, or "Hernia Testis." This term is used to express a condition of the tes- ticle, where a fungus growth protrudes from the tes- ticle and scrotum. The term " granular swelling " has been sometimes used to express this condition, but the mode of origin has caused the term " hernia tes- tis" to be more universally applied. This fungus growth consists of a protrusion of the glandular structure of the testicle through the tu- nica albuginea, the tunica vaginalis, and the adhe- rent scrotum. It results frequently from suppuration of the tes- ticle and ulceration of its coverings, as a sequela of chronic orchitis. It may, however, occasionally fol- low an acute suppurative process within the testicle, but these cases are uncommon. The fungus, on microscopical examination, is found to consist of the tubules of the testicle with intertu- bular changes, and granulations springing up from those tubules which are nearest to the surface. The tunica albuginea is thickened around the margin of the opening, through which the fungus DISEASES OF THE MALE GENITALS. 2G1 protrudes, the edges of which are everted. The scrotum around the margin of the opening is indu- rated and thickened, and in some cases is under- mined. 11. Chronic Inflammatory Induration of the Testicle. This variety of disease, to which the term " chronic orchitis " is applied, is of surgical importance from its tendency to destroy the glandular structure of the testicle. It usually follows an attack of simple acute orchi- tis whose duration has been prolonged by repeated attacks, or by excess in alcohol and venery, or trau- matism. It results in a gradual enlargement of the testicle without any markedly acute symptoms, and is more closely allied in its history to that of tubercular de- posit It differs however from that disease in its primary seat, which is usually Avithin the body of the organ, as Avell as in its general pathological characteristics. It is a frequent cause of benign fungus of the tes- ticle from ulceration of the tunica albuginea. It is to be diagnosed from cancer of the testicle, tubercular orchitis, and hsematocele of the testis. The testicle may present also the following conditions which are not accompanied with an enlargement of the organ, but which are of surgical interest: 1. Arrested Development of the Testicle. 2. Congenital Malformations of the Testicle ; includ- ing Inversion of the testicle. Union of the testicles. Supernumerary testicle. Impervious vas deferens. 3. Congenital Absence of the Testicles : " cryptorchid- ism. 4. Neuralgia of the Testicle. 262 SURGICAL DIAGNOSIS. 5. Atrophy of the Testicle. 6. Incomplete Descent of the Testicle : " monorchidism." 7. Calcareous Deposits in the Testicle. Many of these affections can with difficulty be mistaken in diag- nosis, and will therefore be simply enumerated. In the following pages will be found contrasted, however, those diseases which con- stitute the principal sources of error in diagnosis. DISEASES OF THE MALE GENITALS. 2C3 ACUTE ORCHITIS. NEURALGIA OF THE TESTIS. History. Is usually either of traumatic Is a frequent affection in weak origin, or is associated with a his- and nervous young men, and in tory of venereal disease. masturbators. It also is often as- sociated with varicocele and mala- rial conditions. Testicle. The testicle is swollen, but is not The testicle is retracted during always retracted. the attack, if severe, but is normal in its size. Pain. The pain is constant and not par- The pain is paroxysmal in char- oxysmal. acter, and intense. It comes on gradually with the It comes and goes suddenly, with- sAvelling and disappears slowly. out premonition. Gastric Symptoms. Nausea and Aomiting are infre- Nausea and vomiting are often quent. present. Effect of Pressure. Great tenderness on pressure ex- The testicle is painless on pres- ists, until the swelling or the acute sure during the intervals betAveen symptoms disappear. the attacks. SYMPTOMS IN COMMON. Both are associated with marked pain in the testicle, '* maybe" " nausea and Aromiting. " " " " tenderness on pressure. 264 SURGICAL DIAGNOSIS SYPHILITIC ORCHITIS. TUBERCULAR ORCHITIS. Location of Origin. Begins in the body of the testicle Begins in the globus major of the as a primary disease. epididymis, and involves the testicle secondarily. Age Affected, May exist at any age ; but seldom Occurs in early manhood, as a before puberty. rule. Extent. Is usually a unilateral disease. Is frequently a bilateral disease. Testicle. The testicle is regular in contour, The testicle is marked Avith hard, uniform in its consistence, and knotty nodules, but is soft and elas- harder than normal. tic between them. Hydrocele. Hydrocele is occasionally present. Hydrocele is an infrequent com- plication. Termination. Tends toAvards calcareous or fi- Tends towards cheesy degeneration brous degeneration, or atrophy. and suppuration after an interval. Ulceration and Fungus. Ulceration and fungoid growths Ulceration anil fungoid growths are absent. are frequent in the last stages. Fistula. Fistulae are seldom formed. Fistula? are frequently formed which heal after the gland has been evacuated. History. A history of syphilis exists, or A tubercular history is present, evidences of it are discovered in the and other organs are usually af- skin or the glands. fected. Sexual Desire. Sexual desire is decreased, but the Sexual desire is increased, but power of coition is usually slowly the power of coition is usually im- affected. paired. DISEASES OF THE MALE GENITALS. 265 MALIGNANT ORCHITIS. SYPHILITIC ORCHITIS. Age Affected. Affects all ages, even children. Is very rare before puberty. Previous History. No previous history of causation A history of syphilis, or some exists. evidences of it, is usually present. Seat of Origin. Begins in the body of the testicle, Begins in the body of the testicle, but grows rapidly. but groAvs slowly and painlessly. Characteristics of the Tumor. The tumor ulcerates, and tends The tumor never ulcerates, nor to form a fungoid growth. tends to form fungoid excrescences. The tumor often invades the cord. The tumor seldom invades the cord. The tumor is not of uniform con- The tumor is uniform in consis- sistence. tence. Pain. The pain is severe and lancinat- Pain is seldom present. A sense ing in character during the latter of Aveight only exists. stages. Integument. The skin is always involved in its The skin is seldom involved. advanced stages. Fluctuation. Fluctuation is often detected over localized spots in the testicle. The tumor returns, as a rule, after castration. Fluctuation is absent. The tumor, if removed, never ex- hibits a tendency to return. Effect of Castration. 266 SURGICAL DIAGNOSIS. CYSTS OF TESTIS. HYDROCELE. Frequency. Is a rare malady. Is an extremely frequent disease. Size of Testicle. The testicle may be either en- The size of the scrotum is always larged or diminished in size. increased ; but the testicle is un- affected as to its size. Tumor. The tumor consists of a localized The tumor begins from below swelling which may be situated in and extends upwards. different parts of the testicle. Translucency. The tumor is not translucent. The tumor is translucent on placing a lighted candle behind it. Fluctuation, The fluctuation, if perceived, is Fluctuation is well marked, and very indistinct. It may often be is always detected. absent. Veins of Cord. The veins of the cord are enlarged The veins of the cord are normal and varicose. in their appearance. SYMPTOMS IN COMMON. Both are associated with slow development. " " " absence of pain. " " " oval or globular form. " " " smoothness of the surface. " " '' elasticity. " " " fluctuatioa DISEASES OF THE MALE GENITALS. 267 BENIGN FUNGUS OF TES- CANCER OF TESTICLE, WITH TICLE (Hernia Testis). FUNGUS. Definition. Is a protrusion of the tubular Is a rapidly increasing growth, structure of the gland through the possessing no resemblance to the coverings of the testicle and scro- glandular structure of the testicle. turn. Appearance of Tumor. The tumor has a neck which is The constriction at the neck is markedly constricted. not Avell marked. Surface of Tumor. The surface is granular, but is The surface is friable in its tex- firm in its texture. ture. Effects of Pressure. The tumor is painless to the The testicle fails to yield the nor- touch, but the testicle is normally mal '' sickening sensation " on pres- affected by pressure. sure. Pain. The pain is severe until protru- The pain is of a violent and lan- sion occurs, when it ceases. cinating character. Character of the Discharge. The discharge from the fungus Hemorrhage is frequent from its often contains spermatozoa. surface, especially when handled ; and the discharge is profuse and foetid. Location. The disease is always unilateral. The disease may be bilateral. Complications, The skin, spermatic cord, and The integument, spermatic cord, neighboring glands are usually nor- and neighboring glands are usually mal. involved. General Health. The general health may be good. A marked cachexia exists. 268 SURGICAL DIAGNOSIS. ORCHITIS. EPIDIDYMITIS. Frequency. Is a very rare affection. Is extremely common. History. Is produced by mumps, cold, Is almost invariably associated gout, traumatism, etc., etc. with urethral disease or irritation. Pain. The pain is excruciatingly severe, Pain is usually of moderate se- even in cases of moderate enlarge- A-erity, except in extreme enlarge- ment, and is not relieved by position, ment, and is relieved by position. Shape of Tumor. Is usually associated with an oval The shape is often modified by tumor. scrotal oedema. Effects upon Testicle. The testicle is extremely hard The body of the testicle is, as a and very sensitive to pressure. rule, normal. If complicated, it is less sensitive than orchitis. The epididymis is not distinguish- The epididymis always becomes able from the rest of the tumor. distinguishable when the disease is in its decline, although often ob- scurely so at its height. Hydrocele. Hydrocele is rare as a complica- Hydrocele is ahvays present in tion. acute cases. Course of Disease. The disease is slow in its progress. The disease is usually rapid in its progress. Constitutional Symptoms. The constitutional symptoms are The constitutional symptoms are often marked. absent, or unimportant. PLATE XVI. 1. Calculus behind prostate. 2. Enlarged middle lobe of prostate. 3. Calculus behind pubes 4. Calculus encysted in walls of bladder. 5. Fistula of rectum with a diverticulum beneath rectal walls. 6. Rectal fistula with double openings. 7. Diagram of different varieties of rectal fistula. (B, C, D.) DISEASES OF THE MALE GENITALS. 269 ORCHITIS EPIDIDYMITIS (continued). (continued). Methods of Termination. Resolution, abscess, gangrene, Resolution with chronic thick- atrophy, or chronic induration may ening of epididymis usually takes occur. place. Effects on Function. Impotence may result if both Temporary sterility may occur, sides have suffered destruction of but never impotence. tissue. _. , „ . ... „ (" Genito-L'rinary Diseases and bypnilis, Van Buren and Keyes.) 270 SURGICAL DIAGNOSIS. TABLE FOR THE DIAGNOSIS OF DISEASES OF TESTICLE. SYPHILITIC TESTIS. Bare before pu- berty. Syphilitic. Begins in the body of the testicle. Unaffected. Slow and lent. indo- Skin rarely in- volved. Suppuration rare. Hydrocele com- mon. No pain present; a sense of weight only is perceived. Irregular at first, but ultimately smooth. Hard and stony. Seldom affected. TUBERCULAR MALIGNANT TESTIS. TESTIS. Age Affected. Early manhood All ages are af- and youth. fected, but youth most frequently. History. Scrofulous. No cause or pre- vious history of dis- ease exists. Seat of Origin. Begins in the glo- Begins in the body bus major of the of the testicle. epididymis. General Health. Usually impaired. Impaired in the last stages. Progress of Development. Slow in groAvth. Rapid in growth. its Skin becomes in volved before sup puration. Suppuration pres ent. Skin involved in its late stages. Hydrocele infre- quent. Ulceration and fungus growth fre- quent. Hydrocele infre- quent. Pain in Testicle. Absent until sup- A severe and lan- puration commen- cinating pain is al- ces. ways present in the last stages. Surface of the Tumor. Nodular and knot- Smooth but un- ty throughout. even. Consistence of Tumor. Hard and resist- Soft and fluctu- ant, ant in spots. Epididymis. Begins in it, and it Extends to it in is affected through- the last stages. out the disease. SARCOMA OF TESTIS. Early manhood. No history; cause unknown. Begins in the body of testicle. Unimpaired till late in disease, if ever affected. Very slow, but often becoming sud- denly rapid. Skin unaffected. No suppuration or fungus growth. Hydrocele rare. No pain. Slightly uneven. Fluctuant in spots. Is seldom involved. DISEASES OF THE MALE GENITALS. 271 SYPHILITIC TESTIS. Unchanged. Comparatively small. No pain or any sensation on pres- sure. Both testicles of- ten consecutively at- tacked. TUBERCULAR TESTIS. MALIGNANT TESTIS. Is very rare. SeA'eral years. Recovery, if well treated. Calcareous degen- eration. Fibrous degenera- tion. Atrophy. (Continued.) Scrotal Veins. Normal. Enlarged and va- ricose from pressure of inguinal glands. Size of Tumor. Never very large. May be immense. Effect of Pressure. No pain on pres- Pain aggravated sure. by handling tumor. Number of Testicles Affected. Both testicles of- Only one testicle ten attacked in sue- is, as a rule, affect- cession, ed. Fungus Growth. Is very common; and is pale, soft, and bleeds easily. Pus thin. Sinuses exist leading into testicle. Fungus grows slowly. Fungus is pain- less. Is constant in the advanced stages. Fungus bleeds profusely. Fungus discharge is bad-smelling and ichorous. Fungus grows ra- pidly. Fungus is very painful. Duration. Several years. Average is about two years. Prognosis. Radical cure rare. Bad prognosis. Kills by hemor- rhage, cachexia or return after castra- tion. SARCOMA OF TESTIS. Normal. May be very large. No pain ; but squeezing the testi- cle produces faint- ness. One testicle only is involved. No fungus exists. Indefinite tion. dura- Good prognosis if removed. If left, may become cancer. Termination. Suppuration, for- Ulceration and Cancerous degen- mation of fistufce, fungoid growth. eration, or station- and evacuation of ary condition. the testicle. SURGICAL DIAGNOSIS. HEMATOCELE. HYDROCELE. Rapidity of Development. The tumor develops rapidly if of The tumor develops slowly. traumatic origin, but slowly if spon- taneous in character. History. A history of traumatism is fre- No history of injury exists. quently present. Fluctuation. Fluctuation is detected at first, Fluctuation is well marked at all but soon disappears, as coagulation times and over all portions of the of the blood renders the tumor hard tumor. and non-fluctuant. Shape of Tumor. The tumor is pyriform in shape. The tumor is usually ovoid in shape. Effect of Transmitted Light. The tumor is opaque, as shown The tumor is translucent, save at by a lighted candle placed behind the posterior portion, Avhere the tes- it. tide is usually present. Appearance of Skin. The skin is usually discolored. The skin is normal in color. Constitutional Symptoms. Pallor, prostration, and general No symptoms referable to hemor- evidences of loss of blood exist. rhage are detected. Weight of Tumor. The tumor is heavy in weight. The tumor is light in weight. Spermatic Cord. The cord is free and unaffected The spermatic cord is sometimes in the majority of cases. involved. DISEASES OF THE MALE GENITALS. 273 DISEASES OF THE TUNICA VAGINALIS AND OF THE SPERMATIC CORD. The tunica vaginalis, or the serous covering of the testicle, may contain within its normal cavity either effused blood, constituting haematocele, or an excess of its natural secretion, constituting the disease termed hydrocele. The first of these has already been considered under diseases of the testicle, although it may properly be also classified as a disease of the tunica vaginalis. The second condition, viz. : that of hydro- cele, may be of several distinct anatomical varieties. Hydrocele may be classified into 1. Simple Hydrocele. This condition is the direct re- sult of inflammatory processes occurring in the tu- nica vaginalis and the sub-serous cellular investment. The inflammatory process is, in the majority of cases, essentially of the chronic variety. The testi- cle is found enclosed, or rather displaced by the dis- tended sac, which contains an amber-colored fluid, and is usually located at the posterior portion of the scrotal tumor, rather below its centre. This position of the testicle, although present in the large majority of cases, is not always insured. Old adhesions in the serous coverings of the testicle from previous inflammation often retain that organ in some particular locality, and the fluid is thus forced to accumulate in some special direction. It is thus probably that the so-called " Multt- locular Hydrocele " is produced, in which distinct cysts, having often no communication with each other, are detected. Hydrocele is without doubt the most common disease of the testicle or its coverings. It affects all ages and all ranks of life. It is most common, how- ever, in infancy and in middle life, and occurs in warm climates more frequently than in cold regions. It is generally unilateral, and the left side is most frequently affected. The exciting causes of the disease seem to include SURGICAL DIAGNOSIS. anything which will disturb the nicely adjusted balance between the functions of secretion and ab- sorption. Thus, all causes exciting an abnormal determination of blood to the part, or impeding the free venous return, may result in this condition from interference with the circulation within the gland or its coverings. The dependent position of the left testicle, and the absence of a direct venous return on the left side, afford an explanation of its frequency on that side of the scrotum, although the pressure exerted by the sigmoid flexure of the colon upon the spermatic veins, is also advanced as a possible exciting cause. Hydrocele is usually developed after a violent strain, or great fatigue, or after a slight blow upon the gland which was considered, at the time, as trivial. It may also accompany hydraemia, and may result from sympathetic connection with chronic diseases of the urethra or bladder. If hydrocele is accompanied by an enlargement of the testicle, the condition is often distinguished by the term " Hydro-Sarcocele." 2. Congenital Hydrocele. This condition occurs from an imperfect closure of the canal between the cavity of the peritoneum and that of the tunica vaginalis after the testicle has descended. The opening re- maining is usually small in size, and the fluid which accumulates seems to be due to gravity of the peri- toneal effusion. A rare form of disease, resembling a congenital hydrocele, accompanies a late transition of the testicle when no hernial protrusion simultaneously occurs. Congenital hydrocele is to be confounded with a reducible intestinal hernia, and with ordinary hy- drocele. 3. Encysted Hydrocele of the Testicle. In this form of hydrocele, fluid is effused into an adventitious cyst, or cysts, distinct from the cavity of the tunica vaginalis. They may be developed in one of two situations: DISEASES OF THE MALE GENITALS. 275 eitheT at the epididymis beneath the visceral layer of the tunica vaginalis, or beneath that portion of the tunica vaginalis covering the body of the testicle. The first is by far the more common, the latter being very rare. The cysts of the epididymis often become pedun- culated, but if so, seldom exceed the size of a pea. They usually contain a small amount of fluid, and are hard and semi-transpareni They are quite common after the age of forty. When " encysted hydrocele of the epididymis " at- tains, however, a large size, without undergoing pe- dunculation, the testicle is usually displaced to the bottom of the sac; rarely, if ever, to its posterior portion. The tumor is smaller than an ordinary hydrocele, and seldom exceeds four ounces in con- tents, although the size may, in rare instances, equal that of a large hydrocele. These cysts are fre- quently multiple, and their contents are either straw-colored and albuminous ; or they may be thick, turbid, and filled with coagula. When the body of , the testicle becomes the seat of this disease, the term "encysted hydrocele of the tunica vaginalis" is applied, in contradistinction to simple multilocular cysts, due to adhesions within the cavity of the serous investment of the testis. They enclose a milky fluid, and often contain spermatozoa, probably introduced by a rupture of the tubules of the testicle from OArer-distension. Encysted hydrocele, in general, is characterized by an imperceptible origin, by a slow and painless growth, and by a stationary condition, after attain- ing a moderate size, which often remains for years producing no inconvenience or pain. It is to be confounded only with localized hydro- cele from adhesions, but the aspirator will usually decide this question by the character of the fluid contents of the tumor. 4. Diffuse Hydrocele of the Spermatic Cord. This af- fection is described by Pott, under the denomination of hydrocele of the cells of the tunica communis. 276 SURGICAL DIAGNOSIS. The disease partakes largely of the character of an ordinary oedema diffused throughout the loose connective-tissue of the spermatic vessels, and of the cord, and is enclosed in a layer of compressed tissue, invested by the musculo-aponeurotic structure of the cremaster muscle. The base of the tumor corresponds to that point where the spermatic vessels join the testicle, and is cut off, at this point, by a dense septum from com- munication with the tunica vaginalis. It frequently extends along the cord, and may, in rare cases, enter the abdomen. The tumor is smooth, uniform, and nearly cylindrical in shape. It is a comparatively rare disease, and is produced by obstructed venous return, as exists in case of local pressure from enlarged inguinal glands etc., etc. It is to be diagnosed from omental hernia, and from encysted hydrocele of the cord. 5. Encysted Hydrocele of the Spermatic Cord. This condition is the result of the formation of a distinct cyst, or cysts, within the loose cellular or connec- tive tissue of the spermatic cord. It is usually oval in form, seldom if ever exceeds the size of a hen's egg, and is usually much smaller. It is situated in one of four locations : either just above the testicle, at the external ring, in the mid- dle portion of the cord, or in the inguinal canal. It is usually a solitary cyst, but in some cases multi- ple cysts are formed. It is due, probably, to a partial or imperfect oblite- ration of the peritoneal prolongation which accom- panies the testicle in its descent into the scrotum, resulting in an isolated sac, or a succession of pouches being left, which becomes distended with serous fluid. It is of gradual and slow development, and may possess obscure and indistinct fluctuation. It can be handled without pain, and is often more or less transparent. It is quite freely movable in the longitudinal direction of the spermatic cord. It is frequent in infants, but may exist at all stages in life. DISEASES OF THE MALE GENITALS. 277 It is to be diagnosed from encysted hydrocele of the testicle, if close to the gland, by its mobility and its separation from the testicle when drawn upwards, and from the character of its fluid con- tents. When in the inguinal canal it may be mistaken for a hernia. 6. Varicocele of the Spermatic Cord and Testicle. The term " Varicocele " is used to designate a vari- cose condition of the spermatic veins within the scrotum, while the term Cirsocele is used to denote a varicose condition of the veins of the cord and testicle. The two terms are, however, often used synonymously to express any abnormally varicose condition of the spermatic veins independent of the location affected. In this disease, the venous coats are thickened so as to resemble arteries in their structure, and their course is rendered tortuous and irregular. The calibre of the veins is increased by dilatation of their coats, and the apparent number of the veins is largely increased by the distension of venous capil- laries. The disease is most frequent upon the left side, the proportion being nearly twenty to one. The causes of this excessive frequency upon the left side have been thus explained: 1st. The left testicle hangs lower in the scrotum, and thus the veins of the left side support a heavier column of blood. 2d. The spermatic veins of the left side are pressed upon by the sigmoid flexure of the colon when distended. 3d. The spermatic vein of the left side joins the renal vein at a right angle to the current of blood, thus impeding the rapid return of blood from the left testicle. 4th. The left spermatic vein is by some authorities stated to be poorly supplied with valves; but the 278 SURGICAL DIAGNOSIS. anatomical accuracy of the statement is question- able. Varicocele, as a disease, may result from A. Causes which impair the general vigor of the parts. Under this head may be included 1. Masturbation. 2. Abuse of venery. 3. Chronic orchitis, or repeated attacks of acute orchitis. 4. Lack of proper support from a relaxed scrotum. B. Causes producing varicocele from pressure. Under this head may be included 1. Abdominal tumors. 2. Enlarged lumbar or inguinal glands. 3. Hernia. 4. Trusses, or belts worn around the waist. 5. Accumulation of fat in the omentum and mesentery. C. Causes producing varicocele by muscular effort. This class of causes may include 1. Prolonged riding on horseback. 2. " rowing. 3. " exercise, in running, waltzing, etc. 4. Excessive and violent muscular efforts. 5. Whooping-cough. Varicocele occurs most frequently at the time of puberty. If due to mechanical pressure, it is most frequent in those ad- vanced in life. It is a very common affection, and is indicated by a tumor possessing the appearance and feel of a "bag of worms," associated with a sense of weight and local distress, which increases as night approaches, from the relaxation of the scrotum. A sense of immediate relief is present after coition, but a severe exacerbation of the symptoms follows during the succeeding twenty- four hours. Varicocele is to be diagnosed from scrotal hernia, with which it has many points in common. 7. Lipoma of the Spermatic Cord. Fatty tumors usually DISEASES OF THE MALE GENITALS. 279 form in front of the spermatic vessels, as a loose and movable tumor, having a soft, doughy feel, and a lobular appearance. They may be mistaken for a hernia of omentum. They possess no distinctive symptoms, and are a source of little, if any, incon- venience. 8. Spasm of the Cremastee Muscle, causing Betraction of the Testicle. This occurs in some diseases of the kidney, in the passage of a renal calculus, and in affections of the prostate gland. In all cases it is the direct result of nervous irritation transmitted from other parts. It may be associated in some instances with a local injury to the groin, and may occur when the testicle or epididymis becomes sympathetically inflamed, from an existing ure- thral lesion. It is of diagnostic value as con- firmatory evidence only when the history of the exciting disease is obscure. 280 SURGICAL DIAGNOSIS. HYDROCELE. SCROTAL HERNIA. Development of Tumor. The tumor develops slowly. The tumor develops suddenly, in the majority of cases. History of Tumor. The tumor appeared first at the The tumor developed from above bottom of the scrotum, without downwards, after a strain, injur}-, cause. etc. Density of Tumor. The tumor is very hard and The tumor may be hard or elastic. doughy, but is never elastic. Effect of Light. The tumor is translucent. The tumor is opaque. Inguinal Canal. The inguinal canal is empty. The inguinal canal is filled. Spermatic Cord. The spermatic cord is easily felt. The spermatic cord is concealed. Percussion. The percussion note over the The percussion note over the tumor is flat. tumor is usually resonant. Fluctuation. Fluctuation is apparent. Fluctuation is absent. Cough Impulse. No impulse, on coughing, is per- A cough impulse is perceptible, ceived in the tumor. as a rule, within the tumor. Auscultation. No gurgling is heard within the Gurgling within the tumor is tumor. often detected. Constipation. The function of the alimentary Constipation may result from the canal is unimpaired. displacement of the intestine. Reductibility. The tumor cannot be reduced. Reduction is possible. DISEASES OF THE MALE GENITALS. 281 VARICOCELE. SCROTAL HERNIA. Palpation. The tumor is knotty and irregular The tumor is usually smooth on and feels like " a bag of worms." its surface and regular in its out- line. Color of Integument. A bluish tint is usually present. The integument is normal in color. Location. Is most frequent on the left side. May exist on either side. Effect of Heat. Tumor increases on the applica- The effects of heat upon the tion of heat. tumor are negative. Development. Gradual. Sudden. Percussion. A dull percussion note exists over Resonant percussion usually ex- the tumor. ists. Fluctuation. May exist' if the vessels be very Never exists. large. Spermatic Cord. Not affected. Concealed or displaced. Inguinal Canal. Uninvolved. Usually filled. Cough Impulse. Absent. Usually detected. Reduction. Reduces often spontaneously by Reduction is usually accomplished any position favoring increased ve- by taxis alone. nous return. 282 SURGICAL VARICOCELE (continued). Return The tumor returns when the pa- tient stands up, in spite of pressure at the ring. Sensation A sense of weight, and of constant dragging in the scrotum, exists. DIAGNOSIS. SCROTAL HERNIA (continued). of Tumor. The tumor, if once reduced, can be prevented from a return by pres- sure at the external ring. in Scrotum. There is a sense of distension only, unless inflammation or strangula- tion exist. DISEASES OF THE MALE GENITALS. 283 HYDROCELE, ENCYSTED. CYSTS OF TESTIS. Location. Are most commonly located at Are most commonly situated in the epididymis, but may rarely af- the body of the testicle. feet the body of the testicle. Pedicle. The cysts are often pedunculated. The tumor is rarely peduncu- lated. Number. The tumors are frequently mul- The tumor is usually single. tiple. Size of Tumor. The tumors are usually quite The tumor is usually of the size small in size, but may, in rare cases, of a pigeon's egg when fully de- reach a fluid contents of four veloped, and seldom exceeds it. ounces. Development. The tumors grow slowly and pain- The tumor grows slowly, but is lessly, as a rule, and are often sta- often associated with enchondroma- tionary in size for years. tous deposits. Contents. The tumor, if located on the body The tumor seldom if ever con- of the testicle, usually contains tains spermatozoa. An albuminous spermatozoa, but if on the epidi- fluid and coagula are however fre- dymis an albuminous fluid and oc- quently present. casional coagula are withdrawn on aspiration. Frequency. These tumors are not uncommon Is a rare affection. after the age of forty years. 284 SURGICAL DIAGNOSIS. HYDROCELE. CONGENITAL HERNIA. Age Affected. May affect any age; and, if in Is usually a disease of infant adults, is not necessarily associated life ; but if once present, subse- with a history of a previous attack. quent attacks in adult life may oc- cur. Fluctuation. The tumor is markedly fluctuant The tumor is usually fluctuant in all of its localities. at its upper portion since the peri- toneal effusion gravitates. Translucency. The tumor is always translu- The tumor may be translucent. cent. Pedicle. The tumor is not pediculated. The tumor has a marked pedicle. Shape of Tumor. The tumor is pyriform. The tumor is globular. Development. The tumor always develops slow- The tumor may be of sudden oc- ly and gradually. currence, or may show sudden and rapid increase in its size when once developed. Inguinal Canal. The inguinal canal is empty. The inguinal canal is either dis- tended or involved. Reducibility. The tumor cannot be reduced. The fluid portion, when reduced by taxis or pressure, leaves a previ- ously concealed testicle, which also reduces with a marked gurgle and occasions a peculiar sickening sen- sation during its passage through the inguinal canal. DISEASES OF THE MALE GENITALS. 285 HYDROCELE OF THE CORD. INGUINAL HERNIA. Limits of Tumor. The tumor is circumscribed. The tumor is frequently scrotal, and is generally diffused. Palpation. The tumor is tense. The tumor is soft, as a rule. Reducibility. The tumor is usually irreducible, The tumor reduces with a gur- but if not so no gurgle is present gle. on its reduction. Translucency. The tumor is often translucent. The tumor is opaque. Fluctuation. The tumor is fluctuant. The tumor does not fluctuate. Percussion. The percussion note is dull over The percussion note is resonant the tumor. over the tumor, as a rule. Bowel. No intestinal embarrassment ex- Intestinal embarrassment is often ists. present. Impulse from Testicle. The testicle, if moved, transmits Movements of the testicle have an impulse to the tumor. no effect upon the tumor. Cough Impulse. Impulse on coughing is absent. An impulse on coughing is fre- quently felt in the tumor. Auscultation. No gurgling is detected. < Gurgling is often heard in the tumor. Return after Reduction. The tumor returns after reduc- The tumor remains reduced if the tion irrespective of position. dorsal position is maintained. 286 SURGICAL DIAGNOSIS. HYDROCELE. HEMATOCELE. Rapidity of Development. The tumor develops slowly. The tumor develops rapidly if of traumatic origin, but slowly if spon- taneous in character. History. No history of injury exists. A history of traumatism is fre- quently present. Fluctuation. Fluctuation is well marked at all Fluctuation is detected at first, times and over all portions of the but soon disappears, as coagulation tumor. of the blood renders the tumor hard and non-fluctuant. Shape of Tumor. The tumor is usually ovoid in The tumor is pyriform in shape. shape. Effect of Transmitted Light. The tumor is translucent, save at The tumor is opaque, as shown the posterior portion, where the tes- by a lighted candle placed behind tide is usually present. it. Appearance of Skin. The skin is normal in color. The skin is usually discolored. Constitutional Symptoms. No symptoms referable to hemor- Pallor, prostration, and general rhage are detected. evidences of loss of blood exist. Weight of Tumor. The tumor is light in weight. The tumor is heavy in weight. Spermatic Cord. The spermatic cord is sometimes The cord is free and unaffected involved. in the majority of cases. DISEASES OF THE MALE GENITALS. 287 DISEASES OF THE BLADDER. The diseases and the surgical conditions which may affect the bladder may be thus enumerated: A. Malformations of the Bladder, under which head may be included 1. Deficiency of the Bladder, in which the ureters open directly into the urethra, or, as in some re- ported cases, the ureters may enter the rectum, and thus discharge the renal excretion. In the female sex a few cases have been reported where the ureters communicated directly with the vagina. 2. Multiplicity of Bladders. Two well-known reported cases are on record illustrating this malformation. In one, that of Blasius, two well-defined sacs existed, into each of which one ureter emptied; in the other, that of Molinetti, five bladders, five kid- neys, and six ureters, are said to' have existed in one woman. It is probable that many cases of sacculated blad- der from long-standing disease may have been mis- taken for this deformity. 3. Extroversion of the Bladder. This condition is not one of extreme rarity. It is often associated with absence of the pubes, and is due to a congeni- tal absence of the anterior wall of the bladder. A protrusion of its posterior surface, which is red in appearance, is caused by the pressure of the ab- dominal viscera upon it, and appears as a small vascular flattened tumor. The extroverted portion usually reveals the open- ings of the ureters near its centre, and a small rudi- mentary penis in the male is apparent at its lower margin. In many cases a small pouch, covered with hair, exists, either on the side of, or below the tumor, which, in the male, contains the testicles, 288 SURGICAL DIAGNOSIS. Inflammatory Conditions of the Bladder : and, in both sexes, often a hernial protrusion of the bowel. The tumor is extremely sensitive to the touch, often bleeds on slight irritation, and is continually moistened with the urine, which escapes from the open ureters. This escape of urine not only produces a urinous odor to the patient, but also results in excoriation of the neighboring parts. B. Diseases associated with Structural Changes within the Bladder, under which head may be included Acute Cystitis. Chronic " Ulceration. Suppuration of the vesi- cal walls. Gangrene. Hypertrophy of the Vesical Walls, associated often with sacculation of the bladder, and resulting from obstructed outlet. Fibrous \ ~. , ^'., ( Polypoid. Villous. Epithelioma. Malignant. 4. Bar at the Neck of the Bladder. This occurs chiefly in elderly subjects, and may be due to pros- tatic enlargement, or may be independent of it. 5. Hernia of the Bladder: "Cystocele." Is a rare condition, and occurs as an inguinal hernia in the male, and as a femoral or vaginal hernia in the female. 6. Inversion of the Bladder. This condition occurs rarely, and usually affects children, especially those of the female sex. The bladder is seen to protrude through the urethra. 7. Rupture of the Bladder.—The bladder, like all hol- low organs, as the heart, uterus, stomach, and in- 3. Tumors of the Bladder DISEASES OF THE MALE GENITALS. 289 testine, is liable to rupture either from over-disten- tion, external violence, or secondary ulceration. It is doubtful, however, if rupture of the bladder from simple over-distention ever occurs, without some degeneration or lack of tone in the vesical walls, unless associated either directly or indirectly with some form of external violence. Sudden spasm of the abdominal muscles upon an extremely distended bladder might be justly re- garded as a complicating accident, greatly assisting in its rupture, as its results differ but little in reality from those of a blow or kick. Retention of urine, unless due to organic stricture of the urethra, never occurs in a healthy bladder to such an extent as to giAre cause for apprehending rupture of the organ, provided no external violence occurs simultaneously with its full distention. When excessive accumulation of urine, however, occurs in a bladder long affected with paralysis, enlarged prostate, cystitis as the result of stricture, or other diseases liable to cause weakening or degeneration of the vesical walls, it often requires no external violence to produce a rupture. Thus a sudden slip, turning in bed, violent attacks of sneezing, vomiting, straining at stool or during an attempt at micturi- tion, may, in this condition, produce the most dis- astrous consequences. Extreme external violence, however, is the direct cause of the large majority of cases in which this accident occurs. Sudden falls, with a highly dis- tended bladder, from an elevation; falling over some sharp, projecting edge ; severe blows or kicks in the abdomen; direct puncture of bladder by a ball, knife, or other missile, are among the numerous accidents included under this head. Symptoms.—The symptoms occasioned by rupture of the bladder depend greatly on the seat and amount of laceration; also on the presence or absence of complicating hemorrhage from injury of some large vessel. In the majority of cases, the first sensation ex- perienced is that of laceration of some internal 290 SURGICAL DIAGNOSIS. organ, usually felt in the region of the symphysis ; and this accident is occasionally accompanied by an audible sound denoting rupture. Immediately, as a rule, the sufferer sinks, unable to move; the most intense pain exists, Avifh inability to micturate ; occasionally fainting occurs ; and, in cases associated with hemorrhage, symptoms of collapse rapidly appear. In some instances, how- ever, the patient has been able to walk for some dis- tance before taking to bed or calling medical as- sistance. The face 'becomes pale, the pulse small and fluttering, the respiration hurried and difficult, the skin cold, and covered with a profuse clammy perspiration. An intense desire usually exists to micturate, with inability to pass a drop through the urethra; and subsequent symptoms of peritonitis rapidly follow. The temperature becomes ele\'ated, the face anxious, the legs are drawn up and flexed at thigh and knee with dorsal decubitus; and tympanites, excessive pain, and tenderness in the abdomen appear. De- lirium and hiccough rapidly follow, and mark the approach of death. There are, as far as I know, only nine reported cases of recovery from an injury of this character. Death usually supervenes within two to eight days from the date of rupture, resulting from general peritonitis, though cases have existed where a month has intervened between the accident and the fatal termination. It is, therefore, exceedingly important, in case suspicion of rupture of the bladder is excited, that an immediate diagnosis be fully made. This can generally be done by injecting the bladder with a saline solution to the extent of about a pint, and immediately exploring the cavity of the bladder with instruments, to ascertain if the fluid is retained within its cavity, or whether it has escaped through any existing laceration. Should it be found to have escaped into the peri- toneal cavity, no harm can have been done, as the extravasated urine will only have been diluted with DISEASES OF THE MALE GENITALS. 291 a non-irritating solution, and a positive diagnosis can be made. It has been suggested, and strongly advised, as a means of preventing fatal results, that an immediate section through the abdomen be now made over the region of the bladder, exposing the rent, and that thorough washing of the peritoneal cavity be at once performed, the rent being at the same time pared and closed by small silk sutures, care being taken that these sutures do not pierce the mucous mem- brane of the bladder (in which case they might act subsequently as nuclei for stone), and the external wound closed in the ordinary manner after opera- tions within the peritoneal cavity. 8. Stone in the Bladder. Most of the calculi found within the cavity of the bladder possess a central nucleus, which differs in its character from the in- vesting layers. These nuclei may consist either of inspissated mucus, coagulated lymph, blood clots, renal concretions (chiefly those of uric acid), or foreign bodies which have been introduced in the bladder by the patient, or as the result of some form of accident. Etiology. The principal causes of the formation of vesical calculi may be thus enumerated : (1.) Hereditary or acquired gout. (By tending to form renal calculi, which escape into the blad- der, and act as a nucleus for farther deposit of crystalline salts.) (2.) Intro-uterine development of a small calculus. This may be suspected if young children be af- fected. (3.) Special localities of residence. (Prominently, in this country, in Kentucky, Ohio, Alabama, and Tennessee.) (4.) Sex. (Females are, by far, the least liable to the development of calculi.) (5.) Occupations which necessitate exposure to dampness. (6.) Pace. (The negro race seems to be singularly exempt.) SURGICAL DIAGNOSIS (7.) Existing disease of the urinary organs, such as urethral stricture, prostatic hypertrophy, cys- titis, chronic diseases of the kidney, etc. (8.) Paraplegia. (By causing retention and decom- position of urine within the bladder.) (9.) Rheumatism is occasionally followed by the formation of A-esical calculi. Number and Volume. Calculi of the bladder vary greatly in their size, and in the number present. Certain forms (chiefly those of uric acid, oxalic acid, cystic and xanthic) are usually of small size; while others reach a size varying in weight from two drachms to several lbs. Kesselring reported, in 1739, one weighing some six lbs.; and, in Deschamp's case, one weighing fifty-one oz. was removed. As regards the number present, a rough calculus maybe, as a rule, considered solitary; while smooth- ness of the surface usually indicates that two or more exist, and by attrition have worn each other smooth. Several cases are on record where over one hundred have been removed at a sitting. Sir Astley Cooper reports 142, Murat 678, Physick (in case of Judge Marshall of U. S. Supreme Court) reports 1000 pres- ent, at one time, within the bladder. The number present may also be determined, with some degree of accuracy, by the character of the cal- culus, since the oxalate of lime, or mulberry calcu- lus, as well as the uric acid variety, are seldom mul- tiple, while the phosphatic type are frequently so. Consistency and Appearance. Calculi of the bladder vary from a consistency of wax, as detected in the cystic and. fibrous varieties, to that of granite or mar- ble. The hardest varieties are those formed of uric acid and the oxalate of lime. In proportion to their density, the danger of the operation for crush- ing is relatively modified, since the hard calculi break into sharp fragments, which are liable to ex- cite severe inflammation of the bladder, if not com- pletely removed at the first sitting. The color of calculi is often of value in deciding as to its chemical formation. As a rule, the following statement will be found correct: ^ 1. Annular stricture of urethra. 2. S, stricture; A, urethra in front; P, urethra behind; C, diverticulum or pouch formed by improper use of instruments. 3. Tortuous stricture. 4. Indu- rated annular stricture. 5. Bulbous bougie passing a stricture. 6. Medullary tumor of bladder. 7. Hypertrophy of walls of bladder. 8. Sounding for stone in the bladder. 80 DISEASES OF THE MALE GENITALS. 293 Cystic or fibrinous calculi are yellowish. Phosphatic calculi are whitish or gray. Oxalic calculi are dark brown or black. Uric acid calculi are red or brown. Shape of Calculi. The variations in form of calculi include the oval, spherical, pyriform, conical, cubic, triangular, polygonal, disc-shaped, semilunar, heart- shaped, dumb-bell, and many others. Large concre- tions may present projections which have formed within the ureters or urethral canal, and which may offer serious interference to their removal. Kattonal Symptoms of Stone tn the Bladder. (1.) Pain. This may be confined to the bladder, or radiate through the adjacent parts. It is markedly increased by rough exercise, and often by firm pressure upon the hypogastrium, or in case the rectum be distended. Change in attitude often perceptibly intensifies it. This pain is usually the most severe in very large or rough calculi, or in case complicating diseases of the bladder, prostate gland, rectum, anus, urethra, or testicle exist. (2.) Frequent Micturition. This is usually an early symptom. It is due to irritability of the neck of the bladder, and may be greatly aggravated and intensified by inflammation or complicat- ing ulceration of that organ. (3.) Interruption of tlie Urinal Stream. This is also an early and important symptom. It is due to the closure of the internal urethral ori- fice by the stone, which, in cases of impaction in the urethra, may cause complete retention of urine. Patients, even in childhood, soon learn some peculiar attitude which relieves this tend- ency, such as crossing of the legs, lying down, stooping, or inclination toward one side during the act of micturition. (4) Pain in the Glans Penis. This is usually absent in the early stages, and often in old men. It is accompanied, as a rule, by a sense of scalding, smarting, or itching within the urethral canaL • S URGICA L DIA GNOSIS. (5.) Elongation of the Prepuce or Penis. Patients afflicted with stone in the bladder contract a habit of compressing and pulling upon the glans penis to relieve the pain, by benumb- ing the sensibility of the part. As a result of this, we have evidence in the appearance of the organ, which is often of great diagnostic value. (6.) Changes in the Urine. In cases where the bladder is irritated by the calculus (as espe- cially exists in old men), the urine becomes characterized by a pus deposit, which gives it a milky or mucilaginous appearance; and, in some cases, blood is quite abundantly mixed with the urine. The latter ingredient affords a reasonable ground to suspect the presence of either ulcer- ation or of fungoid growth within the bladder. (7.) Incontinence of Urine. If present, this symp- tom is due either to paralysis, a very large stone, or to some urethral obstruction. It is usually associated with retention of urine. (8.) Rectal Symptoms. Prolapse of the rectum in children, and hemorrhoids in the adult, fre- quently arise from the presence of calculus, when micturition becomes mechanically inter- fered with. (9.) Noise of the Calculi. Multiple concretions fre- quently can be heard to jostle against each other, in case of movements of the trunk, as in walk- ing or running. (10.) Constitutional Symptoms. If calculus exist in the aged, the constitutional impairment is liable to be severe. Emaciation, impairment of sleep, dyspeptic symptoms, hectic fever, night-sweat- ings, colliquative diarrhoea, anxiety of the countenance, and a urinous odor to the patient, indicate rapid dissolution, if the cause be not removed. Physical Signs of Stone in the Bladder. The symp- tom of the greatest diagnostic value, which out- weighs all the rational manifestations of this disease, is revealed by the senses of touch and hear- • DISEASES OF THE MALE GENITALS. 295 ing. The introduction of a metallic sound (termed a searcher), when brought in contact with the foreign body, yields a peculiar sensation to the touch, similar to that obtained by contact with a foreign substance, and an audible clicking sound may often be perceived, especially if the calculus be of moderate size and sufficiently hard to render the sound apparent. The steps of the operation of " sounding for stone" may be enumerated as follows : (1.) The patient should have been relieved of as much irritation as possible, by previous rest in bed, anodynes, hip baths (if excessive inflamma- tion has existed), and diluent drinks. (2.) The patient should be placed in such a position, depending somewhat upon the choice of the operator, that the stone shall roll by gravity away from the prostate towards the fundus of the bladder. The position most used is a dorsal decubitus, with the hips greatly elevated. (3.) The searcher should be hollow, so as to inject water into the bladder, if found to be necessary, and it should be less curved and longer than an ordinary catheter. (4.) The urine should be retained for some three hours before the operation. In children, a tape is often tied around the penis to insure such an accumulation of urine. If the bladder will not bear such a prolonged retention, a few ounces (usually 3-6) of water will have to be injected through the instrument. (5.) The instrument should be inserted sufficiently into the bladder to reach the posterior wall. In case the calculus lies near the fundus, it may be felt at once; if not, it should be carefully felt for, the instrument being withdrawn inch by inch. If the stone be lodged behind an enlarged prostate, by reversing the curve of the instru- ment and draiuing it forward, the point of the instrument may detect its presence. (6.) As the operation of sounding for stone is not without danger, the period of exploration should be rendered as short as possible. SURGICAL DIAGNOSIS. Errors made in sounding for stone have led some of the most famous surgeons to operate for the sup- posed existence of a calculus, only to find them- selves deceived. The conditions, which have thus misled, may be thus enumerated : Cancer of the bladder or the rectum. Osseous cyst of the bladder. Fibrous, polypoid, or fungoid tumors of the bladder. Tubercular deposit in the walls of the bladder. Invagination of the fundus of the bladder. Prostatic calculi. Pelvic exostoses. Prominence of the sacrum. Malposition of the uterus. The operation may, furthermore, fail to give evi- dence of a stone which does exist, and thus lead to an error in diagnosis. This may occur from one of the following causes: The small size of the calculus. A want of experience in the methods of sounding. Encysted condition of the calculus. A cul-de-sac behind an enlarged prostate. A cul-de-sac behind the pubes. A bilobed bladder. Inguinal cystocele. Excess or deficient amount of fluid in the bladder. Large deposits of lymph or mucus in the bladder. Dilatation of the ureter. Excavation of the prostate by ulceration or abscess. The operation of sounding may sometimes be used to reveal to the touch of the accomplished surgeon the condition of tlie bladder, in cases where the exist- ence of calculi is not suspected. The points which may be thus gained by the " searcher " may be enumerated as follows : The capacity of the bladder. The sensibility of the bladder. DISEASES OF THE MALE GENITALS. 29? The smoothness of its inner surface. The presence of ulceration. The presence of sacculations of the bladder. The presence of incrustation. The presence of tumors. 9. Foreign Bodies in the Bladder. These are usually introduced, per urethra, by the patient, either by accident or to elicit sympathy. 10. Tubercle of the Bladder. This occurs rarely and always with similar changes in the prostate gland and the kidney. C. Conditions of the Bladder, not necessarily associated with Structural Changes in that Organ. This class of abnormal conditions of the bladder includes 1. Paralysis of the Bladder. This condition depends upon the existence of some cerebral or spinal lesion. It may follow injury, cerebral or spinal apoplexy, softenings or degenerative changes in the brain or the spinal cord, sexual excesses, shock, fevers, reflex irritation, or poisons. 2. Atony of the Bladder. This condition frequently accompanies any source of obstruction to the free evacuation of the bladder. It may also follow pro- longed voluntary retention of urine, cerebral and spinal affections, fevers, and temporary spasm. 3. Spasm of the Bladder. This condition is seldom un- associated with an exciting cause, as inflammation, calculi, foreign groAvths, etc. It is indicated by in- voluntary, uncontrollable, and exceedingly painful contractions of the bladder. 4. Neuralgla. of the Bladder. This is a rare condition. It is associated with many symptoms indicative of stone in the bladder, and is to be diagnosed from it only by the exclusion of that disease. 5. Retention of Urine. This condition may exist in the young, middle-aged, or the old. It usually results from prostatic inflammation, urethral stricture, stone in the bladder, prostatic enlargement, foreign bodies in the urethra, urethral spasm, and urethral rupture. 203 SURGICAL DIAGNOSIS. It may also occur from pressure of pelvic tumors, fracture of the pelvic bones, shock and reflex irrita- tion. 6. Incontinence of Urine. This is a very frequent con- dition of childhood, but may also affect adults. In adults it occurs most frequently in females, as sloughing from pressure, use of instruments in labor, and over-distension of the urethra in removing cal- culi are frequently followed by it. In men it is seldom unassociated with retention of urine, and is therefore, properly speaking, an overflow rather than pure incontinence. 7. Overflow of Urine. This condition results from an habitual engorgement of the bladder, resulting from a retention of its OAvn secretion. It frequently results from, or accompanies chronic prostatic enlargement, or organic urethral stricture, and is usually first noticed during sleep, although subsequently any movements requiring the action of the abdominal muscles may produce it, by pressure upon the habitually distended bladder. Many of these conditions require no special guides to diagnosis, their simple enumeration being sufficient to prevent confusion; many may also co-exist, since they are often dependent upon each other not only for their origin, but also for their continuance, and thus variations in the symptoms may be produced, which it is difii- cult to clearly elucidate. As examples of this, Ave seldom discover a calculus without inflammatory changes within the bladder, and often lesions of a more advanced character are present; again, re- tention of urine may result from structural disease within the bladder, or, if originally independent of disease within that organ, may excite the same by urinary decomposition or by simple dis- tension of the bladder itself. Inflammatory conditions also, or the presence of obstruction to the free drainage of urine, as from tumors, enlarged prostate, cancer, etc., may, in time, result in the formation of a calculus, the nucleus of which originated either as a plug of mucus, coagulated blood, or an aggregation of urinary salts, precipitated by the am- moniacal reaction of the urine. It is difficult therefore, as evidenced by these few examples, to DISEASES OF THE MALE GENITALS. 299 draw marked contrasts between diseases which are so often com- plicated, and which present, in consequence, the combined symp- toms of two affections. Besides, many of the structural changes within the bladder, or its congenital deformities and malformations, cannot be positively diagnosed during life, although suspicion may be strongly directed towards the possibility of their existence. I have arranged therefore, in the form of differential tables, only such conditions of the bladder as seem to me most liable to be con- founded in a general surgical practice, or to be capable of accurate and positive diagnosis. 300 SURGICAL DIAGNOSIS. CANCER OF THE BLADDER. STONE IX THE BLADDER. Pain. The pain is lancinating in char- The pain is never lancinating in acter, and is felt in the pelvis, rec- character, and is felt chiefly in the turn, back, or hip. penis. The pain is increased by pressure The pain is often increased by and catheterism. motion or exercise, but is not affected by catheterism. Intestinal Symptoms. Intestinal obstruction is frequent. Intestinal embarrassment is rare. Hemorrhage. Hemorrhage is frequent and often Hemorrhage is less frequent and severe. profuse. Tumor. A tumor is felt per rectum which A tumor may be detected per rec- is immovable. turn, and, if so, it is movable. Urine. Blood, pus, cancer cells, organ- Pus, blood, and crystalline de- ized tissue, etc., are often mixed posits are found often in the urine. with the urine. Age. Occurs after the fiftieth year of age. Occurs at any age. History. Dyspeptic gastric derangements An attack of renal colic is fre- often precede its development. quently the apparent commence- ment. Cachexia. A marked cachexia exists. No cachexia is present. Sounding. Reveals empty bladder. Reveals presence of a calculus. SYMPTOMS IN COMMON. Both are associated with pain in expelling the last drops of urine. " " " " frequent interruption of the stream. " " " " frequent hematuria. " " " " pus in the urine. " " " " pain independent of micturition. DISEASES OF THE MALE GENITALS. 301 RUPTURE OF THE BLADDER. RETENTION OF URINE. Percussion. Dulness on percussion over the Dulness over the seat of the blad- bladder is either absent, or diffused der always exists, and is markedly beyond its normal limits. circumscribed. Pain. The pain is not localized, but is The pain is severe, but is local- rather that of a general peritonitis, ized in the vicinity of the bladder. History. A history of traumatism, falls, or A history of urethral stricture, severe abdominal contraction upon calculus, or nervous causation is a distended bladder, exists. most frequent; but traumatism may produce it. Origin. A sense of tearing is often per- No sensation of rupture is pro- ceived by the patient. duced. Catheterism. A catheter, if introduced, either A catheter, if introduced fully fails to reach the urine, or collects into the' bladder, always discloses abnormal quantities if the peritoneal urine and affords immediate relief. cavity is filled. Urine. The urine, drawn by the catheter, The urine is generally normal or is frequently albuminous from ad- ammoniacal, in case its decomposi- mixture of peritoneal effusion, but tion has occurred within the bladder no casts are detected unless a kidney from prolonged retention. complication exists. Injection of Fluid. If water or milk be injected into The bladder is found, on explora- the bladder through a catheter no tion, to be distended after injection distension of the bladder is produced of fluids through a catheter. as revealed by a searcher. Sequels. Peritonitis always follows unless No serious results follow, if relief the abdomen be opened, the peri- is not too long delayed. toneal cavity washed out, and the rent closed by suture. 302 SURGICAL DIAGNOSIS. RETENTION OF URINE. SUPPRESSION OF URINE. Pain. Great pain, in the region of the Pain in the bladder is absent. bladder, results from distension. Percussion. Dulness on percussion exists over No dulness, over the bladder, is the distended bladder. detected on percussion. Tenesmus. Great desire to micturate and No vesical tenesmus, or desire to .vesical tenesmus are present. micturate, exists. History. A history of urethral stricture, A history of injury over the kid- direct injury to the urethra, impac- ney, surgical procedure, severe ex- tion of a calculus, or some local or posure, or some infectious disease, nervous cause, is present. etc., is usually present. Catheterism. A catheter, when introduced, No urine in the bladder is usually affords relief by a withdrawal of the detected by the introduction of a retained urine. catheter, nor is relief of symptoms produced in case a small amount of residual urine is discovered and withdrawn. Constitutional Effects. No constitutional effects are pro- A urinous odor of the skin exists, duced, provided the condition be and rapid symptoms of uraemia de- not complicated with urinal or local velop. changes. DISEASES OF THE MALE GENITALS. 303 RETENTION OF URINE. INCONTINENCE OF URINE. Urinal Escape. The urine is totally arrested, none There is a continual escape of escapes. urine. Bladder. The bladder is found to be dis- The bladder may be occasionally tended, by percussion over its seat, found empty, but is generally dis- tended, as revealed by percussion. Catheterism. Relief is always afforded by the The bladder, if distended with introduction of a catheter. urine, will be relieved by catheter- ism. Exploration of Bladder. No alteration in the neck of the In cases of true incontinence, the bladder nor change from its normal bladder will have a defectiAre power poAver of retention of injected fluids, of retaining fluids, as revealed by will be discovered. artificial distension by means of in- jection into its cavity. Age Affected. Is frequent in middle life and in Is most frequent in youth and old age, but is infrequent in youth, old age. Urethral Exploration. Urethral stricture or prostatic en- The urethral canal is often of largement is frequently detected, on normal calibre, and free from dis- exploration of the urethra, as an ease. exciting cause of retention. 304 SURGICAL DIAGNOSIS. ACUTE CYSTITIS. STONE IN THE BLADDER. Invasion. The invasion of cystitis is often The approach of symptoms, due sudden and accompanied by acute to a calculus, is often insidious and symptoms as rigors, fever, vomit- dates from a previous attack of re- ing, anxiety of countenance, etc. nal colic, in the majority of cases. Pain. The pain may be located above The pain is most frequently lo- the pubes, in the perineum, neck of cated in the glans penis. bladder, loins, or thighs. The pain is of a burning charac- The pain is most increased by ter and is rendered acute by pres- exercise, horseback riding, etc., and sure. during micturition, in some cases. Bladder. The bladder is extremely irritable The bladder retains urine easily, and cannot retain urine. unless a complicating cystitis exist. Catheterism. The introduction of instruments The effects of catheterism are ne- into the bladder produces great gative, as a rule. Sounding detects pain. the existence of a calculus. Urine. The urine contains mucus in The urine may contain pus, large quantities, often blood and blood, crystalline salts, or it may pus. It is frequently alkaline in be normal in its appearance and re- its reaction. action. Rectal Touch. No tumor detected. The calculus often can be felt as a movable tumor. SYMPTOMS IN COMMON. Both are associated with pain in region of bladder. " may be " " urinal changes. " frequent and often painful micturition. DISEASES OF THE MALE GENITALS. 305 PARALYSIS OF THE BLADDER. ATONY OF THE BLADDER. Definition. Is a condition dependent upon a loss of, or impaired contractile power of the organ from imperfect ner- vous supply. Is a condition of temporary loss of contractile power, resulting from obstruction to the free evacuation of the organ, or impaired nutrition. Origin. Paralysis of the bladder is to be diagnosed chiefly by its origin. It may ensue from 1. Injuries to the brain. 2. " " spinal cord. 3. Softening of nerve centres. 4. Apoplexy of nerve centres. 5. Functional derangements of nerve centres. 6. Organic disease of nerve cen- tres. 7. Reflex derangements of nerve centres. 8. Spinal debility from excesses. 9. Shock. 10. Fevers. 11. Poisons, etc., etc. Atony of the bladder may also be chiefly diagnosed by its exciting causes. Among these may be men- tioned 1. Prostatic enlargement. 2. Urethral stricture. 3. Prolonged voluntary retention of urine. 4. Fevers. 5. Poisons. 6. Extreme debility. 7. Acute local inflammations. Improvement. The improvement is slow, and often the condition is incurable. The improvement is rapid if the cause be removed. Frequency. Is a comparatively rare disease. Is a frequent affection. 306 SURGICAL DIAGNOSIS. CHRONIC CYSTITIS. CHRONIC PROSTATITIS. Origin. Is a sequela to an attack of acute prostatitis, or may result from an extension of inflammations from neighboring parts. Is a common disease of the blad- der, and may occur from 1. Continuation of an acute cys- titis. 2. Decomposition of urine. 3. Abnormal condition of urine ; as extreme acidity, presence of irritating salts, extreme dilution, etc. 4. Foreign bodies in bladder. 5. Extension of inflammation from neighboring organs. Size of Stream. The stream may be of normal The stream is diminished in size size. from tumefaction of the prostate. Appearance of Urine. The urine contains pus, often in large quantities, which assumes the character of a semi-transparent, te- nacious, ropy deposit, Avhich rapidly settles in the containing vessel. The urine is generally alkaline in reaction, and often ammoniacal in its odor. The urine is cloudy and may often contain pus and blood in small quantities. The urine is generally acid and is never ammoniacal, unless some bladder complication exists. Pain. The pain is not markedly con- Pain exists in the perineum and fined to the perineum. rectum. Micturition and sexual in- tercourse are often painful. Urethral Discharge. No urethral discharge is produced A gleety discharge is often pres- if uncomplicated. ent. Rectal Examination. The prostate gland is normal. The prostate is enlarged and sen- sitive. DISEASES OF THE MALE GENITALS. 307 DISEASES OF THE PROSTATE GLAND. The prostate gland may be the seat of the following varieties of disease : A. Inflammatory Diseases, under which head may be included 1. Acute Prostatitis. This disease is seldom a primary affection except when caused by injury. It usually results from an extension of disease from adjacent or associate organs. It is a rare disease in child- hood and in old age, but is frequently met with in middle life. It is frequently of gonorrhceal origin, and may, in rare cases, be of idiopathic occurrence. 2. Chronic Prostatitis. In this condition, prostatic en- largement is always present, provided a previous acute prostatitis existed, but otherwise it may be absent. It is indicated chiefly by a gleet, pus and blood in the urine, weight and dull pain in the perineum and near the anus, painful micturition, pain in sexual intercourse, and frequent nocturnal emissions. 3. Prostatic Abscess. This condition, when it exists, is almost invariably the result of an acute inflamma- tion of the prostate. It most frequently affects the lateral lobes of the gland. Abscesses may be solitary or multiple. The seat of rupture may be located in the urethra, bladder, rectum, perineum, or peritoneal cavity. This last-named method of termination, however, is rare, but, when present, is usually followed by fatal inflammation. B. Hypertrophy of the Gland—"Prostatic Enlargement." This condition is one of simple augmentation of the volume of the prostate, dependent upon the increased nutrition of its constitutional elements. It most frequently affects the whole gland, but not uniformly. The urethra is encroached upon in most cases, and the prostate is increased both in size and in 308 SURGICAL DIAGNOSIS. weight. When the middle lobe of the gland is hyper- trophied, a marked obstacle to catheterism is created. This disease is essentially one of advanced age, as it seldom appears, to any marked degree, before the age of fifty. From its mechanical effects it possesses great surgical importance. C. Atrophy of the Prostate. This condition usually occurs as a result of mechanical compression, or of structural disease within the gland. It accompanies abscess and tubercular deposit in the prostate, and frequently follows prolonged compression from a stone in the bladder. It may in rare cases be a congenital defect or result from simple senile decay. D. Cancer of the Prostate. Scirrhus of the prostate is very rare, encephaloid less rare, but by no means common. Both are present most often in advanced life, but no age is exempt from the development of encephaloid cancer. No absolute cause for the appearance of cancer in this region can always be detected, though it may follow the development of a vesical calculus or the formation of a urethral stricture. The duration of the disease seldom, as a rule, exceeds twelve months. It is one of the causes of hematuria. Melanotic deposit is said to be occasionally associated with encephaloid of the prostate. E. Tubercle of the Prostate. This is a condition of extreme rarity and is always associated with a similar condition of the adjacent organs. The volume of the prostate may be either natural, increased, or diminished, though the latter is, by far, the most frequent condition. No abso- lute diagnosis of this affection can be made during life, although the presence of tubercle may be suspected. The symptoms of abscess are occasionally developed by suppuration around the cheesy masses. F. Cystic Disease of the Prostata. Cysts of the prostate gland are rarely met with ; but, when present, they possess a pathological interest. They are usually multiple, several existing at a time, and they vary in size from a mere speck to that of an olive. Their contents are transparent and consist of either a thick, viscid, albuminous substance, or a thin DISEASES OF THE MALE GENITALS. 309 serous fluid. These cysts are due, in all probability, to closure of the prostatic ducts and retention of their secretion. Little is known as to their progress, symptoms, or termination. By some they are regarded as dependent only upon the previous existence of prostatic concretions. G. Prostatic Calculi. These little bodies are probably the result of a disordered follicular secretion, dependent upon sub-acute or chronic irritation. They are most common in old age, but may exist at any period of life. They consist almost entirely of phosphate of lime. When very abundant they may destroy the glandular structure of the prostate and become aggregated into one large cyst. They may often be positively detected during life by introducing the finger into the rectum, while a bulbous bougie is passed in and out of the prostate. By this means they may be felt as immovable bodies, or if encysted, as a bag of small nodules. Their immo- bility is a symptom of great diagnostic importance. H. Prostatic Hemorrhage. Hemorrhage from the prostate is rare, and present usually in the aged, when catheterism is forcibly employed. It may also follow falls upon the nates, riding upon horseback, bloAvs in the perineum, or excessive venereal indulgence. The hemorrhage is occa- sionally spontaneous, and in these cases is dependent upon some ulceration or granular condition of the mucous membrane, or the presence of a fungous, erectile, or en- cephaloid tumor. The blood from the prostate is often unmixed with urine, and often precedes and also follows the act of micturition. I. Phlebolites. By this term is designated earthy concretions within the veins. In the female, the veins of the vagina and uterus, and, in the male, the prostatic plexus of veins are most frequently affected. They usually follow chronic irritation. They consist chiefly of phosphate and carbonate of lime, cemented by a small quantity of ani- mal matter. J. Wounds of the Prostate Gland. These are the result either of accident or design. In the latter case they are 310 SURGICAL DIAGNOSIS. made by the surgeon for some useful purpose, as the ex- traction of stone, etc., etc. Wounds of the prostate gland may be, as respects their character, either incised, lace- rated, punctured, or gun-shot. Wounds, due to accident, may result from forcible catheterism, by inexperienced attempts at extraction of a stone, by fracture of the pelvic bones, by puncture through the perineum or rectum of some pointed stick or instrument, and by gun-shot wounds. The effects of wounds of the prostate gland may be manifested, either as hemorrhage, inflammation, infiltra- tion of urine and consequent sloughing, retention of urine from tumefaction of the surrounding parts, urethro- vesical or urethro-rectal fistulae, and abscess either with- in the substance of the gland or between the gland, and the rectum. If unassociated with wounds of the skin, injuries to the prostate are obscure and often difficult of diagnosis. In old age wounds of the prostate are associated with serious hemorrhage. This is explained on the ground of the great increase in the size and the varicose condi- tion of the prostatic plexus of veins. I have in the preceding pages briefly sketched the general out- lines of diseases of the prostate gland. In some instances I have enumerated, in connection with the de- scription of the disease, the few points upon which our present means of diagnosis of these obscure diseases rest. Atrophy, cancer, tubercle, cystic disease, prostatic calculi, and phlebolites may often exist unsuspected during life, as the symptoms are frequently of a vague and imperfect character. I have, however, arranged in the form of tables the points of contrast between the inflammatory affections of the prostate and the distinctions to be drawn between hypertrophy of the prostate gland and organic urethral stricture. DISEASES OF THE MALE GENITALS. 311 ACUTE PROSTATITIS. CHRONIC PROSTATITIS. History. Is usually of traumatic origin, or Is secondary to the acute form, or follows an extension of inflamma- may folloAV a gonorrhoea by an ex- tion from other parts. tension of that disease backwards. Pain. The pain is violent and pulsatile, The pain, when present, is local situated deep in the perineum in and confined to the pelvis, usually front of the anus, and is augmented in the rectal region. by pressure. Rectal Symptoms. Rectal tenesmus and marked pain Rectal tenesmus is often absent, during defecation are usually pres- and defecation is seldom painful. ent. Urine. The urine is high colored, and The condition of the urine is af- niay contain pus or blood. fected by the weather, habits of the patient, and the amount of exercise taken. Retention of urine is frequent. Retention of urine is infrequent. Rigors. Rigors are frequent if suppura- Rigors are seldom present. tion occurs. Rectal Examination. The prostate, when examined per The prostate exhibits local sensi- rectum, is hot, enlarged and tender, tiveness to the touch and enlarge- In case suppuration occurs it often ment. It seldom, if ever, goes on to becomes fluctuant. suppuration, and is therefore not fluctuant. Abscess. Pus may form and escape through Abscess is of rare occurrence. the urethra, bladder, rectum, pelvic fascia, or perineum. SYMPTOMS IN COMMON. Both may be associated with frequent micturition. " '- " pain during micturition. " " " " elevation of pulse and temperature. 312 SURGICAL DIAGNOSIS. HYPERTROPHY OF THE ORGANIC URETHRAL PROSTATE. STRICTURE. Age Affected. Is most frequent after fifty. Occurs at any age, but usually after puberty. History. A venereal history is often ab- Is commonly associated with a ve- sent. nereal history. Micturition. The length of the act of mictu- Micturition is prolonged, as a rition is often hastened by attitude, rule, but is unaffected by attitude. Bladder. A sense of incomplete evacuation No abnormal sensations are pres- is often present in the bladder. ent in the bladder if not diseased. Urine. The urine is frequently ammo- The urine is seldom ammoniacal, niacal from decomposition of the as the bladder can empty itself com- residual urine retained by the en- pletely. larged prostate. Pus, mucus and blood are com- No abnormal deposits exist, saAre mon ingredients. « when complications are present. Rectal Exploration. The finger when introduced into The prostate is found to be of the rectum detects the enlarge- normal size, by rectal examination. ment of the prostate. Urethral Exploration. Bulbous bougies reveal a perfect- Bulbous bougies, or a urethro- ly normal urethra in front of the meter, reveal the seat, calibre and prostatic region, if uncomplicated. length of the urethral constriction. SYMPTOMS IN COMMON. Both are associated with a prolongation of the act of micturition. " " " " impairment of the force and size of the urinal stream. " " " " frequent retention of urine. " " " " hemorrhoids from straining. " " " " changes in bladder, kidneys and ureters. DISEASES OF THE MALE GENITALS. 313 DISEASES OF THE URETHRA. The surgical diseases of the urethral canal may be classified into A. Inflammatory Diseases. Under which head may be embraced 1. Gonorrhceal Inflammation. This condition depends upon the contact of a specific poison with the ure- thral mucous membrane. It is characterized by all the symptoms of acute catarrhal inflammations, and when long continued, results in new connective- tissue formation outside of the urethral walls. It is the most frequent cause of organic stricture. It is evidenced by local engorgement, a purulent dis- charge, pain in micturition, and occasionally by con- stitutional disturbance. 2. " Urethritis," or, Non-specific Inflammation. This condition is produced by local irritation, and not by the contact of a specific gonorrhceal poison. It dif- fers from the former type of disease in the absence of its severe local symptoms and the amount of the discharge. It may result in the formation of stric- ture if of protracted duration. It is a rare affection. In very acute forms, urethritis is, clinically, closely allied to gonorrhceal inflammation. 3. Local Ulcers, of the Chancroidal or Syphilitic Variety. This type of disease will be considered, in all its bearings, in subsequent pages, arranged in the form of a diagnostic table. B. Diseases of the Urethra, affecting the Structure of its Coats. Under this head may be embraced 1. Urethral Stricture (organic). Under the term urethral stricture I include only abnormal organic contraction of the urethral canal. It may present the following- types : 1. Annular, where a localized ring of contrac- tion exists, as if an external cord were tied around SURGICAL DIAGNOSIS. the urethra. 2. Linear, where an elevated ridge exists, parallel to the long axis of the urethra. 3. In- durated Annular, or " hour-glass" stricture, where the constricting ring is indurated or thickened at its base. 4 Tortuous, where the urethral canal is irregularly constricted. 5. " Bridle stricture," where bands extend trans\rersely across the urethral canal. It may result from specific or non-specific inflam- mation, from cicatrizations or adhesions within the urethra, from abnormal urethral growths, and from congenital malformation. Its early symptoms are chiefly gleet, alterations in the size of the urinal stream, and interference with the act of micturition. Its later symptoms depend upon changes in neighboring parts, pro- duced by its mechanical interference with the free escape of urine, and may be localized within the bladder, rectum, kidney, perineum, or testicle. The diagnosis of.urethrai stricture, to be com- plete, must determine the following points: The situation of the stricture. The length " " The calibre of the opening. The variety of stricture present. The condition (as regard its sensibility). To accomplish all these requirements, the follow- ing aids are employed: (1.) Bulbous bougies, which are larger at the in- serted end than in the shaft, and can thus be arrested only at the point. They thus indicate the exact situation of the anterior portion of the stricture, by measurement being taken of the portion inserted, after its withdrawal. They are more reliable than a solid instrument, since they are incapable of dilating a stricture during their passage; and they thus render the detec- tion of existing strictures comparatively free from a percentage of error. They are capable of recording also the calibre of the constriction. The urethra should be DISEASES OF THE MALE GENITALS. 315 completely filled by the bulb of the first bougie introduced, and, if that be arrested, smaller sizes should be introduced, till one will pass through the orifice of the stricture. The meatus of the urethra may, possibly, have to be di- vided, in some cases, before one sufficiently large to fill the urethra can be first introduced. (2.) The urethrometer, invented by Dr. Otis, is a still more reliable and accurate means of diagnosis. It consists of an instrument which is introduced into the urethra as far as the bulbous portion of the canal, when, by means of a screw in the handle of the instrument, a bulbous projection is expanded at the inserted end, till a sense of moderate distention is perceived by the patient. The instrument is then drawn forward until arrested, as it will be, if strictures exist, when the bulb is reduced in size sufficiently to pass the-constriction. A dial upon the instrument records the first measurement as that of the normal urethra, and the second, as that of the calibre of the stricture. Several successive strictures can be thus measured, provided the instrument is screwed up to the normal urethral measurement after each constriction is passed. (3.) The endoscope, in some cases, enables the surgeon to perceive the character of the urethral mu- cous membrane for nearly its whole extent, and often to examine the orifice of an existing stric- ture. It is of the greatest value, however, in deciding upon questions of the condition of con- cealed mucous surfaces. As an aid to the diag- nosis or treatment of urethral stricture, I have found it of little value. (4.) The sensations of the patient during instrumen- tation are often of great assistance to the surgeon in determining the condition of the mucous mem- brane of the urethra, since the presence of local- ized spots of extreme tenderness often indicate a condition which has been called " granular ure- thritis " by some authors, and which, by some, is considered as the formative stage of urethral 316 SURGICAL DIAGNOSIS. constriction. The presence or absence of a tend- ency to hemorrhage, the sensation given to the touch as the instrument passes the stricture, and the amount of induration detected by an external examination, are also of great value in deter- mining the exact condition of the urethral canal, but they can only be fully appreciated in their bearings by those having a large practical ex- perience in such examinations. An accomplished urethral surgeon should be able, by the sense of touch alone, to appreciate the length and character of a stricture; and also to detect the entrance of an instrument into a false passage, where the mucous lining is gen- erally absent, since the sensation afforded the surgeon by means of the instrument differs in that case from that afforded by the mucous lining of the normal canal. 2. Urethral Dilatation. Urethral dilatation occurs most frequently at the membranous portion of that canal. It is due to obstructed evacuation of urine. It results in the formation often of a perineal tumor, which appears only during micturition. It is a frequent cause of urethral rupture. 3. Urethral Rupture. This condition may be of trau- matic or spontaneous origin. It follows blows or lacerations in the vicinity of the perineum, or it may result from a previously existing local dilata- tion of the urethra. It may occur either within the membranous por- tion, immediately in front of the triangular ligament of the perineum, or anterior to the peno-scrotal junction. It seldom, if ever, affects the prostatic portion of the urethra, unless as the direct result of injury or abscess of the prostate. Rupture of the urethra is always followed by, or accompanied with extravasation of urine. The symptoms produced by this extravasation differ with the locality of the seat of rupture. In all cases, howeATer, if the urine be retained outside of its normal channels, sloughing occurs from decom- DISEASES OF THE MALE GENITALS. 317 position of the retained urea into carbonate of am- monia and the excessive inflammation produced by it, though the symptoms accompanying this de- structive process may vary greatly with the locality affected. 4. Urethral Deformities. The deformities of the ure- thra may be congenital or acquired. In rare cases, the meatus may be located at the side of the glans penis, the urethra may terminate in the groin, the ejaculatory ducts may open as a separate canal on the dorsum of the penis behind the glans, enor- mous congenital dilatations of the urethra may exist, congenital stricture, and valvules pointing backwards and obstructing the flow of urine but not the passage of instruments, have been reported. Atresia, hypospadias, and epispadias, are, how- ever, the deformities of the urethra most frequently encountered. 5. Urethral Tumors. The tumors of the urethra may be either polypi, vascular granulations, tubercle, or cancer. The first two are most frequently located in the prostatic portion of the canal. Tubercular or cancerous deposits in the urethra are rarely primary, but are secondary, as a rule, to similar conditions of the bladder, prostate gland, or kidney, which have reached an advanced stage in the disease. 6. Urethral Abscess. Urethral abscess is most fre- quently located at the fossa navicularis, the bulb of the corpus spongiosum, or in CoAvper's glands. The latter condition is denominated " Cowperitis" by some authorities. When the fossa navicularis is affected, the tumor appears on one side of the frae- num, but if the bulb or Cowper's glands are affected the tumor is situated in the perineum. In either case the symptoms are those of abscess, and the causation is usually gonorrhceal. 7. Urethral Fistula. These may exist in the perineum, scrotum, groin, nates, penis, or even above the sym- physis pubis in case of extravasation of urine. Uri- 318 SURGICAL DIAGNOSIS. nary fistulae may be classified as 1. Simple fistulae where the surrounding parts are normal. 2. Fistulae complicated byT inflammatory induration and de- formity of tissues. 3. Fistulae dependent upon de- struction of the soft parts by sloughing. Fistulae of the urethra are generally associated with urethral stricture or abscess, but they may fol- low impaction of calculi or foreign bodies. They also result from injury causing a rupture of the urethra, and, in rare cases, are congenital. C. Conditions impeding the Normal Exit of Urine and Inde- pendent of Structural Changes. This class of condi- tions embraces: 1. Urethral Spasm. This condition seldom, if ever, ex- ists to a degree sufficient in itself to prevent or im- pede the normal power of expulsion of urine, except when complicated by organic stricture. It is de- veloped, when present, to the greatest degree in the membranous portion of the urethra, in which location the compressor urethrae muscle assists the involun- tary muscular fibres of the urethral walls. It may result from acid urine, cantharides, turpentine, alco- hol, repressed gonorrhceal discharge, organic stric- ture, and rectal diseases. It is associated with marked and intermitting variations in the size of the stream, and if uncompli- cated by organic stricture should disclose a normal degree of patency of the urethra after the attack has subsided. 2. Congestive Stricture. This variety of stricture is always dependent upon turgescence of the urethral mucous membrane, arising from an inflammatory condition of that part. It is always associated with more or less spasm of the urethra, and, like that disease, is to be diagnosed from organic contraction by the existence of a normal urethral calibre after the attack has been relieved. 3. Urethral Calculi. These bodies are usually derived from the kidney or the bladder, but, in rare in- stances, may form behind an urethral obstruction. DISEASES OF THE MALE GENITALS. 319 They may be single or multiple, and may be asso- ciated with retention of urine, or an absence of symptoms of obstruction. If not removed, dilatation of the urethra, ulceration, and frequently rupture, follow. 4. Foreign Bodies in the Urethra. Foreign bodies are frequently introduced into the urethra either through accident or during attempts to relieve retention of urine, or to induce sexual excitement by the friction of some extraneous substance upon the urethral walls. Thus pieces of slate pencil, heads of wheat, leather thongs, hair-pins, etc., etc., have, in numer- ous cases, been reported as present in the urethral canal. 320 SURGICAL DIAGNOSIS. RUPTURE OF THE URETHRA PERINEAL ABSCESS. WITHIN THE TRIANGULAR LIGAMENT. Origin. Appears as a sudden tumor in the Begins as a slowly increasing perineum, associated with an indis- tumor in the perineum. tinct sense of rupture and abnormal sense of warmth in the perineum. Previous History. A previous history of urethral A sense of heat, local pain and stricture is usually present, but no soreness have usually preceded the premonitory manifestations of rup- development of the tumor. ture may have existed. Fluctuation. Fluctuation is present from the Fluctuation appears late. onset. Tumor. Is elastic and tense from the onset, Is hard and cedematous in its until it burrows or escapes from the early stages, but becomes, later on, perineum. fluctuant and elastic. Micturition. Retention of urine is frequent and Retention of urine is seldom pres- follows rapidly upon the appearance ent, but, if so, it occurs late in the of the tumor. disease. Extent of Inflammation. The scrotum, abdominal walls The inflammation and suppura- and thighs, may become rapidly im- tion are confined solely to the peri- plicated when the tumor leaves the neum. perineum. Results. Tends towards rapid sloughing. Tends towards pointing and the evacuation of pus. SYMPTOMS IN COMMON. Both are associated with a perineal tumor. " " " " possible retention of urine. " " " " suppuration. " " " " fluctuation. DISEASES OF THE MALE GENITALS. 321 RUPTURE OF THE URETHRA RUPTURE OF THE URETHRA IX THE MEMBRANOUS IN FRONT OF THE TRI- PORTION. ANGULAR LIGAMENT. Tumor. The tumor is, at first, confined The tumor is never confined to to the perineum. the perineum. Scrotum. If the scrotum be distended by The scrotum is frequently dis- urine, it is only involved after tended from the onset of the attack sloughing of the triangular liga- and appears red, tense and cedema- ment has freed the imprisoned urine, tous. Abdomen. The abdominal walls often escape The abdominal walls frequently infiltration by urine, and subsequent become involved before the tension sloughing. of the scrotum is relieved by in- cision or by sloughing. Thighs. The thighs are involved late, if The thighs are often infiltrated at all. early. Pelvic Organs. The pelvic organs 'may undergo The pelvic organs are never in- sloughing or a general peritonitis volved, as the imprisoned urine es- may ensue, from extension of the capes before the sloughing process, urine into the pelvic fascia. produced by it, is sufficiently exten- sive to involve the deeper struc- tures. 322 SURGICAL DIAGNOSIS. RUPTURE OF THE URETHRA FRACTURE OF THE PENIS. IN FRONT OF THE SCRO- TUM. Origin. May be of spontaneous origin, or Is always due to injury. due to traumatism. It usually follows and is depen- Is not dependent upon urethral dent upon urethral stricture. stricture or any diseased condition. Penis. The penis is red, swollen, tense The penis is greatly swollen and and cedematous. ecchymosed, or, hemorrhage may exist through the urethra or in- tegument. Integument. The integument is always intact, The integument may be lace- but is distended. rated. History. A history of the appearance of The history of some accident to the tumor during attempt at mic- the genital organ while in the state turition is usually present, pro- of erection, is usually present. vided the rupture was not trau- matic. SYMPTOMS IN COMMON. Both are associated with great swelling and deformity. " " " " frequent retention of urine. " " " " frequent sloughing. " " " " frequent suppuration. " " " " possible permanent deformity after recovery. DISEASES OF THE MALE GENITALS. 323 ORGANIC STRICTURE OF ENLARGED PROSTATE. THE URETHRA. Age Affected. Occurs at any age, but usually Is most frequent after the age of after puberty. fifty years. History. Is commonly associated with a A venereal history is often absent. venereal history. Micturition. Micturition is prolonged, as a The length of the act of mictu- rule, but is unaffected by attitude, rition is often hastened by attitude. Bladder. No abnormal sensations are pres- A sense of incomplete evacuation ent in the bladder if not diseased. is ahvays present in the bladder. Urine. The urine is seldom ammoniacal The urine is frequently ammo- as the bladder can empty itself com- niacal from decomposition of the pletely. residual urine retained by the en- larged prostate. No abnormal deposits exist, save Pus, mucus and blood are com- when complications are present. mon ingredients. Rectal Exploration. The prostate is found to be of The finger, when introduced into normal size, by rectal examination, the rectum, detects the enlargement of the prostate. Urethral Exploration. Bulbous bougies, or an urethro- Bulbous bougies reveal a perfectly meter reveal the seat, calibre and normal urethra in front of the pros- length of the urethral constriction, tatic region, if uncomplicated. SYMPTOMS IN COMMON Both are associated with a prolongation of the act of micturition. " " " " impairment of the force and size oi the urinal stream. " " " " frequent retention of urine. " " " " hemorrhoids from straining. " " " changes in bladder, kidneys and ureters. 324 SURGICAL DIAGNOSIS. ORGANIC URETHRAL URETHRAL TUMORS. STRICTURE. Sex Affected. Is principally a disease of males. Urethral tumors affect both sexes and may be of two great varieties, polypoid and vascular. In males the polypoid tumors are most common; in females, the vas- cular, or fleshy tumors are usually present. Location. Urethral stricture is never de- In males the tumors are most tected in the prostatic portion of the frequent just within the meatus, urethra and seldom behind the bulb but they may affect the membra- of the corpus spongiosum. nous and prostatic portions of the urethra. Pain. Urethral strictures are sensitive, The vascular tumors are extreme- often, to the touch, but rarely give ly painful and sensitive, but the pain except during micturition. polypoid tumors are painless. Origin. Strictures are most frequently of The origin of these tumors is un- gonorrhoeal or traumatic origin. known. Hemorrhage. Strictures seldom cause sponta- The polypoid tumors seldom neous hemorrhage. bleed, but the vascular tumors often bleed profusely. Mobility. Strictures are constant in their Polypoid tumors may be movable situation and immovable. Avith the urethra. SYMPTOMS IN COMMON. Both may produce a small stream. " " " prolonged and painful micturition. " " " a gleety discharge. " " " subsequent diseases of adjacent organs. " " " impaired general health. DISEASES OF THE MALE GENITALS. 325 DISEASES OF THE PENIS. The diseases to which the penis is subject may be divided into four groups as follows : A. Diseases of the Glans Penis : under which head may be enumerated the following conditions : 1. Balanitis. This term is used to designate an inflam- mation of the surface of the glans penis. It occurs most frequently in persons of gouty habit, or those possessing an irritable skin. It results often in those not predisposed to its occurrence, from re- tention of the smegma preputii, from contact with gonorrhceal, menstrual, or leucorrhceal discharges, from lack of cleanliness, and from other sources of irritation. Its symptoms are similar to those of the following disease. 2. Posthitis. By the term posthitis, is meant an in- flammation of the mucous membrane of the prepuce. Its causes and symptoms are identical with those of balanitis. The mucous membrane becomes red- dened, mottled and often ulcerated. A purulent discharge is present which arises from the surface of the glans, and not from the urethra. A sense of burning and itching at the penis exists, and scalding during micturition may often be present. Inflammatory phimosis often occurs from swelling of the prepuce, and warty vegetations are a common result of a prolonged balanitis or posthitis. 3. Herpes Progenitalis. This type of the herpes erup- tion appears either upon the glans, the mucous or cutaneous surface of the prepuce, or even upon the body of the penis. It is indicated by the formation of clusters of small ATesicles, which often ulcerate when exposed to moisture, as when within the pre- putial covering, and assume, in rare cases, an angry and deep character. These ulcers more frequently tend, however, towards recovery, but in some in- 326 SURGICAL DIAGNOSIS. stances vegetations, balanitis or inflammatory phi- mosis result as sequelae. 4. Vegetations and Venereal Sores. " Venereal warts" may be located either upon the glans, prepuce, scrotum, anus, or, in some cases, within the urethral canal. Their common designation is a misnomer, as they are more often due to simple irritation than to a venereal origin. They are frequent in children and in pregnant women, who are troubled with irritating vaginal discharge. They are almost invariably multiple. True venereal ulcers however are frequently found in the same situations as are venereal warts. They are of two great types : chancroid and chancre; the former being a purely local disease, the latter being a local evidence only of an existing blood condition. These two diseases are due to the presence of a spe- cific poison, and will be considered in contrast in subsequent pages of this work. 5. Epithelioma. This form of cancer most frequently attacks the glans penis and prepuce, and occurs usually after the age of forty. It is characterized by all the general symptoms of epithelioma in other parts of the body. It will be more exhaustively considered under the head of tumors. B. Diseases of the Prepuce : under which head is embraced the conditions of phimosis and paraphimosis. 1. Phimosis. The prepuce may be incapable of retrac- tion over the glans from absence of the opening (atresia preputii), from inflammation, from adhe- sion, and from congenital defect. It is a normal condition in infancy, and, unless sufficient to cause inflation or " ballooning " of the prepuce during at- tempts at micturition, need cause no surgical inter- ference. Phimosis tends, if extensive, towards im- perfect de\relopment of the glans penis. It may also produce balanitis, cystitis, sperma- torrhoea, and reflex nervous diseases, if severe in extent and long continued, especially if adhesions exist. DISEASES OF THE MALE GENITALS. 327 2. Paraphimosis. Paraphimosis may be the result of an accidental retraction of a tight preputial orifice over the glans penis, or it may occur as a result of in- flammatory oedema, when the preputial orifice has always exhibited a normal condition. This latter condition often accompanies balanitis, gonorrhoea, chancroid, chancre, or even a severe attack of herpes. It occurs, as a rule, during at- tempts to apply local treatment to the existing con- dition of the glans penis. In all forms of paraphimosis the glans becomes rapidly swollen and livid in appearance, from the obstructed venous return, and thus increases the difficulty of reduction. If not rapidly relieved, sloughing occurs, and destruction of the glans or a urinary fistula is liable to be produced. C. Diseases of the Corpora Cavernosa : under which head are included the following conditions : 1. Inflammation. This condition is always one of serious import. It may arise spontaneously from a severe gonorrhoea, or in connection with the exanthematous fevers. It also follows contusions and fracture of the penis. As a rule, suppuration and gangrene result when the inflammatory process is severe. The local pain is very excessive. It is a rare disease. 2. Calcification of the Penis. This condition is ana- logous to atheroma of the blood-vessels. It is insidious in its approach, occurs in middle life or old age, and is first denoted by an imperfect and painful erection of the penis, the organ being bent where calcification has occurred, as the fibrous sheath loses its elasticity in consequence of the osseous deposit. In advanced cases osseous plates can be detected in the body of the organ. 3. Gummata. Gummy tumors may, in rare cases, affect the genitals in advanced stages of syphilis. They are to be diagnosed from fatty, fibrous, cystic and erectile tumors, which may also affect the penis. This can be easily done by the previous history of the patient, and the tendency of gummata to sup- 328 SURGICAL DIAGNOSIS. purate and discharge. Gummata seldom reach a large size. 4. Chronic Circumscribed Inflammation. This affection is very rare. It consists of a local inflammatory induration, the cause of which is unknown, pro- ducing a deformity of the penis during erection. The indurated mass has elasticity, and differs in this respect from the osseous plates produced by calcification. It is usually superficial, with well- defined edges, and is slowly progressive in develop- ment, or occasionally stationary for an indefinite period. 5. Fracture of the Penis. The fibrous sheath of the corpora cavernosa is occasionally ruptured and the adjacent erectile tissue is involved. This condition constitutes the so-called fracture of the penis. It is always accompanied by extensive extravasation of blood, and, in severe cases, may terminate in gan- grene. It is produced by injuries received while the organ is in a state of erection. It terminates usually in recovery, when treated early, but may leave a deformity in erection or a nodular swelling at the seat of fracture, which may render subsequent sexual intercourse difficult and painful. By some authors the voluntary or spontaneous rupture of a chordee during a violent attack of gon- orrhoea or non-specific inflammation, is regarded as a variety of fracture of the penis. In this case, however, the corpus spongiosum only is involved, and, as the blood escapes through the urethra, little local deformity is the immediate result, although a severe form of organic stricture inevitably follows. D. Anomalies of the Penis. The penis may be rudimentary in size, or may in rare instances be enormously developed. It may also be double, as is reported by several authors; and in one case described by Nelaton was congenitally absent. These unnatural conditions, however, have little surgical importance, as nature, usually, provides a means of free urinal escape, and the general health is therefore unimpaired. DISEASES OF THE MALE GENITALS. 329 I have in the preceding pages briefly enumerated the principal surgical diseases of the genital organ. Many of them are infre- quent, and can be excluded as probable causes of confusion in diag- nosis on that ground; while others are too clearly marked in their symptoms to need further elaboration. I have added, however, the distinctive points of diagnosis between chancroidal ulcers and the syphilitic sore, as they are frequently a source of doubt to the prac- titioner, and as a radical difference in the prognosis and treatment depends upon an early recognition of the disease existing. 330 SURGICAL DIAGNOSIS. CHANCROID. CHANCRE. Nature of Ulcer. Is a purely local affection. Is a local manifestation of an ex- isting blood disease. Incubation. The ulcer develops immediately The ulcer develops from 10 to after absorption of the poison :— 24 days after infection, as a rule. 24 hours to third day after infection. Shape of Ulcer. The ulcer is round, as a rule, but Is generally circular or oval. may be oval, or irregular from fu- sion of multiple sores. Edges of Ulcer. Are clean-cut, perpendicular, of- Are smooth, often elevated, ad- ten everted and undermined. herent, not undermined, and grad- ually melt into the floor of the ulcer. Floor of Ulcer. Uneven, honey-combed, warty or Smooth, often concave, and shin- irregular, without lustre. ing. Color of Ulcer. Yellowish ; often a red dish or vio- Grey in centre, darker at edges, let areola exists around the sore. sometimes scabbed ; areola is often absent. Situation. Rarely present except on, or near May exist on genitals, head, hands the genitals. or nipple. Causation. Contact with chancroidal ulcer or Contact with primary sore, a inoculation with its pus. secondary lesion of syphilis, vacci- nation, or inoculation upon an ab- rasion of the surface. Pain. Is usually painful. Is usually painless and indolent. Number. The ulcers are seldom single. A solitary sore is usually present DISEASES OF THE MALE GENITALS. 331 CHANCROID CHANCRE (continued). (continued). Method of Origin. Begins as a pustule, or an ulcer Begins as a papule or an erosion, and remains an ulcer. and remains an erosion or ulcerates. Secretion. Ichorous and irritating pus in Scanty and serous in character, first stage ; but laudable when ulcer unless the sore be irritated when it is healing. becomes purulent. Induration. Is absent, unless the ulcer be ir- Often precedes the sore, and lasts ritated ; is not elastic or abrupt in long after its disappearance. It is its termination, subsides after the hard, elastic, cartilaginous, usually irritation is removed, is adherent to hemispherical in shape and abrupt the skin and sensitive to pressure. in its outline. It is very movable and never sensitive to pressure. Inoculability. Is auto-inoculable, is transmissi- Is not auto-inoculable unless irri- ble and can be communicated to tated, and is transmissible only to animals. human species. Bubo. Suppuration of the lymphatics of The enlarged lymphatic glands in the groin is frequent. The bubo is the groin are usually painless, mul- usually painful and mono-glandu- tiple, and seldom suppurate, unless lar. injured or due to a mixed infection. Extent of Ulcer. Is often of large extent from an Is seldom phagadenic, and shows accompanying phagadaena, and se- little tendency to spread. vere in its local results. Duration. Often lasts from one to tAvo Is slow in development, but heals months. rapidly when once reparative pro- cesses commence. Cicatrix. Not distinctive. Pigmented, as a rule. Results. No constitutional symptoms are Secondary symptoms of syphilis developed. rapidly appear. 332 SURGICAL DIAGNOSIS. HERPES. BALANITIC ABRASION. Origin. It may occur from cold, fever, or It follows only friction, mechani- a nervous condition, as well as from cal irritation, or the contact of friction, irritation, or the chemical acrid discharges from the glans or action of acrid discharges. . prepuce. Locality. May be a local disease only, or Is always a local affection. may exist as an evidence of an ab- normal nervous condition in other parts simultaneously. Development. It begins as a group of vesicles. Begins as an abrasion or a fissure. Pain. Is associated with a stinging and Is painful and sensitive. burning sensation as it develops. Tendency to Recur. A marked tendency to recur at No tendency to periodical relapses regular intervals is often exhibited, is present, but it may be reproduced It is often induced to return by by a return of the exciting cause. dissipation or excessive venery. Appearance of Ulcer. Is rounded in its shape, often Resembles a chancroidal ulcer slightly irregular, and its borders when fully developed. may disclose the remnants of pre- vious vesicles as segments of small circles. SURGICAL DISEASES OF THE ABDOMINAL CAVITY SURGICAL DISEASES OF THE ABDOMINAL CAVITY. Under this head will be considered, in this volume, the following named conditions, A. INJURIES OF THE ABDOMEN. The injuries to the abdo- men may be of three varieties, as follows : 1. Contusion of the Abdomen. Contusions of the ab- domen may be present with or without rupture of the viscera. In either case such an accident is fre- quently accompanied with intense pain, faintness or syncope and vomiting. In some cases death has occurred by an impres- sion made upon the solar and cardiac plexuses, without any internal lesion being discovered. Contusions of the abdomen may produce either rupture of muscles, extravasation of blood, rupture of the peritoneum, rupture of the diaphragm, rup- ture of the stomach or intestine, lacerations of the liver and spleen, rupture of the gall-bladder, or lacerations of the kidney and the ureter. Contusions of the abdomen usually occur from fly- ing objects, as cricket-balls, etc., etc., from blows received during altercations, from falls upon the abdomen, cart-wheels passing over the body, or from some other similar misfortune. If uncomplicated by injury to viscera, contusions of the abdomen may result in abscess or recovery. 2. Wounds of the Abdomen. "Wounds of the abdominal parietes may be either superficial or deep, and may be associated with the absence of complications, or the protrusion, and possible injury of adjacent viscera. They may occur from sharp and pointed instru- ments, from being impaled upon iron spikes, caught 335 SURGICAL DIAGNOSIS. upon iron hooks, tossed by horned cattle, injured by glass, china, or missiles, or by the bites of carnivor- ous animals. "Wounds of the abdomen may vary therefore greatly in appearance, variety, extent and location. They may be complicated with serious hemorrhage and with the introduction of foreign substances into the abdominal cavity through the wound, even in case the viscera escape injury. The intestines, stomach, liver, spleen, bladder, omentum, and mesentery may protrude, in case the location and character of the wound favor such a displacement. Artificial anus may result in cases of wounds of the abdominal parietes, although it is a more fre- quent sequela of diseased conditions of the intestine associated with sloughing. 3. Foreign Bodies ln the Intesttnal Canal. Foreign bodies which are proof against the action of the gastric or intestinal juices are often introduced into the stomach either by accident or with design. The foreign bodies often detected include coins, bullets, fruit-stones, pebbles, marbles, hair, string, oat-husk, pins, fish-bones, false teeth, etc., etc. The results of the introduction of foreign bodies into the stomach differ with the size and shape of the body introduced. Small, flat, or oval bodies may be voided with- out delay, pain, or other symptoms of disturbance. If hair, string, or similar substances, be present in the stomach, they often attain immense size, and, by remaining within that organ, frequently produce symptoms of severe dyspepsia, and subsequently those of ulceration and perforation of its coats. Irregular-shaped or globular bodies frequently be- come arrested at the ileo-caecal valve, if allowed to pass the pyloric orifice of the stomach. Sharp or pointed bodies are best voided by plenti- ful eating and the avoidance of cathartics, as, by so doing, the foreign body is more liable to be inclosed in the abundance of fsecal material. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 337 Needles when swallowed often penetrate the walls of the alimentary canal and are transported to dis- tant points often before their removal. B, DISEASES OF THE INTESTINE: 1. F.ECAL Abscess. Abscess of the abdominal region is often dependent upon an artificial aperture in some portion of the alimentary canal. It may arise from perforation of the bowel as a sequel to simple ulceration, the lodgement of a foreign body in the intestine, ulceration of the gall-bladder from a gall- stone, stricture of the intestine, cancerous disease of the bowel, or faecal impaction as a result of mus- cular atony or paralysis, dependent upon previous catarrhal inflammation of the intestine. The most frequent seat of faecal abscess is in the region of the ilio-cascal valve—the right iliac fossa; but abscess may be present in any portion of the abdominal cavity. Faecal abscesses follow no definite rule as to symptoms, rate of progress, or termination. They may develop slowly and insidiously, or rapidly with severe local pain and marked consti- tutional disturbance followed by symptoms of a general peritonitis. In the diagnostic table be- tween typhlitis and perityphlitis will be found embodied the principal features of abdominal ab- scess. 2. Intestinal Obstruction. Intestinal obstruction may develop suddenly or slowly. "When the attack is of sudden advent, and the symptoms markedly acute, the result is usually fatal to life ; but when slowly developed frequent relief can be afforded or recovery take place, without assistance, even when all hope of life may have vanished. The causes of sudden intestinal obstruction in- clude, 1. Foreign bodies, either artificially intro- duced or formed within the intestine. 2. Con- genital stricture or malformations of the intestine. 3. Twisting of the intestine or " volvulus." 4. Obstruc- tions from peritoneal adhesions. .5. Invagination of; SURGICAL DIAGNOSIS. the bowel or "intussusception" resulting from in- testinal tumors, worms, or unexplained causes. 6. Thickened peritoneal coverings and mesenteric attachments from an old hernial protrusion; and 7. strangulated hernia. The causes of gradual intestinal obstruction may be 1. Tumors pressing upon the bowel. 2. Simple stricture of the bowel from ulceration, injury, etc. 3. Cancer of the bowel occluding its normal calibre. 4. Tubercular peritonitis. 5. Abscess from trau- matism of abdominal walls. 6. Constipation or im- paction of faeces. 7. Inflamed and thickened intes- tine as the result of injury. The prominent symptoms of intestinal obstruction are 1. Local and severe pain. 2. Obstinate consti- pation. 3. Presence, often, of a tumor. 4. Localized dulness, if the tumor cannot be felt. 5. Vomit- ing, which becomes stercoraceous. 6. Tympanites. 7. Symptoms of general peritonitis or collapse. . DISEASES OF THE RECTUM. The rectum may present the following surgical conditions : 1. Hemorrhoids. These are of two varieties, external and internal; the former being located at the anus, the latter higher up within the rectum. They are both due to a varicose condition of the hemor- rhoidal veins. They are largely dependent upon portal obstruction. 2. Prolapse of the Rectum. This is a frequent disease of children. It is due, in children, to lack of tone in the muscular structure of the rectum, or to general debility. If present in adults, a relaxed condition of the sphincter exists. It may occasionally be produced by hemorrhoids and by urethral stricture as a result of straining. 3. Fistula of the Rectum. This condition may arise primarily by either ulceration of the rectum, or the formation of an abscess in the cellular tissue ex- ternal to the rectum. Rectal fistulse may be 1. Complete, where the rec- tal canal and the external opening communicate ; 2. Incomplete or blind fistulae, where one of these PLATE XYIII. 1. Rectal polypus. 2. Glandular rectal polypus. 3. Prolapse of the rectum in its first stage. 4. internal hemorrhoids. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 339 openings is absent. Fistulae may vary in their number, situation, length and calibre. They are frequently associated with inflammatory induration of the neighboring tissues. 4. Ulcer or Fissure of the Anus. This condition may be either a true fissure, or a small, oval-shaped ulcer, located just within the anus. It produces the most intense suffering and can be detected only by a care- ful scrutiny of the parts, as it may be overlooked or concealed by the rugae around the anal margin. 5. Stricture of the Rectum. Stricture of the rectum may involve the whole circumference of the gut, or only a portion of it. The extent of the bowel affected may vary from two lines to two inches, or even more. The seat of stricture may vary from one inch, to four or five inches above the anus. Stricture of the rectum may arise from cicatrices of formerly existing ulcers, from injuries, from sur- gical operations on the rectum, or from the pressure of tumors or organs. It is almost always associated with abscess and fistulas, if of long duration. 6. Cancer of the Rectum. Scirrhus, epithelioma, and colloid cancer, are met with in the rectum. They usually are first recognized as a hardened or indu- rated mass in the walls of the bowel causing dimi- nution in its calibre. Cancer in thio locality usually results in death within four years from the date of its commencement. A marked cachexia becomes apparent as the dis- ease develops. 7. Rectal Polypus. Polypi of the rectum may be of three types: 1, vascular polypi; 2, warty polypi; and 3, fibro-cellular polypi. Of these, the first is most frequent among chil- dren, and is usually associated with hemorrhage; while the other two are comparatively non-vascu- lar. They are all markedly pediculated, and are much less painful than hemorrhoids. 8. Pruritus Ani. This distressing affection may result 340 SURGICAL DIAGNOSIS. from constipation, abnormal intestinal secretion, ascarides in the rectum, prolonged sitting posture, and uterine diseases. It is usually associated with morbid textural changes around the anus, if long continued, from the irritation of scratching. 9. Neuralgia of the Rectum. This condition is diag- nosed by a severe and continuous pain within the rectum, not markedly affected by the condition of the bowel or attempts at defecation, and associated with no appreciable rectal disease. It occurs most frequently in females who have been in a state of depressed vitality. The symptoms of the following conditions of the rectum, viz., hemorrhoids, fistulae, fissure of the anus, cancer, rectal polypi and rectal prolapse, will be found contrasted in diagnostic tables at the close of this chapter on surgical diseases of the abdomen. D. HERNIA. By the term hernia, is meant " a protrusion of any viscus from its natural or containing cavity." Hernia may be classified, first, on a basis of the anatomical loca- tion of the protruding viscus, as follows : Hernia : Classified on a basis of" location. In the cranial region. In the thoracic region. In the epigas- f Diaphragmatic Hernia. trium. [• Hernia Cerebri. Y Hernia of the. Lung. 1 Epigastric Hernia. Ventral Hernia. r Ventral Hernia. In the mesogas- ^ trium. i Umbilical Hernia......i Omphalocele—Exom- ( PHALOS. In the hypogas- trium. I Lumbar Hernia. Above Pouparfs ligament. Below Pouparfs ligament. \ Inguinal Hernia. Inguino-Scrotal Hernia. Inguinc-Labial Hernia. Femoral Hernia. Mero- cele. Through pelvic apertures or in the pelvic region. ' Obturator Hernia. Perineal " Pudendal " Vaginal " Ischiatic " SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 341 Hernia may be classified, secondly, on a basis of the contents of the sac: of Intestines. Hernia : Classified on a basis { of contents: of Omentum. of Intestines and Omentum. of Bladder. of Rectum. of other organs. Enterocele. Epiplocele. Entero-Epiplocele. Cystocele. Rectocele. Hernia Cerebri. of Lung. Liver. Spleen. Kidney. Stomach. Testis. Reducible Hernia. Irreducible Hernia. Strangulated Hernia. Hernia may be classified, thirdly, on a basis of the condition of the sac, as follows : Where the protruded viscus and its cov- erings can be replaced in their nor- mal situation. Where the protruded viscus is retained in its abnormal position by adhesions, thickening of its coverings, or a de- posit of fat. Where the circulation of the displaced viscus is impaired by muscular spasm, oedema, or a sudden forcing of addi- tional contents into the sac. Where a hernial protrusion of intestine is rendered temporarily irreducible by gas or faeces. Where the hernial protrusion has not attained the development common to the region in which it exists. Where a hernial protrusion follows the descended testicle before the cavity of the tunica vaginalis is closed, thus giving it one layer only of peritoneal covering. Where a hernial protrusion into the scrotum occurs outside of, but parallel to the serous coats of the tunica vagi- nalis. This condition is not always one of infancy, although so named. Hernia : Classified on a basis of the i condition of the sac : Incarcerated Hernia sTIA. J Incomplete Hernia. Congenital Hernia. Infantile Hernia. 342 SURGICAL DIAGNOSIS. Certain special types of hernia are also subdivided on grounds of the surgical relations of the neck of the sac, the direction of tlie means of exit, or the location of the tumor. Thus inguinal hernia in its different forms may be spoken of or described under the fol- lowing names : 1. Indirect Hernia; by which term is meant that form of inguinal hernia which passes through both the internal and external abdominal rings. 2. Dlrect Hernia ; by which term is in- cluded all forms of inguinal hernia which pass through the external ring but es- cape the internal ring. 3. External Hernia. This is a synonym for indirect inguinal hernia, the name being applied from the external relation of the neck of the sac to the deep epigas- tric artery. 4l. Internal Hernia. This also is a synonym for direct inguinal hernia, since in both the neck of the sac lies internally to the epigastric artery. 5. Bubonocele. By this term is meant an in- complete indirect inguinal hernia. Its name is applied from its resemblance to an inflamed lymphatic gland in the groin (bubo). Nomenclature of Inguinal Hernia Causes of Hernia of the Abdomtnal Viscera. The conditions which may tend towards a protrusion of any of the abdominal viscera may be either predisposing or exciting. Under the first may be enumerated A. Wounds or Lacerations of the Abdomi- nal Walls. Hernial tumors of the liver, stomach, intestines, spleen and kidney, have been known to exist as a result of wounds of the abdominal parietes. The extent of the wound, its depth and loca- tion, tend greatly to modify its effect upon displacement of viscera. Predisposing causes of Hernia: SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 343 B. Weakening or Destruction of the Ab- dominal Walls by inflammation, ulcera- tion, suppuration, or disease. Hernial protrusions often follow abscess, severe types of ulceration and contusions of the abdominal walls, or when they are sub- jected to excessive strain, as in violent muscular efforts, prolonged attacks of coughing or sneezing, or in cases of straining duiing defecation. C. The Existence at Birth and Persist- ence AFTERWARDS OF A CANAL COMMUNI- CATING with the Peritoneal Cavity. The prolongation of the peritoneal cavi- ty, produced by the descent of the tes- ticle, becomes in the majority of cases a separate sac, called the tunica vagi- nalis, by adhesion of its surfaces with- in the inguinal canal during the first Predisposing causes month of life and often before birth. In of Hernia: rare cases however this union fails to (continued.) 1 occur. • D. A Gradual Protrusion of the Abdomi- nal Walls into an Abnormal Kecepta- cle for Viscera. This condition we see manifested in cases of enormous double scrotal hernia. It occurs where a condition of relaxation of the abdomi- nal muscles or a redundance of tissues exists to a marked degree. E. Sex. Hernia as a disease affects males to a far greater extent than females. Still in the femoral and umbilical types of hernia the contrary holds good. F. Age. Hernia is most frequent in infancy, and is a common affection in youth. It is comparatively rare between the ages of 13 and 21; but as age advances the tendency to this affection steadily in- creases. In women hernia occurs most frequently from the ages of 20 to 50. )U SURGICAL DIAGNOSIS Predisposing causes of Hernia: (continued.) G. Height. Hernia occurs more often in tall than in short people, especially so if the general state of health is not ro- bust. H. Occupation. Occupations demanding great muscular effort or intermitting strain upon endurance, tend greatly to- wards the formation of hernia, espe- cially when aggravated by belts worn around the waist, which, by compress- ing the viscera of the abdomen, tend to assist in the production of their dis- placement. The exciting causes of hernia usually consist of some violent mus- cular effort, under which head may be mentioned A. Lifting of Heavy Weights. B. Violent Efforts in Jumping, Running, or Climbing. C. Severe Attacks of Coughing or Sneez- ing. D. Straining during Attempts at Micturi- tion, when urethral stricture is present. E. Falls associated with Efforts to Re- cover Balance. Exciting causes of Hernia: Symptoms of Hernia ln General. The symptoms, produced by hernial protrusions, vary with the anatomical situation of the tumor, and also with the portion of the body displaced and contained within the hernial sac. As the larger proportion of all hernial tumors is confined to the inguinal and fem- oral regions, the prominent symptoms pertaining chiefly to these will first be considered, and, subsequently, those referable to the other more important varieties. 1. Sudden Appearance of an External Tumor. This symptom is evident in all forms of inguinal, and in femoral hernia, since the coverings are superficially situated, and readily indicate the pres- ence of any protrusion of viscera, by deviations from the normal contour of the affected part. If the hernia be complete, the tumor may attain a large size; but, if incomplete, careful inspection may SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 345 be "required to perceive it. In. femoral hernia, the tumor seldom attains extreme dimensions; but, if complete, it may reach the size of a hen's egg; while, in case of inguinal hernia, the scrotum may, in some instances, be distended to an immense size. In the case of cystocele, rectoceh, gluteal, obturator, sciatic, or perineal hernia, the external tumor may escape detection, if not carefully sought for; while the protrusion of .diaphragmatic hernia can only be detected by the physical signs of local consolidation in the de- pendent portion of the chest and in the median line of the body. In cerebral hernia, the protrusion of brain substance is usually self-evident, as is also the case in hernia of any of the thoracic or abdominal viscera, where the protrusion depends upon some lacer- ation or destruction of the abdominal parietes. 2. Character of the Tumor. The sense of touch may often de- tect the character of the contents of hernial protrusions, since, if soft and cushion-like in feel, the presence of intestine and its inclosed air may be strongly suspected; while, if hard and more resistant to pressure, the protrusion of omentum may safely be diagnosed, if the hernia be situated in the inguinal or femoral regions. Percussion is often of great value in further deciding upon the pres- ence or absence of omentum, since a dull note will indicate the solid character of the contents, while resonance will indicate the inclos- ure of air. Auscultation of the tumor, if it be dependent upon protruded intes- tine, may detect the presence of a gurgling sound as air enters and escapes from its cavity. This symptom, when present, is of great diagnostic value. 3. Weight of the Tumor. In cases where the scrotum is distended, the question of the existence of fluid within the cavity of the tunica vaginalis may often be decided alone upon the weight of the tumor, which will be much greater than if intestine and even some omen- tum be contained. 4. Surface of the Tumor. Hernial tumors are, as a rule, smooth and of regular outline, in contrast to some forms of new growths, where the outline is irregular and the surface more or less nodular. This point is often of value in deciding between the possibility of some extraneous growth and a hernia of long standing, whose pro- trusion may be so slight as not to admit of a positive diagnosis without the exclusion of other abnormal conditions. 5. Cough Impulse. In the inguinal variety of hernia, if not omen- tal in character, and often in femoral hernia, a peculiar impulse may be perceived within the tumor, if the hand of the surgeon 346 SURGICAL DIAGNOSIS. either grasps it or lies in contact with it, and the patient be re- quested to cough violently. This symptom is valuable as a diagnostic sign of hernia, but is not infallible, since fluid communicating with the abdomen and pro- truding through its walls, as in the case of psoas abscess, will yield even a more forcible impulse than the air within a hernia, for the reason that fluid transmits vibrations more readily than any form of gas. 6. Pain. Hernial tumors may often be painless, provided the dragging sensation of weight, in case the tumor be of large size, be not considered as a form of pain. In the majority of instances, pain of a marked character is little complained of by patients afflicted with rupture. Pain may, therefore, be properly considered as an evidence that the protrusion is either inflamed, or constricted by the surround- ing tissues so as to impair the freedom of its circulation (the condi- tion known as " strangulation "). With this pain comes also often tenderness to touch, and often a sensitiveness when motion is attempted. These symptoms should, therefore, never be considered trivial, or allowed to pass unnoticed, since, often, surgical relief is demanded, and, if too long delayed, this condition may result in the loss of the life of the patient. 7. Condition of the Boicel. Constipation is not a necessary result of hernia, even if the bowel be implicated and long retained in its abnormal position, but, should constipation be present, it often be- comes a point of great diagnostic value in deciding upon the char- acter of the tumor or upon the presence or absence of strangulation of the intestine. As long as the bowel acts regularly and performs its proper functions, so long may we safely exclude serious consequences to the patient, even if the tumor be incapable of reduction. 8. Beducibility. Hernial tumors are usually reducible, if of re- cent origin. Not infrequently the recumbent position alone is suffi- cient to cause either the partial or entire disappearance of the tumor; and patients frequently experience relief during their sleep- ing hours, only to experience a return of the tumor on rising. In many cases, however, manipulation or "taxis" is required to restore the hernial protrusion; and, in cases of long standing, the reduc- tion may be rendered impossible, since the coats composing the sac may have become adherent or thickened, or a deposit of fat may have occurred between the different layers of the sac, or even in the protruded omentum, or upon the coats of the intestine. This SURGICAL DISEASES OF THE ABDOMINAL CA VITY. 347 condition of irredudbility is not to be confounded with that of strangulation, since the circulation of the part may still be unim- paired. * Congenital Hernia. Although this form is confined to the inguinal region, it presents two points of diagnostic value, besides the ones previously given, as the symptoms of hernia in general. These special symptoms are (1) the presence of fluid which gravitates from the peritoneal cavity, and which may give both fluctuation and translucency to the tumor, and (2) a reducibility of the testicle, after the hernial protrusion has been replaced, in cases where the hernia has previously reached the scrotum. It is most frequently present in the infant, and shows a marked tendency to recur, if not kept from again protruding, until the cavity of the tunica vaginalis is made to close by mechanical means. Ventral Hernia. This condition usually follows wounds, laceration, or abscess of the abdominal walls, and is rarely a congenital affection, or the ac- quired result of a strain or excessive exertion. It may occur at any age and in any portion of the abdomen, though the anterior wall, near the median line, is its most frequent situation. It is usually an intestinal protrusion accompanied by more or less omentum. Its reduction is often more difficult than where the tumor has protruded through the inguinal or femoral canal, or the umbilicus. In rare cases, the stomach and even the liver and spleen have been known to protrude through a rent in the abdominal walls. Diaphragmatic Hernia. This accident is rarely met with, since it is usually associated with rupture or laceration of some portion of the diaphragm. In some instances, however, a hernial protrusion may escape through some of the normal openings in the diaphragm, and, in rare cases, a protrusion may result from a lack of tone in the muscle, without either a dilatation of the normal openings or a laceration of the muscular fibres. It may follow a fall from a height, the passing of a heaw weight over the abdomen, or even forcible spasm of 348 SURGICAL DIAGNOSIS. the muscle, caused by a sudden slip or slight fall. Laceration of the muscle is usually accompanied hjpain of an intense character, and by difficulty in walking and in respiration. In case the rent in the diaphragm is extensive, it is usually ac- companied by a displacement of the stomach, transverse colon, small intestine, or omentum, into the cavity of the chest, and, in some cases, with a rupture of these organs and an escape of their contents. If such a protrusion exist, irrespective of the cause which pro- duces it or the condition of the diaphragm which allows of the pro- trusion, the chest will usually be rendered prominent on the side where the organs are displaced; the heart may be pushed from its normal position, respiration may be rendered difficult, and the respiratory murmur may be absent over the seat of the protrusion. The percussion note over the tumor will be resonant if the escaped viscera contain air, or flat if a solid organ be displaced. Vomit- ing, of a constant character, will also generally be present. Death will usually follow, if the .contents of the displaced organ have escaped into the thoracic cavity from a laceration in its tunics, as occurs often in case the stomach or intestine is protruded through the diaphragm; and it may also follow a simple displacement of an organ, even when no rupture has taken place, from a subsequent pleurisy, peritonitis, or strangulation of the part. The points of diagnosis between diaphragmatic hernia and medi- astinal tumors will be found contrasted in subsequent pages of this volume. Differential Diagnosis of Hernia. Hernia of the Inguinal Region may be confounded, as a disease, with the following named conditions : 1. Hydrocele of the Testicle. 2. Sarcocele " " 3. Varicocele. 4. Hematocele. 5. Bubo. 6. Undescended Testicle. 7. Impacted Feces. 8. Hydrocele of the Cord. PLATE XIX. 1. Diaphragmatic hernia. 2. Spina bifida. 3. Irreducible umbilical hernia. 4. Congenital her- nia. 5. Infantile inguinal hernia. 6. Loop of intestine from a strangulated inguinal hernia. 9 SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 349 It is often difficult also to discriminate between the inguinal and femoral varieties of hernia, or to detect the various special forms of inguinal hernia from each other. In the diagnostic tables appended, I have endeavored, therefore, not only to exhibit the points of con- trast between inguinal hernia and other surgical diseases confined to that locality of the body, but also to make clear the points of distinction between those various conditions of inguinal hernial pro- trusions, which are liable to be encountered in a surgical practice. Femoral Hernia may be confounded, in diagnosis, with many sur- gical conditions of the thigh, which often bear symptoms in com- mon with that disease. Among these conditions leading towards error, may be enumerated as important 1. Enlarged Glands. 2. Psoas Abscess. 3. Varix of the Saphenous Vein. 4. Lipoma of the Femoral Canal. I have added also, in the following pages, diagnostic tables be- tween ventral and umbilical hernia, thyroid and perineal hernia, diaphragmatic hernia and mediastinal tumors, congenital and infan- tile hernia, and congenital hernia and hydrocele. In connection with diseases of the rectum, which have been enumerated and described in preceding pages of this chapter, will be shown, in contrast, the symptoms of external and internal hem- orrhoids, external hemorrhoids and condylomata of the anus, in- ternal hemorrhoids and rectal polypi, rectal prolapse and rectal polypi, cancer and stricture of the rectum, fissure of the anus, and fistulae of the rectum. I have dwelt but slightly upon the symptoms of the diseases of the organs of the abdomen, as they will be found in full in the follow- ing pages. I have left unmentioned in these tables, also, contusion of the abdomen and its results (abscess and ecchymosis), as they have no special features over similar changes in other parts, and properly belong to the following chapter on diseases of tissues, in which they will be considered. I have introduced, however, a table of diagnosis between Typhli- tis and Perityphlitis, as it seems properly to belong to this chapter; and I have added, in connection with it, a table of the causes and symptoms of intestinal obstruction. 350 SURGICAL DIAGNOSIS. TYPHLITIS. PERITYPHLITIS. Definition. Is an inflammation of the caecum Is an inflammation of the con- and its vermiform appendix. nective tissue about the caecum. History. The appearance of a tumor in the No early diagnostic symptoms right iliac fossa is preceded by co- precede the attack. It occurs from lichy pains and distension of the traumatism, ulceration of the ver- abdomen from tympanites. miform appendix, pyaemia, etc. Pain. The pain is superficial and is con- The pain is deep-seated in the fined to the right iliac fossa and right iliac fossa. right hip. Numbness. No numbness is felt in the right A sense of numbness is present thigh and leg. often in the right lower extremity. Effect of Motion. Motion of the thigh produces Motion of the thigh produces pain only in the later stages. pain early in the disease. Tumor. The tumor is sausage-shaped and The tumor is deeply located and superficial. fluctuates in the advanced stages. Percussion. Flatness is present over the tumor. Tympanitic percussion, from the inflated caecum, exists over the tu- mor, if uncomplicated. Control of Thigh. The patient can raise the right The patient cannot raise the right thigh. thigh, as a rule. Abscess. Suppuration and pointing are Suppuration, and pointing, as a rarely, if ever, present. rule exist, if the abscess is to open externally. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 351 INTESTINAL OBSTRUCTION, Intestinal Obstruction. (2 varieties.) If of sudden origin it may be due to If of slow develop- ment, it may result - from 1. Foreign bodies. 2. Twisting of the intes- tine. 3. Intussusception of the bowel. 4. Congenital stricture of the bowel. 5. Congenital malforma- tion of the bowel. 6. Strangulation of the bowel by bands of lymph. 7. Strangulated hernia. 8. Entanglement of bowel with mesentery or omentum. 1. Malignant disease. 2. Impaction of faeces. 3. Abnormal concretions. 4. Pressure of tumors, ab- scess, etc. 5. Tubercular peritonitis. SYMPTOMS IN COMMON. A tumor is usually detected in the abdomen. When due to impaction of faeces, this tumor indents on firm pressure. Pain is usually a marked symptom; it is local, as a rule, and deep- seated. Dulness on percussion exists often over the seat of pain, in case a tumor cannot be detected. Obstinate constipation exists, which withstands all attempts at removal. Vomiting is a marked symptom. When stercoraceous in character, it is a pathognomonic symptom. If occurring late in the attack it often indicates an obstruction low down in the bowel. Distension of the abdomen from tympanites. This condition is very marked when the large intestine is obstructed, but much less so if the small intestine be the seat of disease. Visible peristalsis is often present, especially in those cases of sudden origin. 352 SURGICAL DIAGNOSIS. EXTERNAL HEMORRHOIDS. INTERNAL HEMORRHOIDS. Appearance of Tumor. The tumor is smooth on its sur- The tumor has often a granular face. surface. The tumor is partially covered The tumor is entirely covered with integument. with mucous membrane. The tumor is seldom pediculated. The tumor is usually pediculated. Situation. The tumor is always situated at The tumor is attached to the the margin of the anus. walls of the rectum. Reducibility. The tumor always presents ex- The tumor can be replaced within ternally, but may often be evacu- the rectum and may remain replaced ated by pressure or position. for days, weeks, or months. Density. The tumor is firm in its texture. The tumor is soft and often fri- able. Hemorrhage. Hemorrhage is infrequent and Hemorrhage often becomes ex- seldom severe in amount. cessive and is of frequent occurrence. Pain. The pain is usually local and The pain is often conveyed to confined to the tumor. neighboring regions. The pain is usually of moderate The pain is severe, as a rule, in severity and is often absent. case the tumor becomes externally apparent. SURGICAL DISEASES OF THE ABDOMINAL CA VITY. 353 EXTERNAL HEMORRHOIDS. CONDYLOMATA OF THE ANUS. Surface of Tumor. The surface of the tumor is The surface of the excrescences smooth. is of a warty appearance, resem- bling that of a strawberry. Number. A solitary tumor is not uncom- The tumors are multiple, as a mon. rule, with deep clefts between them. Shape. The tumors are round or oval. The tumors are flat and broad. Development. The development of the tumors The development of condylomata is often very rapid. is usually slow. Discharge. No discharge is present. A profuse and irritating discharge exists. History. No venereal history is detected as A venereal history often exists as a cause. a cause. Effects of the Condition of the Bowel. The tumor is often affected in The tumors are independent of its size and appearance by the con- changes in the circulation of the dition of the bowel or causes affect- rectum or liver. ing the portal circulation. 354 SURGICAL DIAGNOSIS. INTERNAL HEMORRHOIDS. RECTAL POLYPES. Number of Tumors. The tumors are usually multiple. A solitary tumor is most com- monly present. Size of Tumors. The tumor is generally small. The tumor is usually large. Pediculation. The pedicle is indistinct or absent. The pedicle is marked. Rapidity of Growth. Hemorrhoids often form with Polypus is usually of slow growth. great rapidity. Color. Hemorrhoids are usually of a The tumor is pale in color. violet color. Surface. The tumors are granular on their The surface of the tumor is surface. smooth. Age Affected. The young are rarely, if ever, af- The young are frequently af- fected, fected. Effects of Constipation. The condition of the bowels ex- The size of rectal polypi is not erts a marked influence upon the affected by the condition of the size of the tumors. bowels. Hemorrhage. Hemorrhage is frequent and often severe. Hemorrhage is infrequent, save when the vascular form of polypus is present. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 355 RECTAL PROLAPSE. RECTAL POLYPUS. Tumor. The tumor is continuous all The tumor is located upon one around the circumference of the side of the rectum. rectum. Pedicle. No pedicle to the protrusion can A pedicle is always easily de- be detected. tected. State of Health. This condition is most common Occurs generally in healthy sub- in children with enfeebled con- jects. stitutions. Hemorrhage. Hemorrhage is frequent but is Hemorrhage is infrequent, save moderate in its severity. when the polypus is of the vascular variety. SYMPTOMS IN COMMON. Both occur chiefly in the young. " are reducible within the bowel. " are not severely painful unless retained after protrusion. " are pale in color. " painless to direct touch. " sensitive to traction upon them. 356 SURGICAL DIAGNOSIS. CANCER OF THE RECTUM. STRICTURE OF THE RECTUM. Age Affected. Is rare in the young, but is com- May affect any age. mon in advanced life. Location and Character. It may be detected as a uniform The constriction is usually an- infiltration around the rectum, or nular in character, and is seldom as nodular masses in its walls. It unilateral. It is most frequently is common near the anus, and its detected about two inches from the surface is often friable. anus, and it presents no abnormal condition of surface. Defecation. Defecation becomes difficult ear- Defecation becomes difficult late ly, even before marked constric- in the disease, as the rectal walls tion exists, from loss of contractile are normal in power. power in the rectum. Pain. A violent burning, or boring pain Pain is often absent. is present on defecation and often long after its completion. Abnormal Sensations. A sensation of a foreign body in No abnormal sensations exist in the rectum is present. many typical cases. Health. The general health is rapidly The general health is slowly af- undermined. fected—if much altered. Discharge. A slimy, foetid, and often sanious No discharge is present, if ulcer- discharge from the bowel exists. ation of the bowel does not exist as a complication. SYMPTOMS IN COMMON. Both are associated with interference with defecation. " " diminished rectal calibre. " tympanitic distension of abdomen in advanced stages. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 357 FISSURE OF THE ANUS. FISTULA OF THE RECTUM. History. Occurs most often in females, Occurs most often in men, and is debilitated subjects, or in syphilis, preceded by a history of abscess. Pain. The pain is burning in character. Pain is often absent and, if " " exacerbates often dur- present, is not severe in type. A ing menstruation. sense of moisture and itching is " " is augmented by defeca- however present from the excoria- tion, tion due to the discharge. " " is often constant. " "is frequently not local but radiates to pel- vis, back, thighs, etc., etc. Sphincter of Anus. The sphincter is spasmodically The sphincter ani muscle is not contracted. The finger, if intro- affected. The bowel can be easily duced into the rectum, causes great and painlessly explored. pain. Urinary Symptoms. Retention of urine, painful mic- Reflex urinary symptoms are sel- turition and other urinary symp- dom produced. toms of a reflex character are com- mon. Inspection. A fissure or a small ulcer can be Inspection of the perineum re- detected at the margin of the anus, veals either a papilla at the seat of if carefully looked for, as it is often the external opening of the fistula, concealed by the rugae. or an orifice, which is often con- cealed by folds of the skin. Discharge. No abnormal discharge from the A purulent or faecal discharge fissure or ulcer occurs, sufficient to exists, causing irritation of the cause annoyance or notice. parts, staining the clothing, and generally having an offensive odor. 358 SURGICAL DIAGNOSIS. INDIRECT INGUINAL DIRECT INGUINAL HERNIA. HERNIA. Size of Tumor. The tumor is often very large. The tumor is usually small in size. Shape of Tumor. The tumor is usually flask-shaped. The tumor is usually globular. Location. The tumor is frequently scrotal. The tumor is seldom scrotal. Palpation. The tumor is usually an entero- The tumor is usually omental, cele, and is therefore soft and doughy and is therefore hard. to the touch. Percussion. Resonant percussion usually ex- Flatness on percussion over the ists over the tumor. tumor is frequent. Inguinal Canal. The inguinal canal is filled. The inguinal canal is empty. Spermatic Cord. The spermatic cord usually lies The spermatic cord can be de- concealed behind the neck of the sac. tected at the outside of the neck, as a rule. Epigastric Artery. The pulsation of the deep epigas- The epigastric artery can be often trie artery is concealed. felt to pulsate outside of the neck of the tumor. Reduction. The tumor is reduced by pressure The tumor is reduced by pressure outwards and backwards. directly backwards. ' SYMPTOMS IN COMMON. Both are associated with a sudden advent. " " " " an impulse on-coughing. " " " " reducibility, as a rule. " " " " possible intestinal embarrassment. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 359 SCROTAL HERNIA. SARCOCELE. Palpation. The tumor is soft and doughy to The tumor is usually hard and the touch. resistant. Weight. The tumor is light. The tumor is heavy. Surface. The tumor is smooth and regular. The tumor is often nodular and irregular in outline. Pain. The tumor is seldom painful, un- The tumor is frequently painful. less inflamed or strangulated. Development. The tumor is of sudden advent. The tumor grows slowly, as a rule. Percussion. The percussion note over the The percussion note over the tumor is usually resonant. tumor is usually dull or flat. Inguinal Canal. The inguinal canal is usually The inguinal canal is empty. filled. Cough Impulse. An impulse on coughing is pres- No impulse on coughing can be ent in the majority of cases. detected. Bowel. The bowel is occasionally embar- The bowel is never affected. rassed. Reduction. Reduction is accomplished by The tumor is irreducible. pressure backwards and outwards, unless the hernia is strangulated, incarcerated, or irreducible. Auscultation. Gurgling may be detected. No auscultatory sounds are pres- ent. 360 SURGICAL DIAGNOSIS. SCROTAL HERNIA. HYDROCELE OK TESTICLE. Shape of Tumor. The tumor is usually flask-shaped. The tumor is pyriform or ovoid. Development. The tumor is usually of sudden Develops slowly from below up- advent; and develops from above wards. downwards. Palpation. The tumor is soft and doughy to The tumor is hard, tense and the touch, as a rule. elastic. Fluctuation. Fluctuation is absent. Fluctuation is well marked. Translucency. The tumor is opaque. The tumor is translucent. Percussion. Resonant percussion is usually The percussion note over the tu- present over the tumor. mor is dull or flat. Reducibility. The tumor is usually reducible. The tumor is never reducible. Spermatic Cord. The spermatic cord is usually The spermatic cord is .neither concealed by the neck of tumor. concealed nor displaced. Inguinal Canal. The inguinal canal is filled, save The inguinal canal is empty. when direct hernia enters the scro- tum. Aspirator. The effects of aspiration are nega- Fluid is withdrawn by aspiration tive. or tapping. Bowel. The action of the bowel may be The action of the bowel is un- embarrassed, affected. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 361 SCROTAL HERNIA. VARICOCELE. Palpation. The tumor is usually smooth on The tumor is knotty and irregu- its surface and regular in its outline, lar and feels like " a bag of worms." Color of Tumor. The tumor is of normal color. The tumor is bluish. Location. May exist on either side. Most frequent on the left side. Effect of Heat. Negative. Tumor increases on the applica- tion of heat. Development. The tumor develops suddenly. The development of the tumor is gradual. Percussion. The percussion note is usually The percussion note is dull. resonant. Fluctuation. Fluctuation never exists. Fluctuation may exist if the ves- sels be very large. Spermatic Cord. The spermatic cord is concealed The spermatic cord is not af- or displaced. fected. Inguinal Canal. The inguinal canal is usually The inguinal canal is uninvolved. filled. Cough Impulse. A cough impulse is usually de- No impulse on coughing exists. tected. Reduction. Reduction is accomplished usually Reduces often spontaneously by by taxis only. any position favoring increased venous return. Return of Tumor. The tumor, if once reduced, can The tumor returns when the be prevented from a return by pres- patient stands up, in spite of pres-. sure at the external ring. sure at the ring. Sensation in Scrotum. There is a sense of distension only, A sense of weight, and of con- unless inflammation or strangula- stant dragging in the scrotum, ex- tion exist. ists. 362 S URGICA L DIA GNOSIS. SCROTAL HERNIA. HEMATOCELE OF TESTIS. Advent. The advent of the tumor is sud- The advent is sudden, if of trau- den, and it grows from above, down- matic origin ; but if of spontane- wards. ous origin, the tumor may develop slowly. It grows from below, up- wards. Fluctuation. Fluctuation is never present. Fluctuation is always present un- til coagulation occurs. Palpation. The tumor is soft and doughy. The tumor is soft at first, but hard after coagulation occurs. Shape. The tumor is flask-shaped, unless The tumor is pyrif orm in its shape. due to direct hernia. Integument. Normal in color. Ecchymotic. Reducibility. The tumor is usually reducible. The tumor is irreducible. Percussion and Auscultation. Percussion is usually resonant; Percussion is dull or flat. Aus- gurgling may be also heard. cultation negative. Weight of Tumor. The tumor is light in weight. The tumor is heavy. Spermatic Cord. The spermatic cord is concealed The spermatic cord is unaffected. or displaced. Inguinal Canal. The inguinal canal is usually filled. The inguinal canal is empty. Constitutional Symptoms. None, save when strangulation, Pallor and great prostration are or severe inflammation of the sac often present from the loss of blood. exists. Bowels. The action of the bowel may be The bowels are unaffected. embarrassed. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 363 INCOMPLETE INGUINAL • BUBO. HERNIA. Pain. The tumor is generally painless. The tumor is usually painful. Palpation. The tumor is usually soft. The tumor is hard, at the onset. Fluctuation. Fluctuation is absent. Fluctuation is present if suppura- tion occurs Locality. The tumor is confined to limits of The tumor is often diffused beyond inguinal canal. the limits of the inguinal canal. Reducibility. Reduction is possible and often Reduction is impossible. easy. Outline of Tumor. The outline of the tumor is often The outline of the tumor is usual- indistinct, ly clearly defined. 03dema. 03dema is absent, as a rule. CEdema is present, as a rule. Percussion. Frequently resonant percussion Dull percussion exists over the exists. tumor. Cough Impulse. A«cough impulse is often detected. A cough impulse is usually absent. History. A history of muscular strain is A venereal origin is often de- usually present. tected. Bowel. The bowel may be embarrassed in The bowel is unaffected. its action. Constitutional Symptoms. Absent, unless strangulation, or Frequent constitutional symp- inflammation of the sac, occurs. toms occur. Auscultation. Gurgling may be detected. No gurgle will be heard. 364 SURGICAL DIAGNOSIS. BUBONOCELE. UNDESCENDED TESTICLE. Pain. The tumor is usually painless. The tunror is very painful, and on pressure over it yields the pecu- liar sickening sensation which is characteristic of compression of the testicle. Scrotum. Both testicles are present. The testicle is found wanting upon the side corresponding to the tumor. The scrotum is normal in develop- The scrotum is imperfectly de- ment, veloped on the same side. Reduction. Reduction of the tumor is asso- Reduction may be impossible, but ciated with a gurgle. if not so, no gurgle accompanies its return to the abdomen. Bowel. The action of the bowel may be The bowel is unaffected. embarrassed. SYMPTOMS IN COMMON. Both are associated with a small tumor. " " " " frequent reducibility. " may be " " sudden advent. " " " " impulse on coughing. " " " " vomiting. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 365 INGUINAL HERNIA. IMPACTION OF FAECES. Location of Tumor. The tumor is felt only in the in- The tumor may be felt at the side, guinal region. as well as in the inguinal region. Development. The tumor develops suddenly The tumor develops slowly with after some strain or injury. previous colicky pains and from no apparent causation. Percussion. The percussion note is usually The percussion note over the tu- resonant. mor is flat. Effects of Pressure. Pressure causes no permanent Firm localized pressure over the change in the tumor unless it effects tumor causes indentation. reduction. Sensitiveness. The tumor is not sensitive unless The tumor is always tender on inflamed or strangulated. pressure in its advanced stages. Pain. The tumor is usually painless. The tumor is painful. Bowel. The bowel may be unaffected. Obstinate constipation always ex- ists. Vomiting. Vomiting is absent if the hernia Vomiting is usually present. be not inflamed or strangulated. SYMPTOMS IN COMMON. Both are associated with a tumor. " may be associated with obstinate constipation. 366 SURGICAL DIAGNOSIS INGUINAL HERNIA. HYDROCELE OF THE CORD. Limits of Tumor. The tumor is frequently scrotal, The tumor is circumscribed. and is generally diffused. Palpation. The tumor is soft, as a rule. The tumor is tense. Reducibility. The tumor reduces with a gurgle. The tumor is usually irreduci- ble, but if not so no gurgle is pres- ent on its reduction. Translucency. The tumor is opaque. The tumor is often translucent. Fluctuation. The tumor does not fluctuate. The tumor is fluctuant. Percussion. The percussion note is resonant The percussion note is dull over over the tumor, as a rule. the tumor. Bowel. Intestinal embarrassment is often No intestinal embarrassment ex- present, ists. Impulse from Testicle. Movements of the testicle have The testicle, if moved, transmits no effect upon the tumor. an impulse to the tumor. Cough Impulse. An impulse on coughing is fre- Impulse on coughing is absent. quently felt in the tumor. Auscultation. Gurgling is often heard in the No gurgling is detected. tumor. Return of the Reduction. The tumor remains reduced if The tumor returns after reduc- the dorsal position is maintained. tion irrespective of position. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. 367 FEMORAL HERNIA. ENLARGED GLANDS. Depth of Tumor. The tumor is often felt deep in The tumor is always superficial. the groin. Mobility of Tumor. The movements of the tumor are The tumor exhibits great mo- restricted, bility. Reducibility. The tumor is reducible by pres- The tumor is not reducible. sure downwards, backwards and upwards. Number of Tumors. The tumor is always solitary. The tumor is seldom solitary. Fluctuation. Fluctuation is never present. Fluctuation is often detected within the tumor. Bowel. Intestinal embarrassment is often No intestinal embarrassment is present. produced. Cough Impulse. An impulse on coughing may No impulse on coughing is de- often be detected on flexion and ad- tected. duction of the thigh, with the body bent forwards. Auscultation. Gurgling within the tumor is No gurgling is ever perceived in Sometimes heard. the tumor. History. Is usually due to some severe A scrofulous diathesis is often muscular effort. present. Percussion. Resonant percussion may exist The percussion note over the tu- over the tumor, in some cases. mor is flat. Sex. Is rare in the male sex. Is equally frequent in both sexes. 368 SURGICAL DIAGNOSIS. FEMORAL HERNIA. PSOAS ABSCESS. Fluctuation. The tumor never fluctuates. The tumor often fluctuates, if superficial. Percussion. The percussion note over the The tumor always yields a dull, tumor may be resonant. or flat percussion note. Relation of Femoral Vessels. The neck of the sac lies internal The neck of the sac lies external to the femoral artery. to the femoral artery. Pain. Pain is frequently absent. A pain in the back or loins has always preceded the development of the tumor. General Health. The general health is often nor- The health is impaired. mal. History. A severe muscular effort usually A history of spinal disease or of precedes the advent of the tumor. pelvic affection exists. Bowel. Intestinal derangement is often The bowel acts normally. produced. Reducibility. Reduction occurs with a distinct The tumor disappears gradually and sudden disappearance of the under direct pressure, but no gurgle tumor, usually with a gurgle. is perceived. The reduction requires pressure No absolute direction of pressure downwards, backwards and up- is required. wards. Return of Tumor. The hernia remains reduced if The tumor returns as soon as the the dorsal position is maintained. pressure is removed. SURGICAL DISEASES OF THE ABDOMINAL CAVITY. FEMORAL HERNIA. VARIX OF SAPHENOUS VEIN. Size and Direction of Tumor. The tumor is usually small, and The tumor is variable in size, and is directed obliquely across thigh. lies in the longitudinal axis of the limb. Palpation. The tumor is usually hard and The tumor is soft and often in- tense, but may be doughy. distinctly fluctuant. Effect of Heat. The tumor is not affected by heat. The tumor is increased in size by heat. Sex. The tumor is most frequent in Is equally common in both sexes. females. Percussion. Resonant percussion often exists. Flatness on percussion is present over tumor. Reducibility. Reduces with a sudden slip and a Reduces gradually without any gurgle. gurgle. Is reduced by pressure directed Is reduced by direct pressure and downwards, backwards and up- a recumbent position. wards. Return after Reduction. The return is prevented when the The tumor returns when the patient is allowed to stand up, by patient stands, in spite of pressure pressure over the femoral ring. on the femoral ring. Bowel. Intestinal embarrassment is not No embarrassment of the func- infrequent. tion of the bowel is ever produced. Skin. The skin is normal in color. The skin is often discolored over tumor. Cough Impulse. May be detected by 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 THE 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. " i( " " " inside of the femoral vessels. " " " " " 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 THE ABDOMINAL CA VITY. 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. " " " " resonant percussion. " " " " reducibility. " <: " " impulse on coughing, as a rule. " << " " possible 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 be translucent. The tumor is always translucent. Pedicle. The tumor has a marked pedicle. The tumor is not pediculated. Shape of Tumor. The tumor is globular. The tumor is pyriform. Development. The tumor may be of sudden oc- The tumor always develops slowly currence, or may show sudden and and gradually. rapid increase in its size when once developed. Inguinal Canal. The inguinal canal is either dis- The inguinal canal is empty. tended or involved. Reducibility. The fluid portion, when reduced The tumor cannot be reduced. by taxis or pressure, leaves a previ- ously concealed testicle which also reduces 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 Fluctuation is absent. portion of the tumor from gravita- tion of the peritoneal fluid into the sac. Translucency. The tumor is frequently translu- The tumor is not translucent. cent at the upper portion of the sac. Reduction of Tumor. The reduction of the fluid con- The reduction of the tumor leaves tents and the intestinal portion of the testicle irreducible. the tumor leaves the testicle appa- rent, which also reduces with a gur- gle and marked pain. Age Affected. Never affects adults unless a pre- Is most common in infancy, but vious attack has existed in infancy, may occur at any age from an ab- normal condition of the parts. DISEASES of tissues. DISEASES OF TISSUES. 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 practical insight into its bear- ings upon diagnosis. INFLAMMATION. Derivation. Flamma, qAkypa—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. Inflammation may be classified < 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 (1.) on a pathological basis. (2.) on a basis of its severity and duration. (3.) on a basis of its causation." 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 inflammatory 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 inflammatory 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). Local Arterial Dis--i EASE I (by causing imperfect nutri- Local Obstruction I tion to the tissues>- of Veins J PREDISPOSING CAUSES. * 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 SURGICAL DIAGNOSIS. r (1.) Direct Irritation from chemical agents, ' Heat. Cold. Acids. Caustics. EXCITING CAUSES. ' Introduction of foreign bodies (splinters, bullets, etc.). Stabs. Gun-shot wounds. (2.) Mechanical Injury, -j Lacerations. Contusions. Fractures. Dislocations. Liver. Kidney. Salivary glands. Prostate gland. Lachrymal glands. Joints. Serous cavities. f In the bladder. In the rectum. In the intestine. Blood clots. Tubercle. Gangrene. Sequestra, (3.) Influence of Mor- bid Products gener- ated within the body. Calculi in the - Retained putre- factive ex- cretions. (4.) Altered State of Local Nerves. ' Injury to the brain substance. " " cranial nerves. " " spinal cord and nerves. " " sympathetic. ' Deficiencies in - (5.) Abnormal Proper- ties in Blood. Abnormal in- gredients. ' Nitrogenized food. Salts (chiefly those of potas7t). Arterial supply. Poisons. Purgatives. Diuretics. Emmenagogues. Cathartics. Uric acid. Urea. [ Lactic acid. (6.) Direct Contagion arising from Gonorrhceal 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. Rational Symp- toms. Impaired function. Pain. Heat. Redness. Swelling. ' Changes in Microscopical Changes. ' Momentary contraction. Dilatation with fluxion (the blood current being more rapid than normal). Dilatation with congestion (the blood current being slower than normal). Transudation of plasma. Transudation of leucocytes and red corpuscles. Stasis. Tissues. Exudation. - Due to altered nutrition. Sero-albuminous. Sero-fibrinous. Hemorrhagic. Pus. Catarrhal. . Diphtheritic. 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. Increase of fibrin. '' of albumen. " of white globules. Changes in Blood. -\ Slow coagulation (causing the huffy 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, bv 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. " Keflex act through the sympathetic sys- tem." (3.) Cause of retardation of tlie blood current (Byneck'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—1843. 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.) " Stimulation 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 the ad- jacent elements to the cell elements. (7.) The transudation of red blood-corpuscles. Occurs in mechanical hyperemia, but in less quantities than the white. Is often associated with either a rupture of the vessel or some alteration in its coats. B. Bational Symptoms (localized in the inflamed part). (1.) Cause of pain. Pressure upon, or stretching of the nerve filaments by the hyperemia and exudation. (2.) Causes of heat. (1.) Hyperemia of the affected part. (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 DIA GNOSIS. The tint of red indicates the rate of circidation. Bedness need not necessarily indicate inflammation, since it may exist independently of inflammatory processes. It is not well marked in non-cascular 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. Benal 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 chill 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 full 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. Wliite 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 icater 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.) Hyperemia. (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.) Hyperemia. (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.) Poisons i Pufr^active matters. 1 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.) Bedness of the skin along the course of the lym- phatic vessels. (2.) Swelling of the inflamed part and tenderness to pressure. (3.) Violent 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. INFLAMMATOBY 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 pyemia. It frequently results in the formation of sinuses and fistula?, when the source of irritation remains, as in caries, necrosis, foreign bodies, etc., etc. The character of pus is liable to variations, and separate names have been given the most common varieties. Thus healthy or laudable, ichorous, sani- ous, curdy, muco-pus, and sero-pus are terms most fre- quently used to express the existing condition and appearance of the discharge. Suppuration, if circumscribed and retained within tissue, yields both local and constitutional symptoms. The local symptoms are the development of a tumor, which is at first hard, but afterwards soft or fluctuant, and a change in the skin, which often be- comes red, shiny and cedematous if the suppuration be near the surface. The constitutional symptoms are chills, fever, and elevation of the pulse, followed by hectic and exhaus- tion, if the suppuration be extensive. 4. Ulceration of Tissue. By an ulcer is meant a super- ficial solution of continuity of soft tissues, dependent upon molecular death. The process of ulceration can never occur within the substance of any tissue; it is essentially a condition of the surface. Ulcera- tion may affect the cutaneous and mucous surfaces of the body, the lining coat of the blood-vessels and serous membranes. Ulceration may be the result of, 1. Enfeebled cir- culation or defective nutrition from lack of blood, as exists in newly formed cicatrices, the lower limbs in the aged, the alse 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 PLATE XX. v^i 0";^ m>^ 1 Gangrene 2 Contents of a sebaceous cyst. 3. Lipoma. 4. Fibroma. 5. Spindle-celled sarcoma. 6. Enchondroma. 7. Scirrhous cancer. 8. Epithelioma. 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. GANGBENE OF TISSUE. A condition dependent upon an absolute and permanent arrest of nutrition to some local part of the body, provided that part retains to a greater or less degree its external form and anatomical characters, is termed " gangrene." The appearance of the affected part depends upon its previous vascularity, its solidity of structure, the cause and rapidity of the gangrenous process, and the presence or absence of exposure to the air. Gangrene may be divided into moist, dry, and hospital gangrene, on the basis of its appearance and origin. Of these, the first depends upon obstructed venous return; the second upon impaired arterial supply ; the third upon some epidemic poison causing a tendency to phagedena. Gangrene may result from local violence, excessive heat or cold, escharotics, inflammatory congestion and oedema, embolism, thrombosis, ligature of vessels, pres- sure of tumors, abnormal blood conditions, as in uremia, fevers, etc., etc., old age, atheroma, and in severe malarial affections in children. Gangrene also follows excessive doses of ergot and phosphorus, and the inoculation of farcy, or glanders poison. Its symptoms depend upon its variety. In the dry form of gangrene, a simple withering and mummifying process occurs. In the moist variety, the part becomes dark, soft and infiltrated with gases from decomposition, causing an emphysematous crackling if pressure be made upon the part affected. It is characterized by blebs upon its surface, is offensive in odor, and finally separa- tion of the sphacelus or slough occurs. In hospital gangrene, a phagedenic process commences within a wound and symptoms of pyaemia often rapidly follow. It is markedly contagious and usually fatal. 394 SURGICAL DIAGNOSIS. C. EBYSIPELAS. 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 eiwsipe- 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 cedematous, the fea- tures distorted by swelling, and the eyes closed from oedema when the lids are implicated. The constitutional symptoms increase with the advance of the disease and terminate with its abatement, in from eight to twelve days. As the skin grows pale, it becomes scaly, abscesses or boils frequently occur, and the beard falls out but subsequently returns. Erysipelas occurs most in the spring and fall of the year. It may follow absorption of poisonous matter by the lymphatics, and frequently accompanies suppuration, when occurring 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 ABABUM.—"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 choriumis 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 cedematous swelling of the lymphatic glands, or as an eczema, phlebitis, or lymphangitis. Elephantiasis may affect the feet, legs, scrotum, penis, labia and clitoris. The size of the affected part often be- comes immense. This disease is essentially one of hot climates. It is endemic in the East Indies, Syria, Japan, Egypt, the Barbadoes, and occasionally on the continents of Europe and America. It seldom begins before pu- berty, and is most frequent in males. It is sometimes hereditary. The absence of luxuriant vegetation seems to favor its development. When the scrotum becomes affected, as it frequently does, either independently, or when a similar condition of the leg exists, the penis is usually drawn into the tumor, as it enlarges, and becomes lost to 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 fence throughout. centre. Fluctuation. The tumor fluctuates as suppura- The tumor never fluctuates. tion advances. Chills. Rigors are often present if the Chills are absent, unless some suppuration be extensive. complication exists. SYMPTOMS IN COMMON. pain. redness of the skin. marked local swelling. elevation of local temperature. constitutional disturbance. Both may be associated with tt a tt a tt a tt tt << tt a a it it tt tt 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, edematous and ad- dom edematous 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. " " tt a fluctuation. tt tt t: a a detection of pus by the aspirator or exploring needle. (i tt a tt 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. rale, as long as a recumbent position is maintained. 402 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 The temperature and pulse may are usually increased. be affected if malarial enlargement exists. Rigors. Chills may be present. Chills are absent, save in malaria. History. A history of contusion, or of some The tumor develops without any exciting cause exists. apparent causation. Integument. The skin is usually involved and The integument is normal in its becomes red and edematous, as appearance. pointing takes place. 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, uremia, 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. Septicemia is often produced by Blood poisoning, as evidenced by absorption of the decomposing ani- pyemic or septicemic 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. tt tt a a diminished sensibility " " tt a «. -t 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 f ol- 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 activity, independent of the surrounding tissues. In attempting to classify tumors, I am led to follow the arrange- ment of T. Henry Green, of London, as it seems to me more clearly to elucidate this obscure subject than any other classification with which I am acquainted, and combines both simplicity of language with clearness of expression. Solid tumors 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 ) t,Fibnma» 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. f Fibro-Pla8tic. " Recurrent. " Nucleated. Myeloid. Glioma. Psammoma. Gummata. Lupus. Glanders. Myxoma. Lipoma. Enchondroma. Lymphoma. Leukaemia. Tubercle. Osteoma. Myoma. Neuroma. Angioma. Cutaneous surface. ' Papillomata ; growing from -j Mucous " Serous " Adenoma. Carcinoma. Glandular tumors. Scirrhus. Encephaloid. Epithelioma. Colloid. Cystic tumors may also* be divided into two great classes with their subdivisions, as shown in the following table, in which not only the varieties of cysts are enumerated, but the mechanism of their formation is also clearly explained. DISEASES OF TISSUES. 407 CYSTIC TUMORS. A. Cysts formed in preexisting cavities. B. Cysts formed in sacs of inde- pendent ori- gin. Retention Cysts ; (due to obstructed escape of secretion). Sebaceous ( True sebaceous tumors. cysts. "j Comedones. ( Atheromatous tumors. Mucous cysts. Cysts in or- gans or glands. j- 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 duets. Simple cysts of the ovary, due to di- latation of Graafian follicle. Compound cysts of the ovary, due to dilatation of Graafian follicle. Cysts of the liver, due to occlusion of ducts. Cysts of the kidney, due to occlusion of tubes. Exudative Cysts ; (due to excessive secre- tion). Extravasation Cysts ; (due to hemorrhage into closed cavi- ties). Cysts due to softening of tis- sues in the cen- tre of tumors, as in, Cysts due to ex- ' pcmsion and fu- sion of the spaces in connective tissue. Bursas. Ganglia. Hydrocele. Cysts of broad ligament. [ Hematocele. Sanguineous tumors. Lipoma. Enchondroma. Sarcoma. New bursa?. Serous cysts of the neck. Compound ovarian cysts. Cysts formed t Parasites. around foreign -] Extravasated blood. bodies. ( Bullets, etc., etc. 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. Fibroid. Gummata. Epithelioma. Encephaloid. Cystic. Fibroid. Myeloid. . Osteoma. DISEASES OF TISSUES. 409 B. TUMORS OF THE^ NECK. Vessels. Muscles. Parotid Gland. Thyroid Gland. Lymphatic Glands. Integument. Mucous Membranes of Pharynx, (E- sophagus, and Larynx. ( Encysted Aneurism. \ Diffuse ( Cystic. < Lipoma. t Myoma. Cystic. Fibrous. Enchondroma. Hypertrophy. Abscess. Cancer. ( Cystic. •< Hypertrophy. t Encephaloid. Lipoma. Hypertrophy. Abscess. Syphilitic Induration. Tuberculous " Cancer. Fibroid. Serous Cysts. Moles. Warts. Keloid. Eloid : (coil-like tu- mor). Cystic. Myxoma. Fibroma. Adenoma. Sarcoma. Papillomata. Carcinoma. 410 SURGICAL DIAGNOSIS. Mammae. Cysts. Fibroma. Adenoma. Enchondroma. Lipoma. Scirrhus. . Encephaloid. Labia. ' Cysts. Abscess. Haematocele. L Epithelioma. Uterus. C. TUMORS OF TRUNK. THE Cystic. Fibroid. Myoma. ' Enchondroma. Pulsatile. Carcinoma. Rectum. ( Fibrous. -j Fatty. ( Carcinoma. Prostate. Hypertrophy. Abscess. Scirrhus. Encephaloid. Testicle. 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 difiicult from their situation and depth. Tumors of the axilla may be thus enumerated: AXILLARY TUMORS. Dependent on j 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. Dependent on ) ^ of ^ ^ organs. ) 412 SURGICAL DIAGNOSIS. r Abscess of lo- cal origin. TUMORS OF THE GROIN. In region of in- guinal canal. In the region of femoral canal. In the iliac fossae. 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. EpitJwlioma, The colloid variety, termed also gelatiniform and cdveolar 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. SCIEEHUS. 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 medidlary, is usually a secondary disease, some other form having first developed. It is extremely malignant in its progress, grows rapidly, invades 414 SURGICAL DIA GNOSIS. 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 clastic 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 cidaneous 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 lamina?, 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- mie, 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 (Epithelial Cancer ; Clay-pipe Cancer ; Chimney - sweep's Cancer). A small section of the tumor, un- der a microscope, reveals epithelial nests and epithelial spheres. SCIRRHUS (Fibrous or Chronic Cancer). A section of the tumor reveals excessive development of a fibrous stroma and epithelial cells in a state, often, of atrophy. 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. 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 GLANDS. Ulceration rapidly develops after the tumor has become superficial. A return of the disease, after re- moval of the tumor, within two years is frequently present. TUBERCULAR DISEASE OF AXILLARY GLANDS. Suppuration occurs in the majori- ty of cases, and its evacuation is preceded by a sense of fluctuation within the tumor. re- The disease shows no tendency svo towards a return after removal. 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. Effects of Removal. 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- mon4 five 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 or the Scalp. 2. Fatty 3. Exostoses of the Skull. 4. Abscess. 5. Cephalhematoma. 6. Encephalocele. 7. Dropsy of the Meninges op 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. « « " " similarity in feel and consistence. " " " " rapid or slow formation. « « "■ « an absence of apparent causation or a knowl- edge on the part of patient or friends of a congenital defect or deformity. 426 SURGICAL DIAGNOSIS. ENCEPHALOCELE. DROPSY OF THE BRAIN. Situation. Occurs at the occiput, sutures, Is most frequent at the anterior anterior fontanelle, and occasionally and posterior fontanelles, but may at the root of the nose 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 brain substance. The tumor is due to an excessive 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. No acute inflammatory symp- toms are present, (such as pain, oedema, great sensitiveness, and con- stitutional disturbance). Acute inflammatory symptoms are present, such as Chills, Great pain, " 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. Exploring Needle. The exploring needle in cases of The exploring needle gives nega- doubt decides the diagnosis. five 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 Majole. 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. The 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 MAMMAE. THE BREAST. Origin. Occurs most frequently in maid- Is most frequent in the married ens between twenty and forty years during the term of pregnancy or of age, and is often associated with menstrual derangement. menstrual derangements or trauma- It is never of traumatic origin. tism. 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- The breasts are usually less mova- able. ble than normal. SYMPTOMS IN COMMON. Both are usually firm and incompressible. " " " painless. " " " of slow growth. " " " unassociated with tegumentary changes. " " " associated with normal health. * " " " free from 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. five. 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. Fcstal 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. " " " " " vomiting. a a a « " local uterine disturbance. a a t< a i( vesical and rectal irritability. 438 SURGICAL DIAGNOSIS. FIBROID TUMOR OF UTERUS. PREGN aNC Y. Menstruation. Menorrhagia or metrorrhagia is Amenorrhcea 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. Foetal Manifestations. Quickening, foetal movements Fcetal 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. " " " " " a uterine tumor. " " " " " frequent local pains. " " " " " vesical irritation. „ tt tt a a rectai " 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. Fcetal 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. " " " " " leucorrhoea. " " " " " pain in the back and in the loins. " " " " " dysmenorrhoea. 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-carclnoma. 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 ovariau 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. sition. 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. Amenorrhcea 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. Fcetal 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. t( tt a pain in the breasts. " '•' " areola " " (i •• " morning sickness. 450 SURGICAL DIAGNOSIS. TUMORS OF THE PELVIS. The various types of tumor found within the pelvis may be enu- merated as follows: 1. Pelvic Cellulitis. 2. Pelvic Peritonitis. 3. Pelvic 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. I . 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 ruptur,e. 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 it3 when introduced into the rectum. normal position. Conjoined Manipulation. By pressing the abdominal walls The uterus is not detected, save firmly downwards 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 Avill 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 which are developed external to the spine comprise those of a congenital and an acquired variety and the condition called spina bifida. Among the different forms of congenital tumors of the spine which have been reported may be enumerated: 1. Parasitic growths (containing the remnants of an obliterated foetus). 2. Cystic Tumors (simple and compound). 3. Fibroid Tumors. 4. Fatty Tumors. Congenital tumors of the spine are most frequently located in the vicinity of the sacral or the lower lumbar regions. They are often connected directly with the spinal membranes, in which case the bony encasement of the spinal cord is locally deficient. They may be present upon the anterior or posterior aspect of the spine and are not infrequently intra-pelvic for that reason. If situated so as to press upon the pelvic viscera they may create a displacement of the coccyx, and a protrusion of the anus and perineum may be also produced. If the tumor have a direct connection with the spinal membranes, it will, with few if any exceptions, lie in or spring from the median line. If cystic in its variety it will usually reveal a contents similar to the cerebro-spinal fluid in its chemical composition provided any communication with the cavity of the arachnoid is present, and differs little, therefore, in its actual construction from that of spina-bifida. Congenital tumors in the spinal region communicate in rare cases with the cavity of some viscus, as the intestine, rectum, bladder, etc. In this event a possible escape of the contents of the tumor into these various organs will be the only means of determining such an abnormal condition. Spina Bifida. This condition is in reality a congenital hernia of the spinal mem- branes through an abnormal opening in the vertebral column. It is a frequent deformity and is either distinctly localized or affects the whole or greater portion of the spinal column. The sac DISEASES OF TISSUES. 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. Tumors of the Spinal Meninges. These will be considered in a subsequent chapter, among the so- called " focal lesions " of the spinal cord. They produce symptoms which vary with the regions of the cord that are subjected to the pressure consequent upon their growth. 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- the patient stands erect. fected by the attitude of the pa- Is fluctuant usually when the tient. patient lies upon the abdomen. Effects of Respiration. The tumor is often decreased in The tumor is not altered in size size by a full inspiration and is in- by the respiratory function. creased in size during expiration. Effects of Pressure. The tumor decreases in size on The tumor is often resistant to direct pressure being applied. pressure and is, as a rule, but slight- If other tumors of the same ly affected. variety co-exist, they often increase in size 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 with the Mem- branes of the Spinal Cord) (continued). Transmitted Light. The tumor is often translucent, as The tumor is always opaque. is perceived by holding a candle be- hind it. Appearance of the Integument. The integument covering the The integument is usually of nor- tumor may be reddened, thinned mal color and appearance, but is, as and transparent, or even absent, a rule, adherent to the tumor. In some cases 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. iC tt a a imperfect development of the lower limbs. 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. i( may result in atrophy of the lower limbs. u *< « tt paraplegia or extreme muscular weakness and reten- tion or incontinence of urine if the tumor be situated above the second lumbar vertebra. DISEASES OF THE BRAIN AND ITS ENVELOPES. DISEASES OF THE BRAIN. In connection with a surgical practice, congenital and acquired abnormal conditions of the brain are constantly encountered and must be differentiated one from the other. In a chapter like the present one, no attempt at an exhaustive exposition of these con- ditions can be made. The literature of each disease is so extensive that an apology is due for the many omissions and defects which a condensed resume of the entire subject must of necessity exhibit. The abnormal surgical conditions of the brain must first be classi- fied in order to simplify the descriptive text which is to follow. The table offered is in many ways imperfect and perhaps not the best that can be made, but it may assist the reader in the study of sub- sequent pages. - (1.) Congenital abnor- malities OF THE HEAD ■{ OR ITS CONTENTS. A TABLE OF THE MORE IMPORTANT ABNORMAL CON- i DITIONS OF THE BRAIN. (2.) Diseased conditions of the vascular ap- PARATUS. (3.) Inflammatory con- ditions. (4.) Degenerations. . (5.) New growths. ' Double-Head or Fusion of two heads. Absence of the Brain or Head. Cyclocephalic deformity. Abnormalities of the Cerebral Envelopes. Incomplete development of spe- cial ganglia. Hydrocephalus. Encephalocele. Aneurismal dilatations. Atheroma. Rupture or Spontaneous perfora- tion—Apoplexy. Thrombosis — Arterial or \Te- nous. Embolism. Fibroid degeneration. Inflammatory changes. Pachymeningitis (inflammation of the dura mater). Arachnitis. Hydrocephalus. Cerebritis or Encephalitis. (Red. Softening. < White. (Yellow. Sclerosis. Atrophy. Carcinoma. Epithelioma. Glioma. Myxoma. Gummata. Psammoma. Cholesteatoma. Tubercle. Fibrous and Fibroplastic. 462 SURGICAL DIAGNOSIS. Before we pass to a special consideration of the diseased condi- tions of the brain, it may be well to refer to a few special symptoms (some of which are often erroneously spoken of as diseases) that result from impairment of the functions of certain nerve centres. The more important of these are as follows : Motor Paralysis—which can vary both in degree and type. Sensory Paralysis— " " " " " " " " Aphasia. Impairment of Intellect, Memory, Consciousness, etc. Pain. Abnormal Electro-Muscular Phenomena. Abnormal Conditions of the Organs of Special Sense. We are enabled chiefly by a careful study of these symptoms to determine the existence of many of the diseases which have been enumerated; and to decide often as to the location and extent of the diseased conditions of the nerve centres that produce them. The art of localizing lesions of the brain and spinal cord is based upon anatomical and physiological facts which are too complex to be given here in detail—a deficiency which the Author has endeav- ored to supply in a work devoted exclusively to that subject. (See bibliography.) Some statements made in the pages which follow will be, of neces- sity, somewhat dogmatic, because the limits of this volume will preclude lengthy explanations. A few will possibly be open to criticism, because the data from which the conclusions have been drawn are not yet accepted as proven by all neurologists. I have intentionally omitted in the preceding table certain con- ditions of the brain which have been made, of late, the subjects of frequent literary discussions. Among these may be mentioned the much disputed ground of cerebral hyperaemia and anaemia. In ex- planation, I can only say that in my opinion they are not within the special province of Surgery. They are now treated of in most of the later works upon the Practice of Medicine, and still more exhaustively in the various treatises upon Nervous Diseases. CONGENITAL MALFORMATIONS OF THE BRAIN. Two heads have been repeatedly met with on the same body. They may be distinct; or joined together either laterally or pos- teriorly. They may be also of different sizes and shapes, and may evidence different degrees of development. DISEASES OF THE BRAIN AND ITS ENVELOPES. 463 An entire absence of the brain at birth, and, in some instances, of the spinal cord in part, has been not infrequently recorded. The cerebrum, cerebellum, pons Varolii, medulla oblongata, and even a part of the spinal cord may be occasionally wanting, and yet the cranial nerves may be perfectly developed. In rare instances, the base of the skull has been exposed to view; in others, the upper cranial bones have been wanting and the integumentary covering of the head has been found to be distended by a fluid accumulation beneath it; while, in some cases, only parts of the brain have been absent, the remaining ganglia being normally developed. The condition termed " Cyclocephalous"—due to a fusion of the two orbits into one cavity—is sometimes encountered. The meninges may be occasionally found to be incomplete. The corpus callosum, fornix, and septum lucidum have been found want- ing. The optic nerves have sometimes no commissure. The whole brain may be occasionally so small as to constitute the "microcepha- lous state." Again, only certain convolutions may exhibit arrested development, and a cyst filled with serum is then found to spring from the meninges and fill the 'space thus left vacant. The two hemispheres of the cerebrum may present extreme variation in point of size and weight; and the thalami and corpora striata may occasionally exhibit atrophy. Finally the " hydrocephalic condition " may exist (characterized by excessive fluid outside of or within the ventricles of the brain). It usually tends to increase after birth. The brain may occasion- ally protrude from the cavity of the cranium at the various sutures or fontanelles—constituting " encephalocele.." The various types of congenital malformations of the nerve cen- tres which are encountered seem to depend upon some violence to the uterus, or mental shock to the mother during pregnancy. DISEASED CONDITIONS OF THE CEREBRAL VASCULAR APPARATUS. Under this heading come aneurismal dilatations; atheromatous and calcareous changes; rupture or spontaneous perforation of blood-vessels ; thrombosis of arteries or sinuses ; embolism ; fibroid degeneration ; inflammatory changes in the coats of blood-vessels ; hyperaemia; and anaemia. A. Aneurismal Dilatations. The vessels most frequently affected are the internal carotid, basilar, and middle cerebral. Within the 464 SURGICAL DIAGNQSIS. cavernous sinus, large aneurismal tumors are not uncommon. It must not be supposed, however, that the smaller vessels of the brain are exempt. Miliary aneurisms, which give to an artery and its branches an appearance resembling a bunch of grapes, fre- quently affect the vessels that form the circle of Willis and even those of the pia mater within the substance of the brain and in the ventricles. The small vessels which nourish the corpora striata and the optic thalami are sometimes affected. Miliary aneurisms frequently coexist with aneurismal tumors outside of the cranium; but they seem to exhibit an independence of atheroma which is quite remarkable. Charcot, Zenker, Bouchard, Meynert, Hammond, and others who have devoted special attention to this subject, differ regarding the cause of these dilatations; some regarding them as due to a " scle- rosis of the tunica intima " of the arterioles, while others believe that small " dissecting aneurisms " (page 7) first form on account of a rupture of the inner coat. When the external coat of such an aneurism ruptures, a cerebral hemorrhage ensues. The fact that this condition affects all ages (even children are not exempt) seems to point to an " aneurismal diathesis " as an exciting cause in some instances—the arterial coats exhibiting marked congeni- tal defects in their construction. Among the other exciting causes of cerebral aneurism may be mentioned the cachexia of cancer; tuberculosis ; uraemic poisoning ; chronic alcoholism; lead poison- ing ; leucocythaemia; rheumatism; gout; syphilis ; and general paralysis. The remarkable tendency of alcohol to excite aneuris- mal tendencies (not only in the brain and retina but in other parts as well) is adduced by some authors as an argument in favor of the view that arterio-sclerosis precedes and causes the alterations in the calibre of the vessels. These miliary aneurisms give rise not infrequently to headache and vertigo ; and attacks of paralysis which follow one another rapidly, and from which the patient quickly recovers, are almost a positive proof of their existence. In the case of aneurisms of large size, atheromatous or calca- reous changes within the arterial coats are seldom absent. B. Atheroma. This subject is treated of in a preceding chapter. (Page 4.) It is, perhaps, one of the most common causes of arterial thrombosis, and a frequent one of apoplexy. C. Spontaneous Perforation of Vessels. In rare instances, a DISEASES OF THE BRAIN AND ITS ENVELOPES. 465 spontaneous perforation of a vessel within the cranium occurs without any appreciable cause being discovered. These localized changes in the walls of arteries are not well understood, but syph- ilis seems, as a rule, to be associated with spontaneous perforation. D. Cerebral Thrombosis. A coagulum of blood may form in either the sinuses, veins, or arteries of the brain. The causes which chiefly tend to produce this result are (1) atheroma, which produces a roughened condition of the internal coat of the blood- vessels ; (2) hyperinosis—or that condition of the blood in which a marked excess of fibrine is present, as in some acute diseases, of which inflammatory rheumatism stands foremost; (3) pressure upon some large vessel or sinus, so that the circulation within it is rendered extremely slow ; (4) chronic interstitial nephritis; (5) syphilis; and (6) pyaimia, which seems to be associated with a special tendency toward spontaneous coagulation of blood within the vessels, when the rapidity of the current is slowed. Thrombosis is much less common in arteries than in venous channels, but it is not uncommon in the internal carotid, the verte- bral, the basilar, and the middle cerebral arteries. In the superior longitudinal and lateral sinuses, thrombosis is frequently found in connection with pachymeningitis. Old age seems to predispose to the development of cerebral thrombosis; and males are more commonly affected than females. The effect of thrombosis of arteries or veins within the cavity of the cranium is to render the nutrition of surrounding parts more or less imperfect, and thus to impair the function of those parts. If it be of pyaemic origin, the clot may cause suppuration of the adja- cent structures ; and, by its disintegration, other vessels more or less distant from the seat of the original thrombus may become plugged by the detritus. The symptoms produced by cerebral thrombosis must, of neces- sity, be modified by the situation of the clot and the vessel oc- cluded by it. A knowledge of the functions of different portions of the brain can alone decide questions which may arise respecting the situation and the probable termination of the lesion. Either coma or paralysis (in any of its forms) is apt to be one of the results. The more common symptoms of this condition will be given in a table of contrast on a subsequent page. It is liable to be confounded chiefly with cerebral embolism or cerebral hemor- rhage. It must be remembered that syphilis and chronic nephritis are CO 466 SURGICAL DIAGNOSIS. among the most frequent of the causes of arterial thrombosis. This fact is explained by the development of an inflammatory con- dition of the internal coat of the vessel—the so-called " endarteritis obliterans." For this reason, the history of the patient may prove an important factor in the differentiation between cerebral throm- bosis and some other conditions of the brain which might be mis- taken for it. E. Cerebral Embolism. Most of the clinical facts which per- tain to this condition in general have been mentioned in a previous chapter (page 15). The most frequent seat of cerebral embolism is in the middle cerebral artery of the left side, because this artery forms the ter- mination of the most direct channel from the heart. The left carotid is so situated in reference to the aorta as to favor the passage of floating particles in the blood into its mouth. Next in point of frequency comes the right Sylvian artery, because the innominate artery, although larger than the left carotid, leaves the aorta at an angle opposed to the current of blood in that vessel. Floating particles in the circulation (which become emboli with- in the vessels of the brain) may spring (1) from the heart cavities or from the mitral and aortic valves ; (2) from the walls of the aorta; (3) from the cavity of some aneurism ; (4) from the disintegration of some thrombus in other parts of the body {the loosened particles being swept into the circulation); and (5) from foreign bodies in- troduced into the circulation from without. The size and number of the floating particles modify the seat and number of the emboli. If small, the capillaries of the brain alone may be occluded ; if large, one or more of the main trunks are liable to be plugged, and a much larger area of brain substance is thus deprived of blood. Not infrequently many vessels are simul- taneously obstructed at the same time. Sometimes all the main vessels on one side, and at other times vessels of both sides are more or less occluded. The common effects of occlusion of a large trunk are sudden aphasia and hemiplegia (usually of the right side of the body). When the capillaries alone are involved and the main trunks escape, the effects and symptoms vary with the seat of the embolus, because only certain limited portions of the brain are then deprived of their nutrition. Cerebral embolism is a constant source of extravasation of blood, because it induces infarction. It may result in localized softening DISEASES OF THE BRAIN AND ITS ENVELOPES. 467 of the parts that are imperfectly nourished, provided the embolus is large. If the embolus is of suppurative origin, " embolic ab- scess " results. An infarction is a wedge-shaped spot of consolidation and discol- oration within an organ dependent upon occlusion of a blood-vessel and the subsequent rupture of neighboring capillaries. Whenever a vessel of an organ becomes occluded, the parts nourished by the occluded vessel are deprived of blood, until a collateral circulation is established. Now, it is found that, after such occlusion, the parts which are at first deprived of blood become subsequently the seat of a rupture of the capillary blood-vessels as the result of an excessive pressure produced by the collateral fluxion. Hence the infarction is wedge-shaped, as a rule, owing to the distribution of the blood-vessels ; and its apex (corresponding to the seat of the plug) usually points toward the centre of the organ in which it is detected. If the circulation is not speedily restored, the result of defective nutrition caused by the embolus is evidenced in one of three ways : either in gangrene—if the part be totally cut off from its blood supply ; fatty degeneration and absorption of the embolus and blood coagula—if the nutrition be only partially cut off; or more or less extensive suppuration—if the plug in the vessel be derived from a suppurative focus or be septic in its origin. We usually find, therefore, that old infarctions are liable to appear pale, and to be firm and incompletely organized, provided that the character of the plug (an embolus or thrombus) does not create suppuration ; in which case disintegration takes place rapidly in the centre of the infarction, and an abscess results—" embolic abscess." The more complete the obstruction, the more vascular the tissue, and the less the vessels are supported, the greater is the amount of infarction and the more rapid the softening and disintegration that ensues. The development of " metastatic " or " embolic abscesses " is one of the distinctive pathological features of pyaemia, and no case can be properly so called when these abscesses are not found after death. For some unexplained reason the female sex is more frequently affected with cerebral embolism than the male sex. It is also more common in youth and adult life than in old age. The diagnostic points of cerebral embolism are enumerated in a previous table (page 44). 468 SURGICAL DIAGNOSIS. INFLAMMATORY CONDITIONS OF THE BRAIN AND ITS ENVELOPES. In a previous chapter the subject of inflammation has been dis- cussed. The more common conditions of this type which the sur- geon encounters within the cranium are pachymeningitis; arachnitis; hydrocephalus ; and encephalitis. A. Pachymeningitis or Inflammation of the Dura Mater. This condition is usually circumscribed and rarely spreads over the whole convexity of the brain. It is of two forms, the suppurative and the non-suppurative. As it is frequently associated with extrava- sation of blood, it is described by some authors under the name of "haematoma of the dura mater." Other authors classify it as of two forms, the external and the internal—the latter being san- guineous. The causes which tend to produce it are as follows : (1) Injuries to the cranial vault; (2) Syphilitic disease of the bones of the cranium—most commonly of the temporal; (3) Hemorrhage be- tween the dura mater and the bone ; (4) Diseases of the cervical ver- tebrae and their ligaments. Suppuration more commonly accompanies the carious and hem- orrhagic varieties. It may occur after traumatism, especially if thrombosis follows. A general arachnitis is then liable to be in- duced as a complication of the circumscribed inflammation of the dura. The base of the brain is usually exempt from this form of meningitis, except as a sequel of traumatism, tumors, or diseases of the vertebrae. In the non-suppurative variety, the dura becomes composed of superimposed layers which are rich in vessels. It subsequently becomes united to the arachnoid. These layers occasionally ossify. The newly formed vessels sometimes rupture and thus create cir- cumscribed sanguineous cysts. When syphilitic caries is the excit- ing cause, the dura may become gangrenous. Lesions of this character may excite paralysis of parts supplied by cranial nerves which lie adjacent to them ; and when the pres- sure becomes extreme even coma may follow. Localized pain is usually present over the seat of the disease ; and percussion of the skull over the lesion tends, as a rule, to increase the pain. The de- fective blood-supply (in those convolutions of the brain which lie adjacent to the lesion) that ensues from pressure upon them, may PLATE XXI. A Diagram designed by the Author to show t he relative Depths of the Cranial Cavity and the Situation of the more important Motor Centres in the Cerebral Convolutions. A—B. Out- line of the floor of the cranial cavity, showing the anterior, middle and posterior fossae, of the crani- um. R, fissure of Rolando. The upper limit of this fissure lies 45 millimetres (14-5 inches) posterior to a vertical line passing through the external opening of the ear when the patient is in the standing posture, and the head at a right angle to the spinal column. Its anterior or lower extremity lies nearly at the point of intersection of this vertical line (auriculo-bregmatic) and a horizontal line intersecting the upper level of the orbit. The auriculo-bregmatic line should be at a right angle to an imaginary base line (C—D). which corresponds to the alveolo-condyloid plane (that upon which a denuded skull naturally rests when'upon a table, and with the lower jaw removed). DISEASES OF THE BRAIN AND ITS ENVELOPES. 469 lead to softening. When suppuration occurs the symptoms are greatly aggravated. They are discussed in a subsequent page. B. Arachnitis. Thickening and opacity of the arachnoid has been observed in connection with atheroma; cancer of the abdomi- nal viscera; granular kidney ; senile dementia; delirium tremens ; tuberculosis; heart lesions ; cerebro-spinal meningitis ; hemorrhage into the pia mater; and as a sequel to disease of the bone and the dura mater. It may be associated with an effusion of lymph or pus, and be either local or general. The exciting cause will be of the greatest aid in determining its character during life. It is often impossible to discriminate during life between lesions involving the dura mater from those of the arachnoid ; and it is still more difficult to sepa- rate its morbid conditions from those of the adjacent pia mater which underlies it and which usually participates to a greater or less extent in its changes. Atheromatous degeneration of the cerebral vessels seems to be commonly associated with those forms which have their apparent origin either in cancer or the abuse of alcohol. As in all inflamma- tory conditions of the coverings of the brain, the symptoms are produced either by the hyperaemia in the early stages, or by the pressure of the exudation upon the brain or cerebral thrombosis, in the later stages of the disease. C. Hydrocephalus. The chronic form of this disease is essenti- ally surgical, while the acute form comes more particularly under the province of the physician. In either case, however, the " tubercular diathesis " seems to influence its development. The chronic variety appears to be produced by a low grade of inflamma- tion which attacks the lining of the ventricles during foatal life or early childhood. In some instances it appears later in life, and in a few isolated cases the serous effusion seems to be external to the brain. Some authors state that this latter condition never occurs except as the result of a hemorrhage into the cavity of the arachnoid. They consider the condition which simulates true external hydro- cephalus as an evidence either of a congenital defect in develop- ment (the cerebro-spinal fluid taking the place which the brain should have occupied), or of atrophy of the brain substance, that has resulted from the pressure of the fluid within the ventricles. In chronic hydrocephalus the sutures fail to unite and the cal- varia fails to ossify as in health; the ventricles are enormously 470 SURGICAL DIAGNOSIS. \ distended and the channels of communication between them are widely dilated and open; finally, the convolutions are flattened and the cerebral substance rendered extremely thin and attenuated. The ossa triquetra are often found to be excessive. A complicating meningitis (which often exists) may involve some of the cranial nerves (especially the optic) and induce atrophy of them. Fluctu- ation may usually be detected in the region of the fontanelles and the open sutures. The deformity of the cranium is evidenced by the overhanging brow, the increase of the circumference of the cranium and its disproportion to the size of the face, and the open fontanelles and unclosed sutures, which are often widely separated. The mental condition of the subject is below the normal standard when the pressure of the fluid has induced changes in the brain substance. This condition may not in some cases materially shorten life; although, as a rule, it is fatal within a period extending from a few months to two or three years. If apparent recovery ensues, the intellect of the subject is always more or less impaired. The symptoms of this condition will be found in a subsequent page, contrasted with those of other diseases with which it may be confounded. D. Encephalitis. The substance of the brain may take on in- flammatory action, with or without the existence of a complicating meningitis. It is generally circumscribed, although many spots may be simultaneously affected. The latter is sometimes termed the " general" variety. Sometimes the gray matter of the cortex is alone involved; again, only the medullary substance iof the brain may be implicated ; finally, the basal ganglia (the " corpora striata " and " optic thalami,") the cerebellum, the medulla oblongata, the pons Yarolii, the crura cerebri, and the floor of the fourth ventricle have been known to be the seat of this condition. The existence of encephalitis may be manifested after death (1) as spots of injection associated with abnormal friability; (2) by the presence of punctate extravasations seen on cross sections of its substance ; (3) as localized indurations ; (4) as red softening of the brain substance ; (5) as circumscribed collections of pus; and (6) by gangrene. If cerebral abscess has occurred, the cavity is usually encapsu- lated by a new connective-tissue formation. Rindfleisch divides the stages of cerebral abscess as follows : 1. A stage of hyperaemia ; 2. The development of infarction (page 467); DISEASES OF THE BRAIN AND ITS ENVELOPES. 471 3. (Edema or hemorrhagic extravasation; 4. Proliferation of the cell-elements ; 5. Hypertrophy and induration, in chronic cases ; 6. Softening of the brain substance ; 7. Suppuration ; 8. A condition of fa'tid suppuration, resembling gangrene, which is occasionally preceded by the development of a false membrane ; 9. Atrophy, as a result of the inflammatory changes. Among the causes of encephalitis which tend to induce suppura- tion may be mentioned pyaemic infarction; direct injury to the head; disease of the internal ear or temporal bone ; diseases of the nasal cavity ; syphilitic disease of the bones of the cranium ; dis- eases of the orbit; cancer; and certain idiopathic causes which are not well understood. Encephalitis is so closely allied to red cerebral softening that it will be further discussed under that heading. The symptoms of the disease must of necessity vary with the seat and extent of the lesion; hence it is difficult to interpret them correctly unless the functions and anatomy of the various component parts of the brain are well understood. DEGENERATIONS OF THE BRAIN SUBSTANCE. Under this head, we will consider (1) the three forms of cerebral softening ; (2) sclerosis; and (3) atrophy. A. Cerebral Softening;. The three forms of this condition which are recognized by most authorities are the white, yellow, and red. The while variety results from causes that tend to so impair the blood supply of the softened part as to deprive it of nutrition with- out creating at the same time a hemorrhage from the surrounding capillaries. It is of ten designated as the "non-inflammatory form," in contrast to the red, which is commonly of inflammatory origin. The nature and mode of suppression of the blood supply, to por- tions of the brain more or less limited, governs to a great extent the variety of softening which results. As has been stated in a previous page, the arteries, capillaries, or sinuses of the brain may be independently occluded. Thrombosis or embolism may be the immediate cause of such occlusion, or the blood supply may be arrested by pressure upon the vessels from without, as in the case of hemorrhage, tumors, ligation, cedematous infiltration, etc. The rapidity of arrest of the circulation, and the extent of collat- eral fluxion which immediately follows (within 24 or 48 hours), are the key-notes to the results which follow. The collateral cir- 472 SURGICAL DIAGNOSIS culation may be sufficient in some cases to arrest the immediate death of the parts suddenly deprived of blood by an embolus or thrombus or some quickly developed and extreme pressure upon the blood-vessels. Again, it may be so great as to cause a capillary hemorrhage, giving the softened area a red appearance (infarction) immediately after the arrest of its normal blood supply. Finally, inflammatory action, as in true encephalitis, may create the red variety of softening. The pathology of the three varieties of softening of the brain may be thus summarized : The white variety is a chronic condition in the great majority of cases, and is usually dependent upon some disease of the small arteries and capillaries which gradually deprives the parts of their normal nutrition. There is no hyperemia. The parts are usually of an opaque dirty white. White softening may sometimes be acute, in which case it is due to a sudden obstruction of some artery of large size by an embolus or a thrombus. The yellow variety is simply an altered state of either the white or the red. Its color is due either to the presence of altered blood- pigments which have arisen from a previous slight extravasation; or to a fine state of division and a close aggregation of particles of fat formed within a mass of the former variety. The red variety is commonly an acute affection. As has been stated, it follows vascular occlusion from an embolus or thrombus; or it may be the result of an attack of encephalitis. A marked ex- travasation of blood into a mass of white softening may cause a red appearance to the mass, but the microscopical appearances will differ from that of the acute form now under consideration. In the red variety there is intense hyperseniia from the onset, followed by a rupture of the capillaries and an extravasation of blood. Its pathol- ogy is similar to that of " infarction" elsewhere in the body (page 467). The symptomatology of this affection will be discussed in a subse- quent page, in contrast with that of others which must be differ- entiated from it. All forms of cerebral softening are liable to be accompanied by disturbances of motion and sensation, aphasia, and mental impairment. The seat and extent of the lesion will govern the type of its external manifestations ; and the history of the patient will often be indispensable in deciding as to the existence of softening, if in the anterior part of the frontal, the occipital, or the temporal lobes, where the so-called " motor centres " of the brain are wanting (see plate). DISEASES OF THE BRAIN AND ITS ENVELOPES. 473 B. Sclerosis or the Brain. The term " sclerosis " is used to desig- nate a condition characterized by an increase in the connective tissue of an organ. This newly formed connective tissue subse- quently contracts and induces atrophy of those parts which are thus subjected to pressure. This is because the blood supply is thus gradually diminished. In the nerve centres this condition may assume different forms: 1. It may constitute the so-called " general sclerosis," seldom in- volving the brain but not infrequently affecting large tracts of the spinal cord. 2. It may be disseminated throughout the brain and spinal cord—constituting the " sclerose en plaques " of the French authors. 3. A variety of the second form, termed " miliary sclerosis," has also been described. Sclerosis of the brain probably starts as a chronic congestion, which leads to an exudation of an albuminous fluid, and subse- quently to cell-proliferation in the neuroglia. It is closely allied to inflammatory processes, if not strictly dependent upon them. Injuries to the convolutions of the so-called " motor area " of the brain seem to act as an exciting cause of a so-called " descending sclerosis " which confines itself to the tract of fibres that are func- tionally associated with the parts injured. In this way it eventu- ally reaches the spinal cord. Similar changes may involve the cranial nerves, chiefly the optic. In chronic insanity, sclerosis of the brain is not infrequently detected. The same may be said of general paralysis; epilepsy; Duchennes malady; paresis; para- lytic tremor; and idiocy. The symptoms of this disease vary somewhat with the seat of the disease and its type, whether general or disseminated. It is to be confounded chiefly with cerebral softening, embolism, and throm- bosis. In children, chorea might be mistaken for it. A table of differential diagnosis is given later, in which the main clinical feat- ures of this disease are presented. C. Cerebral Atrophy. This condition may be of two varieties— the infantile and senile. In the infantile form the characteristic lesions include (1) ob- liquity of the skull—one lateral half being shrunken and deformed ; (2) premature closure of the sutures ; (3) atrophy of the correspond- ing cerebral hemisphere, involving its convolutions and basal ganglia. The atrophic changes may even involve the pedicles of the brain, the pyramids of the medulla, and the columns of the spinal cord. This form is due chiefly to foetal apoplexy, encephal- itis, hydrocephalus, and physical shocks or violent emotions on the part of the mother during pregnancy. 474 SURGICAL DIAGNOSIS. The symptoms of this variety vary with the extent of the atrophy. Weakness of intellect; deaf-mutism; abolition of some of the special senses ; incomplete paralysis ; contractures ; and impair- ment of the sensibility of the paralyzed parts may be present in addition to the cranial deformity. The bones, muscles, nerves, etc., of the side opposite to the cerebral atrophy may be imperfectly developed. Ptosis and strabismus often occur. In the senile variety the atrophic changes may be due to any cause which tends to slowly impair the nutrition of the brain. Among such may be mentioned embolism, thrombosis, hemorrhage, tumors, encephalitis, inflammations of the pia mater, alcoholic, opium, or lead poisoning, syphilis, etc. The symptoms of this form include many manifestations of en- feebled mental powers. The memory and intelligence are affected early; apathy and somnolence develop; the power of motion is slowly but gradually lost; tremor makes its appearance ; finally, the patients take to their beds and pass into the condition of child- ishness, accompanied by the symptoms of bulbar paralysis, from which they die. Bed sores, bronchitis, and acute pulmonary oedema are frequent complications. TUMORS OF THE BRAIN AND ITS ENVELOPES. The various forms of new growths which may be encountered in the brain have been enumerated in a tabulated form on pages 403 and 408. All of the attempts which have been made to classify tumors of the nervous system, from that of Jaccoud to the present day, are more or less illogical. Every classification must be open to some objection ; but attempts of that kind unquestionably serve to assist memory and to systematize description. We have already touched upon aneurisms as one of the lesions of the vascular apparatus. Parasites of the brain, which are enumer- ated by Jaccoud as a tumor, are discarded by Fox, because they can hardly be said to constitute a tumor. Exostoses have been discussed among the tumors of bone. Among the entire list, gummata, or syphilitic tumors, possess more clinical interest than any of the others, This is because they are more frequent than the rest, and also because the prognosis is favorable—often after the most severe effects to the brain are mani- fested. We owe much of our knowledge of these lesions to Broad- bent, who studied their effects upon the nerve centres. They start from the membranes or attack the surface of the brain directly. DISEASES OF THE BRAIN AND ITS ENVELOPES. 475 They are strictly localized and grow slowly. They usually affect only small portions of the organ. Gradually, they tend to induce adhesions of the membranes both to each other and to the brain itself; and, by pressure, they cause local softening of the brain substance. In the same way, the effects of pressure upon the cranial nerves which lie adjacent to these tumors are often exhib- ited early; and thus the diagnostician is enabled to locate the tumor. This statement applies, however, with equal force to all tumors of the brain. Tumors of the brain, and in fact any lesion which tends slowly to increase intra-cranial pressure, tend to manifest their existence by development of a double optic neuritis—the so-called " choked disc." This condition is only apparent when the ophthalmoscope is em- ployed, but it possesses a decided clinical value. I have described the condition in detail in another work, from which I quote as follows : " When the radiating fibres of the internal capsule are involved in a lesion which creates a gradually increasing pressure (as in the case of tumors which grow slowly) the fundus of the eye exhibits morbid changes in the region of entrance of the optic nerve which are of value in diagnosis. The condition so produced is commonly known as the ' choked disc' It is nearly always bilateral, but often most marked in one eye. It may be considered as one of the most positive signs of an extensive intra-cerebral lesion, and espe- cially of tumors of the* brain. When the eye is examined with an ophthalmoscope, this condition is characterized by a swollen ap- pearance of the optic nerve, which projects appreciably above the level of the surrounding retina; the margin of the disc is either obscured or entirely lost; the arteries appear small, and the veins large and tortuous; finally, small hemorrhagic spots may often be . detected in the retina near the margins of the disc. In spite of this condition, the power of vision may be little impaired; so that the existence of ' choked disc' may be unsuspected unless the oph- thalmoscope be used before the diagnosis is considered final. After a number of weeks, and very much longer if a tumor is the exciting cause of the condition, the appearance of the disc changes. An unnatural bluish white color, which denotes atrophic changes, develops ; the outline of the disc becomes sharply defined; the retinal vessels become small; and vision becomes markedly inter- fered with." Tumors of the brain are to be differentiated chiefly from menin- gitis ; encephalitis ; cerebral softening; slight cerebral hemorrhage; 476 SURGICAL DIAGNOSIS. cerebral abscess ; thrombosis ; and embolism. A table of differential diagnosis is given later, which will help to make the chief points in the symptomatology of cerebral tumors clear ; although it is im- possible to make general statements in reference to brain lesions to which exceptions will not frequently occur. SPECIAL SYMPTOMS INDICATIVE OF BRAIN LESIONS. Before we pass to the consideration of the tables of differential diagnosis of the various conditions of the brain, which have been described in previous pages, let us consider, a little more in detail, some of the symptoms which have been enumerated on a preceding page as possessing a peculiar diagnostic importance. MOTOR PARALYSIS. Anything which tends to impair the generating power of nerve- centres or the conducting power of nerve-fibres may produce pa- ralysis of motion or sensation. Motor paralysis can result, therefore, from any cause which inter- feres with the motor convolutions of the brain, or the nerve-fibres which start from them and are continued a3 the so-called " motor tract." The latter pass through the following parts : (1) The white substance of the cerebral hemispheres ; (2) the corpora striata ; {;}) the crura cerebri ; (4) the pons Varolii ; (5) the medulla oblongata ; and (6) down the motor columns of the spinal cord. The disturbing lesions may be therefore classified as : (1) Those of the gray matter of the convolutions of the brain (cortical lesions) ; (2) those of the central mass of the cerebral hemispheres, including lesions of the " internal capsule " ; (3) those of the corpora striata ; (4) those of the crura cerebri; (5) those of the pons Varolii; (6) those of the medulla oblongata ; (7) those of the spinal cord. The various tests which are employed to determine the existence and extent of a loss of muscular power will be found in all text- books upon nervous diseases. Cortical Paralysis, or that form- dependent upon some lesion of the gray matter of the cerebral convolutions (the cerebral cortex), may occur in connection with abscesses, blood-clots, spots of soften- ing, tumors, depressed bone, periosteal and meningeal thickenings, embolism, thrombosis, etc. The researches of Ferrier have lately taught us the situation of special motor centres scattered over the convolutions of the so-called DISEASES OF THE BRAIN AND ITS ENVELOPES. " motor area " of the cerebrum. From this standpoint we are often enabled to judge of the seat of the lesion by the aid of the groups of muscles which exhibit the paralytic state (monoplegia). Hugh- lings-Jackson and Brown-Sequard have added to our knowledge of the relative effects of destructive and irritative lesions of the cerebral cortex. Irritative lesions are usually ushered in by convulsive at- tacks, which leave the subject paralyzed in. some special group of muscles (monoplegia) ; or, if hemiplegia ensues, some parts of the body are more affected than others. The paralysis is usually tran- sient and returns again after subsequent convulsive attacks. These irritative lesions are generally of syphilitic origin. Destructive lesions of the cerebral cortex are characterized by paralysis of special groups of muscles, or monoplegia, as was the case with the irritative lesions. This is in marked contrast to the " hemiplegia," which follows lesions of the central portions of the nervous system. If the lesion be very extensive, coma may be produced, but consciousness is not usually lost unless the attack be accompanied by convulsions. Pain of a local character within the head is often complained of, and percussion over the seat of the lesion frequently elicits it, if it should be absent. The sensibility of the paralyzed parts is not impaired, unless more or less sensory paralysis exists as a complication. The paralyzed muscles exhibit the normal electro-contractility. As is the case with all cerebral lesions, the paralysis is developed on the side opposite to the ex- citing cause (except in very rare instances). The various types of monoplegia, and the surgical guides for trephining over special motor centres, have been discussed in the author's work upon the anatomy of the nervous system. Space will not allow of their repeti- tion. In cortical lesions of the motor area the muscles frequently ex- hibit a, state of post-paralytic rigidity in the early stages of the disease. Hemiplegia. This condition is characterized by a paralysis of motion in one lateral half of the body. It is often associated with more or less anaesthesia, but it may exist independently of it. Hemiplegia may be produced by any lesion which interferes with the free action of the " motor tract " of fibres during their passage from the motor convolutions of the cerebrum to the columns of the spinal cord, and lesions even of the spinal cord itself (if suf- ficiently high up and restricted to that lateral half of the cord on the side which corresponds to the paralysis) may induce it. 478 SURGICAL DIAGNOSIS. If the lesion be within the cavity of the cranium, the hemiplegia will be on the opposite side of the body; if it be spinal, the hemi- plegia will be upon the same side. Hemiplegia from intra-cranial lesions may be the result of embo- lism, thrombosis, apoplexy, softening, abscess, tumors, compression of the brain from traumatic causes, destruction of limited portions by injury, general pressure from inflammatory exudations, etc. Consciousness is generally lost when the hemiplegia is developed. Convulsive attacks are not usually present at the onset of the paralysis. The paralysis is more prof bund, as a rule, than that of cortical lesions, and of longer duration. The special senses are not infrequently in- volved to a greater or less degree. Other cranial nerves, which are not associated with the special senses, may also give evidence of being implicated by the lesion. By these guides the seat and extent of the lesion may often be determined with positiveness. The co-existenre of impairment of sen- sation with motor paralysis is a valuable diagnostic sign that the ex- citing lesion is within the substance of the brain and not upon its surface. The exceptions to this rule are extremely rare. The localization of non-cortical lesions is more difficult and less certain than those which are confined to the cortex. A careful study of all the symptoms presented (when combined with accurate anatomical knowledge) will often, however, lead to most positive deductions. It should be remembered that accuracy of diagnosis often leads to success in treatment of disease, and in no case is it better exemplified than in the nerve-centres. Crossed Paralysis. A condition in which the face or some organ of special sense gives evidence of an impairment of a cranial nerve, while the body is simultaneously rendered hemiplegic on the oppo- site side, is termed "crossed paralysis"—the "paralysie alterne" of the French authors. We owe much of our knowledge of this subject to Prof. Romberg, of Berlin, who has written extensively upon it. The more common forms of crossed paralysis are named from the cranial nerve, which exhibits an impairment of its functions. They are as follows : First Cranial Nerve (olfactory) and body type. Third " " (motor oculi) Fifth " •" (trigeminus) Seventh " " (facial) " " PLATE XXII. Frontal lobe. SENSOR/ 2 sHiica 1. Side View of the Brain of Man and the Areas of the Cerebral Convolutions. R, Fissure of Rolando. S, Fissure of Sylvius, dividing into its two branches. 1 (on the postero-parietal (.superior parietal] lobule). Advance of the opposite hind-limb as in walking. 2, 3, 4 (around the upper extremity of the fissure of Rolando). Complex movements of the opposite leg and arm, and of the trunk, as in swimming; a, b, c, d (on the ascending pari- etal [posterior central] convolution), individual and combined movements of the fingers and wrist of the opposite hand; prehensile movements. 5 (at the posterior extremity of the su- perior frontal convolution). Extension forward of the opposite arm and hand. 6 (on the upper part of the antero-parietal or ascending frontal [anterior central] convolution). Supination and flexion of the opposite forearm. 7 (on the median portion of the same convolution). Retrac tion and elevation of the opposite angle of the mouth by means of the zygomatic muscles. 8 (lower down on the same convolution). Elevation of the ala nasi and upper lip with depression of the lower lip on the opposite side. 9, 10 (at the inferior extremity of the same convolution, Broca's convolution). Opening of the mouth with 9, protrusion, and 10, retraction of the tongue —region of aphasia, bilateral action. 11 (between 10 and the inferior extremity of the ascending parietal convolution). Retraction of the opposite angle of the nionth, the head turned slightly to one side. 12 (on the posterior portions of the superior and middle frontal convolutions). The eyes open widely, the pupils dilate, and the head and eyes turn toward the opposite side. 13, 13 (on the supra-marginal lobule and angular gyrus). The eyes move toward the opposite side with an upward 13, or downward 13" deviation; the pupils generally contracted (centre of vision). 14 (of the infra-marginal, or superior [first] temporo-sphenoidal convolution). Pricking of the Dpposite ear, the head and eyes turn to the opposite side, and the pupils dilate largely (centre of hearing). Ferrier, moreover, places the centres of taste and smell (15) at the extremity of the temporo-sphenoidal lobe, and that of touch in the gyrus uncinatus and hippocampus major. A Spinal Segment. The two roots of each spinal nerve are shown; also the sensory and motor fibres of which each is composed. • DISEASES OF THE BRAIN AND ITS ENVELOPES. 479 The symptoms of these four varieties will be found by referring to subsequent pages, where they are arranged in the form of con- trasted columns. It may be well to remark in this connection that " crossed paraly- sis " is of special clinical importance, because it often imparts the most positive information to the surgeon in regard to the seat of tlie lesion which has produced it. These facts will also be found in the tables above referred to. Complete Paralysis. When a lesion is situated at the base of the brain, and is sufficiently large to involve the motor tract of both hemispheres, the body may be completely paralyzed below the head. Various cranial nerves—chiefly the third, fifth, sixth, and sev- enth—are liable to then exhibit the effects of simultaneous pressure upon them ; hence the general paralysis of the body is apt to be associated with paralytic symptoms confined to the face. Bilateral spinal lesions when situated high up in the cervical region may also cause this form of paralysis. SENSORY PARALYSIS. The sensation of special parts of the body may be so modified by lesions of the nerve-centres as to constitute a type of paralysis. The various forms of this condition may exist independently of motor paralysis or may coexist with it. The tests commonly employed to detect the limits and degree of sensory paralysis can be found by consulting the later text-books upon Nervous Diseases. Sensory paralysis may be classified as follows : (1.) Paralysis of those cranial nerves which are not endowed with motor attributes. (2.) Paralysis of sensory nerves below the head. This subdivision comprises, hemianesthesia; general anaesthesia; and local ancesthesia. The latter will be considered later, in connection with lesions of the spinal cord. Among the various clinical evidences of lesions which affect the sensory nerve-tracts of the brain and spinal cord, the following may be mentioned: Hyperesthesia—or an excitation of sensibility. Numbness. Formication—or a sensation like the creeping of ants. Abolition of Sensation—or complete anaesthesia. This condition may be general or local. 480 SURGICAL DIAGNOSIS. Anosmia and Hemianopsia. Delayed Sensation—as is evidenced by a perceptible interval of time between the contact of a foreign body with the skin and its conscious appreciation by the patient when the eyes are closed. The pricking of the skin with a needle is a test commonly employed to determine this condition. It is clinically related to lesions of the spinal cord only. Some of these conditions will be now considered in their more important aspects. Others will not be separately described, as they would require too much space, provided such a resume was attempted. Hemianesthesia. This condition is characterized by a loss only of sensation (not of motion) in one lateral half of the body. It is often associated with more or less marked hemiplegia. The tests employed to determine the existence of this state and its degrees of intensity are the same as those employed in any form of sensory paralysis. Hemiansesthesia indicates that the exciting lesion has impaired the conducting power of the fibres associated with the so-called " sensory area " of the cerebral convolutions. There is strong clin- ical evidence to sustain the opinion that these fibres run in the posterior third of the " internal capsule." Lesions of this latter region are not infrequently the cause also of more or less impairment of sight, smell, hearing, and taste, in addition to their effects upon gen- eral sensation. Charcot, Ferrier, Rendu, Raymond and others who have studied the effects of lesions of the posterior third of the internal capsule of the cerebrum concur in this statement. Hemiansesthesia is frequently accompanied by the development of choreiform movements after the paralysis has developed. These may assume the type of athetosis, true ataxia, or tremor. The same may also be said of that type of hemiplegia which occurs as the result of lesions of the internal capsule of the cerebrum. Finally, a condition characterized by an abnormality of the eyes, termed " conjugate deviation " may be associated with lesions of the white centre of the cerebral hemispheres. I quote an extract from my late paper upon the diagnosis of lesions of the internal capsule regarding this symptom : " When, in connection with rapid softening or an extravasation of blood into the substance of the cerebrum above the level of the basal ganglia, this peculiar symptom is developed (either simul- DISEASES OF THE BRAIN AND ITS ENVELOPES. 481 taneously with or following paralysis and coma), the patient's head and eyes will be observed to be turned constantly away from the par- alyzed side and toward the side upon which the seat of the lesion is. Various attempts have been made by late authors to throw discredit upon the clinical significance of this symptom as particularly in- dicative of a lesion of the cerebral hemisphere, but I am convinced that it is a valuable differential sign. Ferrier has demonstrated that a cortical centre, which he locates in the first and second frontal gyri near to their bases, presides over conjugate movements of the head and eyes, and causes dilatation of the pupils. He at- tributes this symptom, when occurring in connection with hemi- plegia of cortical or ganglionic origin, to the unantagonized action of the corresponding centre of the uninjured hemisphere, thus explaining the fact that the distortion is toward the side of the lesion. Clinical evidence of the correctness of this view has been brought forward by Hughlings-Jackson, Priestly Smith, Chouppe Landouzy, Carroll, and others ; and, in some cases reported, the situation of the lesion has been verified by pathological observation. The opportunity to record pathological observations upon cases where this symptom was well marked during life is, unfortunately for science, a comparatively rare one. It is impossible, therefore, to speak positively concerning the diagnostic value of this symptom, although the weight of clinical evidence seems to be strongly in its favor." Finally, it must be said that in cerebral hemiancesthesia there is more or less insensibility to touch, pain, and temperature, and also abolition of muscular sensibility with complete retention of electro- motor contractility. The mucous membranes of the eye, nose, and mouth are also anaesthetic. Numbness and Formication. In connection with sensory paralysis, a condition of numbness, which the patient describes as feeling as if some special part was " fast asleep," is often experienced. In others a sensation which has been compared to the " creeping of ants " over some special region is complained of. The latter has been termed " formication." These abnormal sensations are confined exclusively to those parts to which the sensory nerves are more or less impaired; either after their escape from the brain or spinal cord or by lesions of the nerve-centres which involve their fibres of origin. By a careful study of these symptoms, a skilled anatomist is often enabled to decide whether the lesion is cerebral, spinal, or 31 482 SURGICAL DIA GNOSIS. confined to special nerve-trunks. This field is too extensive, how- ever, to be considered in detail here. Hyperesthesia. In connection with lesions of the brain and spinal cord, a condition of excessive sensibility is sometimes encountered. It is termed " hypersesthesia." It may exist independently of motor or sensory paralysis; or, again, it may coexist with them. Its clinical significance depends upon its seat and extent, and the other evidences of disturbed nervous functions which coexist. Hemianopsia. A loss of vision in one lateral half of each retina is termed "hemianopsia" and "hemianopia." It is called " hemi- opia" by some authors; although incorrectly so, as that term means "half-vision" while the two others mean what they are in- tended to express. I quote from a late article of mine in regard to this condition, as follows : " The following steps are commonly employed to detect the exis- tence of this symptom : Request the patient to close one eye by pressing the lid down with the finger, and to so direct the open eye as to concentrate its gaze upon some fixed object near to it. [I usually hold up the forefinger of my own hand within a foot of the patient's open eye, and tell him to look steadily at it.] Having done this, take some object which is easily seen (such as a sheet of white paper) in the unemployed hand, and move it to the right and laft of the object upon which the patient is gazing, and also above and below the object, asking the patient, in each case, if the two objects are seen simultaneously and with distinctness, and notice upon which side of the fixed object the patient cannot perceive the moving object. It is self-evident that the retina is blind upon the side opposite to that upon which the moving object is lost to sight. " The most common form of hemianopsia is that in which the nasal half of one eye and the temporal half of the other is blind ; this condition being the result of pressure upon, or actual destruc- tion of, one of the optic tracts. " When the chiasm is affected, we meet the bi-nasal type. " There is still one more form which is occasionally encountered, viz., the bi-temporal type. This has been interpreted by an autopsy made upon a case entrusted to the care of Professor H. Knapp, of this city. It must be evident that the chances would be extremely small of ever encountering a bi-lateral lesion which would affect PLATE XXIII. 1. Diagram explicative of hemiopia. The shaded intra- and extra-ocular parts, A and B, indi- cate the obscuration in right lateral (or homonymous) hemiopia. as caused by lesion 3, so placed as to destroy one optic tract. In that tract are two sets of nerve-fibres, one represented by a dotted line supplying the nasal half of right retina, the other fibres by a broken line supplying the outer or temporal half of the left eye. As visual lines cross in the eye the obscuration of the half fields is the opposite. Lesion No. 1, anterior to chiasm, produces blindness of inner half of each retina, and consequently bi-temporal hemiopia. Lesions No. 2, a pressing upon the sides of the chiasm, injure fibres supplying the temporal naif of each retina, and cause bi-nasal hemiopia. C Q, corpus quadi'igeminum, in which Professor Charcot bel:eves a second partial decussation takes place. I C, internal capsule containing, on Charcot's hypothesis, all the fibres coming from the eye of the opposite side. 4. Lesion of internal capsule injuring all the fibres connected with the right retina, and causing amblyopia of the right eye. 2. Diagrammatic representation of the skin symptoms in unilateral lesion of the dorsal portion of the spinal cord on the left side The diagonal shading (a) signifies motor and vaso-motor para- lysis; the vertical shading (d and b) signifies anaesthesia of the skin; the dotted shading (c) indicates hyperassthesia of the skin. 3. Localization of the diseased area in the anterior horns of the lumbar enlargement of the cord in a child two years old, eleven months after the beginning of the disease. A larger area of oftening in the right, a smaller one in the left anterior column; 13, 30, 30, 36 an J 43 mm. above the termination of the cord. DISEASES OF THE BRAIN AND ITS ENVELOPES. 483 only those fibres of the optic chiasm, or optic tract, which supply the temporal half of each retina, and, at the same time leave the decussating fibres intact. How, then, are we to account for the fact that this form is sometimes met with ? In the preceding por- tion of this article I have called attention to a peculiar arrange- ment of th§ arteries in the region of the optic chiasm. Now, it has been shown that atheromatous degeneration of the ' circle of Willis ' (a peculiar arrangement of blood-vessels at the base of the brain) so impairs the elasticity of the arteries as to create a type of injury to the chiasm, so limited in its extent as to impair only the fibres distributed to the temporal halves of the retinae, and thus to create bi-temporal hemianopsia. " We may, therefore, summarize the clinical significance of this peculiar form of blindness as follows : " (a.) The homonymous or crossed variety indicates lesions affecting the optic tract. " (b.) The bi-nasal variety indicates a lesion pressing upon the cen- tral portion of the chiasm. "(c.) The bi-temporal variety indicates atheromatous degeneration of the circle of Willis. Possibly (?) symmetrical lesions of the outer part of the chiasm might also cause it. I am not aware that the view of Charcot, that a decussation of the optic fibres takes place within the substance of the corpora quadrigemina, is as yet sustained by a recorded case of bi-temporal hemianopsia produced by a circumscribed lesion within the optic lobes. "(d.) Finally, lesions of the internal capsule are often associated with amblyopia, or indistinct vision confined to one eye." APHASIA. An impairment of the idea of language or its expression (inde- pendent of paralysis of the tongue) constitutes this condition. It is commonly described as of two varieties ; the " amnesic," in which the memory of words is more or less effaced; and the " ataxic" in which the memory of words is perfect but the subject cannot properly pronounce them, from an inability to perfectly coordinate the muscles concerned in articulation. The sjonptoms of this malady in either of its forms are always of great clinical interest; because some peculiarity in each case causes 4gi SURGICAL DIAGNOSIS. it to differ from others which may have been previously encount- ered i " In the amnesic variety, the most familiar objects are commonly mis-named; the subject being oftentimes aware that the error has been committed and yet is not able to correct i. The form which this loss of memory takes is liable to vary with each case As an illustration of this, some forget only names; others only numbers. In certain reported cases, the names of things only m dead or foreign languages were retained; in others, the reverse has been observed, the patient losing all memory of acquired tongues. ASain, the sound of words often will not be recognized, when the letters which form them will; and the reverse of this condition is not infrequently met with in aphasic subjects. We owe to Broca the credit of the discovery that the centre of articulate speech could be located in the posterior portion or base of the third frontal convolution, and to many of the later pathologists the debt of overthrowing what once was the popular view, viz, that this centre is not confined exclusively to the left cerebral hemi- sphere. Subsequent pathological observation seems to have added strength to the view that lesions of the "island of Reil," as well as the medullary substance which intervenes between it and the centre of Broca, must be included in the so-called " speech area;" and that the amnesic form may be dependent likewise upon lesions of the so-called " sensory area " of the brain seems probable, although the limits of the speech centre are not yet defined with accuracy. The " centre of Broca " is supplied with blood by the middle cerebral artery. An embolus within that vessel will tend, there- fore, to arrest the circulation of that important area; and, at the same time, will interfere more or less with the nutrition of the cor- pus striatum—the ganglion which probably controls all motor im- pulses sent out from the brain to the muscles of the opposite side of the bod}% Now we know clinically that embolism is a frequent cause of aphasia, and that hemiplegia almost always accompanies it. We also know that the middle cerebral artery of the left side is the most frequent seat of embolic obstruction. This fact helps us to interpret the development of right hemiplegia in connection with aphasia, as is found to exist in the large proportion of such cases. Seguin found two hundred and forty-three cases in which right hemiplegia existed out of a total of two hundred and sixty—left hemiplegia being present in but seventeen cases. In the ataxia variety of aphasia the patient can usually write what cannot be spoken, thus proving that the memory of words is not DISEASES OF THE BRAIN AND ITS ENVELOPES. 485 effaced, but rather the ability to so coordinate the muscles of speech as to properly pronounce them. This condition must not be confounded with aphonia (loss of voice). Several cases have been reported where the amnesic form has given place to the ataxic, and the lesion has been found over the centre of Broca. It would seem, therefore, that the third frontal convolution (although placed in close relationship with the oral and lingual centres by Ferrier) has some connection with the memory of words as well as the simple apparatus of speech. Cases of aphasia should be subjected to a variety of tests, which will tend to bring out the special peculiarities of each. If lesions of the cerebral cortex exist as the exciting cause of the aphasia, convulsions may be associated with its development. The explanation of this symptom is given on page 477. If numbness or anaesthesia coexist with hemiplegia and aphasia, it indicates that the " motor and sensory tracts " are involved, as well as the centre of speech. PRACTICAL, CLINICAL, AND PHYSIOLOGICAL DEDUC- TIONS, OFFERED AS A GENERAL SUMMARY OF THE MAIN POINTS IN THE LOCALI- ZATION OF LESIONS OF THE BRAIN AND SOME OF ITS NERVES. In closing this chapter it has been deemed advisable to attempt the somewhat difficult feat of presenting in condensed paragraphs the more important points in the diagnosis of lesions which impair the free action of the brain or the cranial nerves. Should the pre- ceding pages fail to cover any of the subjects embraced in this resume, the reader is referred to the author's more complete work, that deals exclusively with the nervous system. (See Bibli- ography.) Many imperfections are necessarily entailed when an abbrevi- ation of such a complex subject is stripped of all explanatory text. Space precludes, however, more than a simple statement of a few clinical facts which the later investigations (respecting the nerve- centres and the cranial nerves) have placed upon a footing worthy of credence. In this summary the various guides afforded by the cranial nerves will be considered first. Subsequently lesions of separate parts of the brain will be reviewed. Some of this matter has been published previously by the author in various medical journals. 486 SURGICAL DIAGNOSIS. LESIONS AFFECTING THE OLFACTORY NERVE. 1. Anosmia (loss of smell) may occur from any lesion which in- volves the first cranial nerve. It is usually unilateral. If it occurs in connection with hemiplegia, the body paralysis is on the side opposite to, and the anosmia on the same side as the lesion (page 478). It indicates a lesion situated in the anterior fossa of the cranium. 2. Crossed Paralysis of the " olfactory nerve and body type" indi- cates a localized pressure which is chiefly exerted upon parts within the anterior fossa of tlie skull. The motor tract is probably involved by upward pressure upon the caudate or lenticular nucleus, or the fibres of the internal capsule ; thus accounting for the hemiplegia of the opposite half of the body. The olfactory nerve, which lies near to the optic chiasm, is affected by pressure in the downward direction, and the optic chiasm or tract may be simultaneously in- volved ; hence, a loss of smell in the nostril on the same side as the lesion may coexist with some form of hemianopsia, as well as with a crossed hemiplegia. LESIONS AFFECTING THE OPTIC NERVE. 1. Amblyopia of one eye may result from lesions involving the optic nerve in front of the chiasm, or from lesions of the " internal capsule " of the cerebrum. If from the latter, the field for color-perceptions will be found to be markedly contracted, or color-vision will be wanting ; both eyes may be affected, the most marked changes be- ing found, however, in the eye opposite to the seat of the lesion. We have not sufficient data for positive clinical deductions respect- ing lesions of the " visual area of the cortex " in man. The blind- ness of the opposite eye appears to be absolute, while it lasts, in all animals upon whom the visual area has been destroyed. 2. Hemianopsia only occurs when the optic tracts or the optic chiasm are pressed upon or destroyed by lesions in the region of the base of the cerebrum. It is evident, therefore, that the trephine cannot afford relief of this symptom. When syphilitic gummata may be suspected, the prognosis is extremely favorable if active treatment be employed. The variety'of hemianopsia indicates the seat of the lesion with great exactness (see page 482). If paralysis fin any of its forms) coexist with hemianopsia, a valu- PLATE XXIV. D 1 Eyeball. ic chiasm. Optic Internal capsule. (Left hemisphere.) Internal capsule. (Right hemisphere.) A Diagram designed by the Author to show the Course of Fibres within the Optic Nerves, and some of the more important Relatons of the same. A, A', A", and D, D', D", fibres which do not cross at the chiasm, but probably do at the corpora quadrigemina (C, Q). C, C, and B, B', fibres which do decussate at the chiasm. The relations of these fibres to the " internal capsule " of the cerebrum is also shown. This portion of the cerebral hemisphere is shown to be in relation with the fibres distributed only to the opposite eye; hence, lesions within it tend to produce " crossed ambly- opia." The relation of bundles within the chiasm is made apparent. The fibres of the chiasm which connect the two eyes directly (inter-retinal fibres), and those which conneet the two cere- bral hemispheres directly (inter-cerebral fibres), are not shown, because they have no bearing upon symptoms, even if their existence is to be considered as demonstrated. C, G, I, internal geniculate body. C, G, E, external geniculate body. ' A Diagram designed to show some of the Relations of the Optic Nerve-Fibres to surround- ing Parts. F, frontal lobes of cerebrum; P, parietal lobe; T, temporo-sphenoidal lobe; S, fissure of Sylvius; R, fissure of Rolando; O, occipital lobe; C, cerebellum; M, medulla oblongata. 1. Cor- pora quadrigemina. 2. Optic tracts. 3. Optic chiasm. 4. Optic nerves. 5. Olfactory nerve. 6. Motor-oculi nerve. 7. Trigeminus nerve, a. basis cruris; 6, tegmentum cruris. The circles in the parietal lobe represent the cortical visual centres of Ferrier; the diamonds in the occipital lobe the cortical visual centres of Munk. The cerebellum and pons Varolii are shown as if sep- arated from the cerebrum, in order to make the relations of the crus to the optic tracts apparent. DISEASES OF THE BRAIN AND ITS ENVELOPES. 487 able guide will often be afforded in determining the extent of the lesion. The bi-nasal, and also the bi-temporal varieties, are due (as a rule, at least) to lesions confined to the anterior fossa of the cranium; hence we sometimes find the olfactory nerve of the side correspond- ing to the seat of the lesion simultaneously affected, and creating anosmia (loss of smell) with or without subjective odors. If the lesion be situated within the middle fossa of the cranium, the optic tracts will be affected, thus causing crossed hemianopsia; while the motor nerves of the eye may be simultaneously pressed upon, as they pass through that fossa on the way to their foramen of exit from the cranium (the sphenoidal fissure), thus producing more or less impairment of the movements of the eyeball of the same side. The value of these complications cannot be over-esti- mated, when they exist, because they are of the greatest aid in diagnosis, and often enable the skilled anatomist to positively determine the seat of the lesion. Hemiplegia may occur in connection with hemianopsia ; provided that the lesion is of sufficient size to affect any part of the so-called " motor tract" simultaneously with the optic nerve-fibres. The motor paralysis is on the side opposite to the lesion, because the fibres of the motor tract decussate at the lower part of the medulla. Flechsig has shown that, in rare cases, exceptions to this general rule are to be explained by an abnormality in the decussation of the motor fibres. Hemiplegia is seldom observed in connection with hemianopsia alone, since the olfactory, motor oculi, trigemi- nus, and facial nerve-roots are especially liable to be simultane- ously involved. This explains the mechanism of the four varieties of " crossed paralysis" which are encountered, the hemiplegia being on the side opposite to the lesion, and the symptoms pro- duced by paralysis of the cranial nerve being confined to the side corresponding to the lesion. Ataxic manifestations, occurring in connection with evidences of impairment of the sense of sight, open a wide field for speculation. The proximity and intimate structural relations of the cerebellum with the optic lobes, basal ganglia, crus, and medulla, suggest the possibility of cerebellar lesions when these two symptoms are pres- ent to a marked degree. Hemiancesthesia indicates some disturbance of the nerve-fibres of the so-called "sensory tract"; the loss of sensation being con- fined to the lateral half of the body opposite to the lesion which causes it, because the sensory fibres decussate in the spinal cord. 488 SURGICAL DIAGNOSIS. In cerebral hemiancesthesia there is more or less insensibility to touch, pain, and temperature, and also abolition of muscular sensi- bility with complete retention of electro-motor contractility. The mucous membranes of the eye, nose, and mouth are also anaesthetic. Now the upper portion of the sensory tract lies in the posterior regions of the crus cerebri and the internal capsule, and is in close relation with the posterior basal ganglia. The fibres of the optic tract may be likewise affected simultaneously with lesions of the following parts : the crus, the internal capsule, the optic thalamus, the corpora quadrigemina, the geniculate bodies, and the medulla. It has been already stated that lesions of the internal capsule are often associated with amblyopia, but not with hemianopsia. Our ability to definitely locate lesions of the sensory tract, or of the ganglia connected with it, is, as yet, imperfect. It is only by the careful study of associated symptoms that conclusions can be arrived at. Crossed paralysis of the " motor oculi nerve and body " type indi- cates a lesion situated within the crus cerebri. If hemianopsia be pres- ent in connection with this condition, it proves conclusively that the optic tract, which lies in close relation with the crus, is simul- taneously affected by the lesion. The symptoms of this condition will be summarized later. 3. Choked Disc is a common symptom of lesions of the base of the cerebrum, and of any intracranial disease which produces a gradu- ally increasing pressure. It is specially diagnostic of tumors. It is not associated with impairment of vision until late, so that it is often unsuspected when present. The ophthalmoscope is neces- sary for its detection. It may coexist with hemianopsia, and is always bi-lateral. It is a positive contra-indication to trephining. Lesions at the base of the skull may cross the mesial line, and still involve only one optic tract. If this occurs, the hemianopsia will be accompanied by other symptoms of diagnostic importance, no longer confined to one side. Double anosmia, general paresis or complete paralysis, general anaesthesia, and paralytic symptoms referable to both eyeballs might be thus produced. Lesions of this character are more liable to affect the chiasm of the optic nerves than the optic tracts ; in either case, however, hemianopsia would result, and its type would be a reliable guide to the seat of pressure. 4. Ceossed Paralysis of the " facial nerve and body type " is not as DISEASES OF THE BRAIN AND ITS ENVELOPES 489 liable to coexist with hemianopsia as the two forms previously mentioned. The reason for this is a purely anatomical one. 5. Uncomplicated Hemianopsia indicates that the effects of the lesion are -confined to the optic tracts of the chiasm, and that no pressure-effects are exerted upon the motor or sensory projection tracts, or adjacent nerves. 6. Aphasia sometimes coexists with hemianopsia. I have met with two instances of this kind. In one there was slight paresis of the left side, tending to prove that aphasia can occur with lesions involving the right hemisphere. Both were cured with specific treatment. "We must attribute the development of this complication to pressure upon parts in the neighborhood of Broca's centre. LESIONS AFFECTING THE MOTOR OCULI NERVE. Lesions confined to the crus cerebri seldom create impairment of any of the special senses (excepting that of the sight in exceptional cases, by creating pressure upon one of the optic tracts). These cases are not associated with impairment of intellect or of speech. It has been claimed that severe lesions cause paralysis of the blad- der, but I have never encountered it. The third cranial nerve may be affected independently of, or in connection with, hemiplegia of the opposite side. The latter con- dition has been discussed already as a type of " crossed paralysis." When the third cranial nerve is paralyzed from cerebral lesions, the lower part of the face is often paretic on the same side as the lesion; this is not the case when a lesion involves the nerve after it escapes from the crus cerebri, viz., within the middle fossa of the cranium or the orbital cavity. Crossed paralysis of the " motor oculi nerve and body " type indi- cates a lesion situated within the crus cerebri. We find that the eye on the same side as the lesion can no longer be turned toward the nose or made to act in parallelism with the opposite eye; that the pupil is dilated; and that the upper eyelid droops over the eyeball, giv- ing it a sleepy appearance. On the side opposite to the lesion the body is hemiplegic. There are few conditions which are of greater clinical importance than this type of crossed paralysis, because the seat of the lesion is positively indicated. If the op lie tract, which lies in close relation with the crus, be simultaneously affected by the lesion, the evidences of " crossed hemianopsia " will be superadded, viz., the eye on the same side as 490 SURGICAL DIAGNOSIS. the lesion will be blind in its temporal half, and that of the oppo- site side in its nasal half. LESIONS AFFECTING THE FOURTH CRANIAL NERVE. The nerves which are associated with the movements of the eye- ball—the third, fourth, and sixth cranial—pass through the middle fossa of the cranium in company with the fifth cranial nerve. For this reason, lesions situated at the base of the brain are liable to in- volve any of these nerves separately or all simultaneously, according as their pressure-effects are felt in one direction or another. In addition to cranial causes, lesions of the orbit may also create impairment of the third, fourth, ophthalmic branch of tlie fifth, or sixth cranial nerves—all of which pass through the sphenoidal fis- sure into the orbit. Impairment of the sixth cranial nerve is indicated by the devel- opment of internal strabismus ; the extent of which varies with the degree of the paralysis. If this nerve be affected by lesions within the cranium, other nerves are liable to be simultaneously involved; and an impairment of the cerebral motor tract may also be evidenced by a coexisting hemiplegia or paresis of the side of the body opposite to the seat of the lesion. LESIONS AFFECTING THE FIFTH CRANIAL NERVE. The following propositions will cover the diagnostic points of lesions of the trigeminal nerve : Peripheral lesions cause ancesthesia of special parts supplied by small branches or single filaments of the nerve. The coexistence of paralysis of other cranial nerves with anaesthesia of the face, indicates a lesion in the vicinity of the base of the cere- brum. If a part of tlie face and the corresponding facial cavity (orbital, nasal, or buccal) are simultaneously affected with a loss of sensa- tion, the lesion is within the cranium, and so situated as to involve one of the three main divisions of the nerve. If the anaesthesia extends over the entire area supplied by all of the branches of the nerve, and evidences of disturbance in the nutrition of the parts are also present, the lesion affects the ganglion of Gasser or its immediate neighborhood. If the muscles of mastication are paralyzed, and no anaesthesia ex- DISEASES OF THE BRAIN AND ITS ENVELOPES. 491 ists, the lesion is outside of the cranium and involves only the motor root of the inferior maxillary branch of the nerve. The anterior two-thirds of the tongue, the mucous lining of the floor of the mouth, and the integument of the chin will be rendered anaesthetic simultaneously if the sensory trunk of the inferior maxil- lary nerve is involved ; and taste may be affected also on the same side as the sensory paralysis. Neuralgia of the various branches of the fifth nerve may exist in place of anaesthesia, provided the lesion simply irritates the nerve- trunks, but does not impair their power of conduction of sensory impulses. LESIONS OF THE SEVENTH CRANIAL NERVE. The following propositions will cover the diagnostic points of lesions which induce facial paralysis (Bell's palsy): If the paralysis be limited to distinct parts of one lateral half of the face, the lesion affects only individual branches of the nerve, and is outside of the cranium. An apparent exception to this rule is sometimes met with in connection with lesions of the crus cerebri— paralysis of the lower half of one side of the face being clinically observed to occasionally accompany a paralysis of the motor oculi nerve on the same side as the lesion. If the fauces and palate exhibit paralytic changes lesion is within the cranium or in the temporal bone. If the sense of taste be lost in the anterior two-thirds of the lateral half of the tongue of the same side as the general facial paralysis, the lesion is either within the cranium, or in the temporal bone. above the origin of the chorda tympani branch. i If the sense of hearing is rendered very acute upon the same side as the facial paralysis, the lesion is probably within the temporal bone and involves the ganglionic enlargement found upon the nerve in the aqueduct of Fallopius. Facial paralysis dependent upon cerebral lesions is commonly as- sociated with liemiplegia, which may be upon the same side as the lesion or on the opposite side. Crossed paralysis of the " facial nerve and body typs " indicates a lesion of the pons Varolii posterior to the line which connects the trigeminus nerve with its fellow at their escape from the pons (Gubler). If the lesion be situated in front of Gubler's line -the facial pa- ralysis and the hemiplegia will be on the same side. \ 492 SURGICAL DIAGNOSIS. LESIONS AFFECTING THE CRANIAL NERVES AND NERVE-TRACTS OF THE MEDULLA OBLONGATA. The facial, auditory, glossopharyngeal, pneumogastric, spinal accessory, and hypoglossal nerves have their apparent origin from the medulla, and are more or less imperfectly understood in regard to their connection with different parts of the encephalon. Labio-glosso-pharyngeal paralysis (Duchenne's disease or " bulbar paralysis ") is associated with successive destruction of the nerve nuclei in the floor of the fourth ventricle and a secondary degeneration of the nerve-trunks connected with them. The nerve which ex- hibits the first evidences of paralysis will often afford clinical data from which some deductions respecting the original seat of the lesion may be drawn. The more common lesions of the medulla include arteritis, thrombosis, traumatism, softening, hemorrhage, sclerosis, and tumors. The development of " bulbar paralysis " is associated, as a rule, with neuralgic pains, muscular spasms, anaesthesia, and disorders of special senses. Compression of the medulla oblongata has been shown to cause the respiratory phenomena termed " Cheyne-Stokes respiration," and also albuminous and diabetic urine. In the former the fre- quency and character of respiration constantly changes in some regular order—gradually increasing to a certain maximum, and then gradually decreasing in frequency till they cease, when they begin again to increase in frequency and depth. The vaso-motor centres, which are situated within the medulla, help to explain many other visceral phenomena which are observed when it is diseased. These are too numerous and complex in their nature to be discussed here. The differential diagnosis of suddenly developed lesions of the medulla, which are not immediately fatal, must rest upon the co- existence of certain functional disturbances. Among these may be chiefly mentioned : 1. Epileptiform attacks, occurring at the onset or later ; 2. Hemiplegia or paraplegia ; 3. Loss of consciousness ; 4. Hyperaesthesia or circumscribed anaesthesia ; 5. Dysphagia, vom- iting or hiccough, and Cheyne-Stokes respiration, from interference with the pneumogastric nerve ; 6. Embarrassment of speech, from interference with the hypoglossal nerve ; 7. Deflection of the velum palati and uvula, from interference with the facial nerve ; 8. Hydru- ria, from interference with the centre of renal circulation; 9. Dia- DISEASES OF THE BRAIN AND ITS ENVELOPES. 493 betes, probably from interference with the centre of the vaso-motor nerves of the liver ; 10. Normal electro-muscular contractility in the paralyzed parts. If the lesion be very extensive and of sudden advent, death may occur without the bulbar symptoms being well defined. LESIONS OF THE CEREBRAL CORTEX. If the gray matter of the convolutions (cerebral cortex) be dis- eased, or affected by the pressure exerted upon it by lesions of the bone or meninges, the symptoms which result will be modified by the convolutions whose functions are so impaired. If the so called " motor area" of the convolutions be involved, the paralysis of motion which ensues will be confined exclusively to those groups of muscles (on the side opposite to the lesion) that arc controlled by the special motor centres within the limits of the convolutions affected. This type of paralysis is called " monoplegia" in contradistinction to hemiplegia. The type of monoplegia is a guide to the seat and extent of the lesion which has induced it (see description of the motor centres of the cortex in the author's work upon the anatomy of the Nervous System). Cortical paralysis may often be transitory, if the lesion be slight and superficial; or it may be permanent, if deep and impinging upon the medulla oblongata. In cortical paralysis, a rigidity of the paralyzed muscles is fre- quently developed early in the disease. Consciousness is not usually lost in consequence of suddenly devel- oped lesions of the cortex, unless the deeper part of the brain be injured. Pain over the seat of lesions of the cerebral cortex is often com- plained of spontaneously with the attack; again, it may sometimes be elicited or increased by percussion over the seat of the lesion. If convulsive attacks precede or accompany an attack of mono. plegia, the lesion is probably cortical and of a kind which is induc- ing irritation of the motor convolutions. In a large proportion of such cases (Jacksonian epilepsy) the lesion is dependent upon syphilis. The convolutions of the frontal lobes are not associated with motion ; excepting the ascending, and the bases of the first, second, and third, frontal convolutions. Outside of this area, lesions of the frontal lobe apparently produce no symptoms. If Broca's centre be destroyed, aphasia follows. 494 SURG1CAL DIA GNOSIS. The convolutions of the occipital lobes are apparently associated with more marked mental derangement when diseased than the frontal or temporal. Irritative lesions of the occipital convolutions some- times tend to produce colored perception of objects and other ocular spectra. The power of vision seems to be more or less affected by lesions of this lobe. The convolutions of the temporal lobe are associated with the special senses of smell, hearing, sight, and touch. Some cases of aphasia have been apparently induced also by lesions of this lobe. Our ability to localize lesions of the sensory regions of the brain is less positive than of the motor area. LESIONS OF THE INTERNAL CAPSULE OF THE BRAIN. The situation of this bundle of nerve-fibres renders it liable to become directly involved when hemorrhage, softening, or tumors of the central portions of the hemisphere e:::st; or, indirectly, when these conditions affect the caudate nucleus, the lenticular nucleus, or the optic thalamus. The most frequent seat of cerebral apoplexy is the corpus striatum ; because that ganglion is extremely friable and very vascular. The optic thalamus probably ranks next in the order of comparative frequency. The blood-vessels which enter these bodies * through the anterior and posterior perforated spaces at the base of the cerebrum seem to be frequently affected with atheromatous degen- eration and miliary aneurisms, and are often ruptured when sub- jected to any unnatural strain. Nature has given to the carotid and the vertebral arteries a remarkable tortuosity before their entrance into the cavity of the cranium, in order, as it were, to diminish the liability to rupture of blood-vessels by decreasing the velocity of the flow when the heart's action is excessive ; but even this mechanical safeguard is not always sufficient to protect the intracranial vessels from rupture when extensively diseased. Again, the condition of softening may result from embolic obstruc- tion to some branches of the carotid (usually of the left side), because the nutrition of the parts supplied by the occluded vessel is thus arrested either entirely or in part. The same result may also follow an attack of cerebritis or a previous extravasation of * The motor regions of the cortex are supplied by the middle cerebral artery; the nucleus caudatus by branches of the anterior cerebral and anterior communicating arteries ; the lenticular nucleus by the middle cerebral; and the optic thalamus by branches of the middle and posterior cerebral vessels. DISEASES OF THE BRAIN AND ITS ENVELOPES. 495 blood into the substance of the brain, both of which tend often to create impairment of the blood-supply to adjacent regions. Finally, tumors sometimes develop within the cerebral hemi- spheres, and create pressure upon, as well as destruction of impor- tant nerve-tracts. Time will not permit us to enter into detail respecting all the diagnostic points by which the existence of each of these conditions may be recognized during life. I direct at- tention, therefore, only to such points as are of importance in the diagnosis of disturbance of the supposed functions of the internal capsule. It may be stated with some degree of positiveness that, if the anterior two-thirds of the internal capsule be affected, a hemiplegia of the opposite side is developed.* This is more or less complete, according to the seat and extent of the lesion which causes it. The exciting cause may possibly be situated within the anterior or middle portions of the white centre of the cerebral hemisphere, above the level of the basal ganglia, in which case it interferes with the normal action of certain bundles of the internal capsule which spring from the motor convolutions of the cortex previously enu- merated. Again, it may be situated within the constricted portion of the capsule, in which case bundles of nerve-fibres that are func- tionally associated with widely diffused areas of the cortex may be affected by a lesion of small size. Finally, it may be apparently confined to the substance of one of the two nuclei of the corpus striatum, or the optic thalamus, and still exert sufficient pressure upon the constricted part of the internal capsule to produce more or less extensive and complete paralysis of the opposite lateral half of the body. The hemiplegia of intracerebral lesions forms, as a rule, a strik- ing contrast with the various types of monoplegia, which are pro- duced by circumscribed lesions of the cortex. The latter are often of the greatest aid to the neurologist in localizing the seat of the exciting cause. The second symptom which may indicate a lesion of the internal capsule is hemianesthesia. By this I mean a loss of sensation, more or less complete, which is confined to the lateral half of the body. It exists on the side opposite to the seat of the lesion. This may occur when fibres of the posterior third of the internal capsule are * Exceptions to this rule are occasionally observed. The hemiplegia, in rare cases, exists on the same side as the lesion. The explanation of this fact has been shown, by the researches of Flechsig, to lie in the varying proportions of. the direct and decussat- ing fibres which pass from the cerebrum to the spinal cord. 49G SURGICAL DIAGNOSIS. destroyed or impaired by diseased conditions directly affecting them, as noted by Charcot, Raymond, Rendu, Feriier, and others, or by the pressure exerted by lesions situated in parts adjacent to them. It is usually accompanied with a slight form of motor pa- ralysis ; probably because a few of the motor fibres of the internal capsule are, as a rule, simultaneously interfered with. A third symptom of lesions of the internal capsule includes a variety of manifestations of impairment of the special senses. In con- nection with the discussion of the optic thalamus, views will be ad- vanced later respecting the possibility of existence of special centres of smell, sight, hearing and sensation within the substance of that ganglion. Some clinical facts point strongly to a relationship between nerve-fibres connected with certain special-sense perceptions and the internal capsule. It is impossible, with our present knowledge, to definitely place the situation of the cortical centres which preside over the various special senses, or the course of separate fibres which seem to be associated with them, but we are forced to admit that some of the fibres of the posterior part of the internal capsule have a direct or an indirect association with smell, sight, hearing, sensation, and perhaps of taste also. One peculiar fact cannot be omitted, however, which Charcot has endeavored to explain, viz., that hemianopsia (page 482) never (?) occurs in connection with lesions of the internal capsule, but an amblyopia is developed on the same side as the cutaneous anaesthe- sia, with a remarkable contraction of the field of vision and diffi- culty in discrimination of color. The explanation which this author makes of this fact is, that a second decussation of the fibres of the optic nerve takes place somewhere between the optic chiasm and the internal capsule, probably in the tubercula quadrigemina. When the radiating fibres of the internal capsule are involved in a lesion which creates a gradually increasing pressure (as in the case of tumors which grow slowly) the fundus of the eye exhibits mor- bid changes in the region of entrance of the optic nerve which are of value in diagnosis. The condition so produced is commonly known as the " choked disc." In exceptional cases of destruction of the internal capsule, the sense of smell has been found to be abolished on the side opposite to the seat of the lesion. This fact requires special consideration, as it has been shown that the centre proper for olfactory perceptions seems to be in the hemisphere of the same side. Meynert claims, however, to have demonstrated the existence of an olfactory chiasm in the region of the anterior commissure (in animals where the PLATE XXV. MeduIIa A Diagram designed to show the general Course of Fibres in the " Sensory " and " Motor Tracts," and their Relation to certain Fasciculi of the Optic Nerve-tracts. S, sensory tract in posterior region of mesocephalon, extending toO andT, occipital and temporal lobes of hemi- spheres; M, motor tract in basis cruris, extending to P and F, parietal and (part of) frontal lobes of hemispheres; G Q, corpus quadrigeminum; O T, optic thalamus; N L, nucleus lenticularis- N O, nucleus caudatus. 1. The fibres forming the " tegmentum cruris " (Meynert). 2 The fibres forming the " basis cruris" (Meynert); a, fibres of the optic nerve which become associated with the " optic centre " in the optic thalamus, and are subsequently prolonged to the "visual area" of the convolutions of the cerebrum; b, optic fibres which join the cells of the " corpora quadrigemina," and are then prolonged to the visual area of the cerebral cortex." A Diagram of the Base of the Brain, de=igned to show the Parts adjacent to the Optic Nerve- tracts and Chiasm. The nerves are represented by their repective numbers; IL, optic; in., motor oculi; IV., trochlearis; V., trigeminus; VI., abducens; C, crus cerebri of each hemisphere; 6, infundibulum, the pituitary body being cut off to show the optic chiasm; a, the corpus albicans (mamillary tubercle); e, external geniculate body; t, internal geniculate body. The dotted line which crosses the pons Varolii, connecting the roots of the fifth nerves, is Gubler's line, an impor- tent guide, since lesions of the pons in front of it cause " crossed facial paralysis." Lesions in the region of the crus may involve the third and second nerves simultaneously. Lesions about the chiasm may press upon the corpus striatum within the mass of the cerebrum. The crus com- prises both the motor and sensory tracts of the cerebrum. DISEASES OF THE BRAIN AND ITS ENVELOPES. 497 bulbs are largely developed); and fibres have been traced in the region of the " subiculum cornu Ammonis," or the tip of the temporo- sphenoidal lobe, which connect the olfactory centres with each other. The experiments of Ferrier tend to disprove the decussation of the olfactory paths in the anterior commissure; so that the question still remains unsettled. The sense of smell is more commonly affected in the nostril of the side which corresponds to the seat of the lesion.* Among the fibres of the internal capsule which are distributed to the temporo-sphenoidal lobe some appear to have some association with the sense of hearing ; but experimentation upon animals to de- termine the exact seat of the centres of hearing and the effects of their destruction are exceedingly difficult, because the evidences of impairment of this sense are more or less vague. Ferrier thinks, however, that the superior temporal convolution is unquestionably connected with acoustic perceptions. The area which he maps out as acoustic in function is quite extensive. The region of the hippocampus seems to be chiefly connected with tactile sensibility, because its destruction has been found to create a total loss of that sense on the opposite side of the body (Ferrier).' As regards taste, the results of experimentation upon the monkey tribe seem to point to the lower portion of the middle temporal convo- lution as the probable seat of the centres which are related to that sense.f When this region is subjected to irritation, certain reflex movements of the lips, cheek, and tongue are observed, which seem to point to an excitation of the gustatory sense. Its destruction causes abolition of taste. We have now considered three of the more prominent symptoms which are produced by lesions of the internal capsule, and I pass to a fourth, which I believe to be of great value in aiding the rec- ognition during life of an extensive and rapidly developing lesion of the white centre of the cerebral hemisphere, viz., conjugate devi- ation of the eyes and head. This has been already discussed on page 480. A fifth symptom, which points strongly to an existing lesion of the internal capsule, is choreiform movements following hemiplegia or hemiansesthesia. These movements vary in type and degree. In some cases, the movements exhibit the peculiarities of athetosis, the * Ferrier reports a case where smell and taste were simultaneously abolished by a blow upon the top of the head. Ogle records a similar instance. + This may help to explain the fact that injuries received upon the vertex and oc- cipital protuberance cause, in some instances, an abolition of taste. The temporal lobe being injured by concussion against the adjacent bone. 32 498 SURGICAL DIAGNOSIS. fingers or toes being thrown into active motions which cannot be controlled by the patient; in others, true ataxia may be developed ; again, the spasmodic movements partake of the character of genu- ine chorea; finally, a tremor, more or less marked, may be detected. It is not uncommon to find that both hemiplegia and hemianaes- thesia may co-exist with these post-paralytic forms of spasmodic disease; but one usually overshadows the other, the hemiplegia being, as a rule, the more marked. How we are to explain these late phenomena, is not definitely settled. They are probably to be classed with other morbid manifestations which paralyzed muscles sometimes exhibit, chiefly that of "late rigidity" so often seen, concerning the cause of which many conjectures have been advanced, but nothing of a positive nature demonstrated. Finally, it has been observed that lesions of the internal capsule, if very extensive, are often followed by a very marked rise in the temperature of the body. We have yet much to learn concerning the vaso-motor centres which are variously disposed within the sub- stance of the brain and spinal cord. The fact has been mentioned that most of the fibres of the inter- nal capsule probably terminate, anteriorly, in the motor convolutions of the cerebral cortex. Although there are still some neurologists of note who deny the value of the late attempts of Fritsch, Hitzig, Broca, Ferrier, Charcot, Hughlings-Jackson, Pitres, Landouzy, Ex- ner, Chouppe, and a host of others, to locate special centres within the convolutions of the cortex, clinical and pathological observa- tions are constantly being brought forward in support of the more generally accepted views. The region which embraces these motor centres appears, however, to be somewhat limited. A critical re- view of the recorded cases shows, I think, beyond cavil, that the white centre of each hemisphere of the cerebrum, as well as the cortex, may, in some instances, be extensively diseased or injured without any motor or sensory results which can be determined. Pathological evidence seems to demonstrate, however, that the re- gion so impaired must not be situated where the fibres of the inter- nal capsule suffer destruction or pressure if we expect to meet with negative results. Abscesses of immense size have been found in the anterior part of the frontal lobe, as well as in certain portions of the occipital and temporo-sphenoidal lobes, without any sensory or motor paralysis during life to indicate the existence of such a lesion. Tumors, softenings, and the most severe types of traumatism have likewise occurred without creating serious effects. In case of the occipital and temporo-sphenoidal lobes, to which DISEASES OF THE BRAIN AND ITS ENVELOPES. 499 some of the posterior fibres of the internal capsule are probably distributed, sensory and psychical symptoms have been observed by some to follow circumscribed lesions. A more careful consider- ation of such cases will perhaps demonstrate the functions of these convolutions more clearly; but at present they are somewhat con- jectural. Some forcible arguments have been advanced of late to prove a relationship between the occipital lobes and the mental fac- ulties in opposition to the more commonly accepted doctrine that the frontal lobes were those of intelligence. The temporal lobes seem to exert an influence upon the special senses of touch, smell, and hearing. The angular gyrus of the parietal lobe is probably associated in some way with vision. An apparent connection of the optic and auditory functions with the cerebellum and optic thala- mus exists. The bearing of morbid phenomena of the special sense of sight upon diagnosis has been considered in previous pages. In closing this important subject, let me suggest, that it is by no means certain that lesions, which primarily affect the constricted portion of the internal capsule, may not, in themselves, create suffi- cient pressure upon the corpus striatum and the optic thalamus to cause interference with the free action of some of the special centres which- are believed to exist within those bodies. If this be the case, many of the interesting phenomena which will be described during our discussion of lesions of the optic thalamus, would coexist with those symptoms of disease within the internal capsule already mentioned. Bitti's views respecting the relations of the optic thalamus to hallucinations, and those of Luys pertaining to its olfactory, optic, and acoustic functions have a special interest in this connection. LESIONS OF THE OPTIC THALAMU^. Efforts have been made by some of the later anatomists, who have specially investigated the brain, to subdivide the gray matter of the thalamus into circumscribed masses or nuclei, and to trace the fibres which appear to arise from these nuclei to special regions of the brain and spinal cord. Among the most attractive of these attempts may be mentioned that of Luys, whose views will be subse- quently given in detail. Whether clinical research and physiological experiment will confirm all of these attractive theories, and place them upon a ground as worthy of credence as the deductions of Broca and Ferrier regarding the functional attributes of other parts of the brain, time alone can decide. According to the researches of Luys, four isolated ganglions may I 500 SURGICAL DIAGNOSIS. be demonstrated in the thalamus. Arnold, in common with some other anatomists, has recognized three of these, and the fourth is now added by the author quoted. This author states that these ganglia are arranged in an antero-posterior plane, and form succes- sive°tuberosities upon the thalamus, giving that body the appear- ance of a conglomerate gland. Tlie anterior ganglia (corpus album subrotundum) is especially prominent. It appears to be developed in animals in proportion to the acuteness of the sense of smell. By means of the " tamia semicircularis," this ganglion (according to Luys) may be shown, in the human species, to be connected with the roots of the olfactory nerve. Kespecting it he says : " Direct anatomical exam- ination shows that there are intimate connections between the anterior centre and the peripheral olfactory apparatus. On the other hand, in confirmation of this, in the animal species, in which the olfactory apparatus is very much developed, this ganglion itself is proportionally very well marked. Analogy has thus led us to conclude that this ganglion is in direct connection with the olfactory impressions, and that this marks it as the point of concentration toward which they converge before being radiated toward the cortical periphery." The second or middle centre is in apparent continuity with the fibres of the optic tract. It may therefore be considered, on the same grounds as those previously quoted respecting the anterior centre, as a seat of condensation and radiation of visual impres- sions.* There seem to be indisputable grounds for the belief that the geniculate bodies, the corpora quadrigemina, and the angular gyrus of the parietal lobe are, in some way, also associated with the perceptions afforded by the retina. Possibly, moreover, the occipital lobes may be added to the ones previously mentioned, since physiological experiment tends toward that view. Bitti has pointed out that irritation of the thalamus may play an important part in the development of hallucinations. We know that extirpa- tion of the eye is followed by more or less complete atrophy of the outer geniculate body of the opposite side, although the inner geniculate body seems to remain unaffected. The experiments of Longet, who destroyed the optic thalami upon both sides without being able to note any impairment of vision or influence upon the movements of the pupil; and those of Lussana and Lemoigne, who found that blindness of the opposite eye followed unilateral destruc- * Luys states that it is scarcely visible in those animals (the mole as an example) where the optic nerves are rudimentary. DISEASES OF THE BRAIN AND ITS ENVELOPES. 501 tion of the thalamus, may suggest the possibility, in the former, of the escape of this centre and, in the latter, its destruction. It is difficult to devise any experiment which will positively settle the bearings of the thalamus upon vision; because it is almost impos- sible to destroy special portions with accuracy, or if this were in- sured, to avoid injury to adjacent structures. Fournie claims to have effected the separate annihilation of the special senses of smell and vision by injections made into different parts of the thalamus of animals ; and his experiments, if subsequently verified, will tend to confirm some of the theories advanced by Luys. The third centre (" median ganglion " of Luys) is described as about the size of a pea, and situated mathematically in the exact centre of the thalamus. To it the discoverer ascribes the function of presiding over and condensing all sensory impressions. The fourth posterior centre is stated to act as a halting place and condenser of auditory impressions. Two instances where the brains of deaf-mutes were found to present a localized lesion of this centre are reported by Luys. The views here expressed are quoted on account of their origi- nality ; and the author of them ranks high as an authority upon the subject of which he speaks. The numerous cases of cerebral hemorrhage which have been reported, where the thalamus was apparently the seat of localized injury, are too often accompanied with a clinical history which points toward pressure upon the in- ternal capsule to. be of value as confirmatory evidence of the existence of special centres in the thalamus. The effort of Luys to adduce cases of hemianaesthesia in support of his views regarding the function of the " median centre " of the thalamus, merely be- cause a lesion of that ganglion was found in an area defined by him as the normal limits of that special centre, must not be deemed conclusive ; because the same effect might have been produced by pressure upon the posterior third of the internal capsule of the cerebrum. There is every reason to hope and possibly to believe that sooner or later isolated ganglia within the optic thalamus will be demonstrated to exist by normal and pathological anatomy as well as by physiological experiment; but the conclusions even of so prominent an author should not be fully accepted without fur- ther testimony to substantiate their accuracy. Some interesting cases have, however, already been brought for- ward, which certainly seem to sustain the views advanced. A case reported by Hunter,* where a young woman successively lost the * Medico-chirg. Trans., London, 1825, vol. xiii. 502 SURGICAL DIAGNOSIS. senses of smell, sight, sensation, and hearing, and who gradually sank, remaining a stranger to all external impressions, disclosed at the autopsy a fungus haematodes which had gradually destroyed the optic thalamus of each side, and the optic thalami only, if the drawing given is reliable. Again, Fournie's experiments on living animals points strongly to the existence of localized centres in the thalamus. Three instances of unilateral destruction of smell, ob- served by Voisin and reported by Luys, have been found to be associated with a destruction of the anterior centre of the thalamus. A hemorrhagic effusion into the thalamus, on a level with the soft commissure (the situation of the optic centre of Luys), produced (in the experience of Serres) a sudden loss of sight in both eyes. Bitti's paper upon the effects of irritation of the thalamus upon the development of hallucinations, lends strength to the view that that ganglion in some way regulates the transmission of sensory impres- sions of all kinds to the cerebral cortex ; and confirms the opinion that " the optic thalami are to be regarded as intermediary regions which are interposed between the purely reflex phenomena of the spinal cord and the activities of psychical life." The view taken by Lussana and Lemoigne, that the optic thalami contained motor centres in animals for the lateral movements of the forelimbs of the opposite side, seems to be completely over- thrown by pathological statistics in the human race. The results obtained by these experimenters are also at variance with the be- lief, which has now become general among neurologists, that the thalami are intimately connected with the sensory tracts of the cerebrum and cord ; since they concluded that no evidence of pain or any loss of sensibility resulted from injury to these bodies. The effects of all experiments on animals, however, agree entirely with the general experience of pathologists, that lesions of both the thalamus and corpus striatum produce results upon the opposite side of the body ; whether the symptoms produced point to a dis- turbance of the kinesodic (motor) or aesthesodic (sensory) tracts. The view originally advanced by Carpenter and Todd, that the thalami are concerned in the upward transmission and elaboration of sensory impulses, in contradistinction to the corpora striata, which are concerned in the downward transmission and elaboration of motor impuls.es, seems to be gaining ground, and many facts may be urged in its favor. When the cerebrum is removed from some animals, the frog in particular, the basal ganglia being left intact, and some outward excitation be afterward used to induce movement in the animal so DISEASES OF THE BRAIN AND ITS ENVELOPES. 503 mutilated, there is every indication that the animal can see, because it avoids objects placed before the eyes, in case they tend to ob- struct its passage.* Its movements are those of an entire frog, except that they require some external stimulus to call them forth. It can be made to crawl, jump, croak, swim, and perform all other acts of an automatic machine. It is the effect of light upon its movements, however, that has some bearing upon the existence of a visual centre within the substance of the thala'mus, since no ob- server has ever demonstrated that the corpus striatum is related either anatomically or physiologically with that sense. LESIONS OF THE COBPUS STBIATUM. The lenticular nucleus of this ganglion is probably connected with the motor fibres of the " internal capsule of the cerebrum." There is more doubt in reference to the functions of the caudate nucleus. The results of lesions of either nucleus are attributed by most authors to pressure-effects upon the anterior or motor fibres of the internal capsule. In no instance, to my knowledge, has the de- struction of these nuclei produced psychic manifestations. The hemiplegia, which follows injury to the corpus striatum, is absolutely confined to the side opposite to the lesion ; in cases of extreme rarity, paralysis of motion on the same side has been clin- ically recorded ; but Flechsig has proved that such cases are to be interpreted as the result of an individual peculiarity in the relative number of decussating and direct pyramidal fibres. These and other facts pertaining to the so-called " motor tract " of the cerebrum have been touched upon (page 476). The corpus striatum, like the optic thalamus, may be considered, therefore, as a territory in which cerebral, cerebellar, and spinal activities are brought into intimate communication. It acts as a halting place for voluntary motor impulses emitted from the cere- bral cortex. It enables these impulses to become modified and possibly reinforced by currents derived from the cerebellum ; and, by its efferent fibres, it transmits centrifugal motor impulses along the projection system to different groups of cells within the spinal gray matter, whose individual functions they tend to evoke. This ganglion probably acts as a condenser and modifier of all motor acts which are the result of volition; and ' manifests, through * Such an animal will even try to avoid strong shadows thrown by the sunlight across its path. 504 SURGICAL DIAGNOSIS. the agency of its satellites (the cells of the anterior horns of the gray matter of the spinal cord), the outward expressions of our per- sonality.' Without the influence of the cerebral hemispheres, it is also capable, by means of cerebellar innervation, of governing all the complex muscular movements required in maintaining equilib- rium (coordinated movements). Finally, it may be presumed to possess the power of analysis of cerebral and cerebellar currents received simultaneously, and of materializing them by the interven- tion of its nerve-cells, projecting them in a new form, amplified and incorporated with the requirements of the general organ- ism. Experiments made upon the caudate and lenticular nuclei can hardly be said to have afforded results which can be made the basis for positive deductions respecting the functions of each. Nothnagel employed injections of chromic acid into the substance of each, and also destroyed them by means of an instrument devised for that purpose, but he made no positive conclusions save that the lenticu- lar nucleus seemed to have a more decided influence upon motion than the caudate nucleus, when both sides were simultaneously destroyed. Some observers claim to have removed the entire ganglion without any marked disturbance of sensory or motor phenom- ena. BULES GOVEBNING THE USE OF THE TBEPHINE. If anaesthesia coexists with motor paralysis, following an injury over the motor area of the brain, trephining is contra-indicated. The lesion is either too extensive to be relieved, or the brain is torn or compressed at a point removed from the seat of apparent injury (probably the " internal capsule," in its posterior third, is involved). For the same reason, convulsive movements or motor paralysis, if following an injury over the sensory regions of the cortex, are not fit cases for surgical interference. Paralysis of motion on the same side as that upon which the cranial injury has occurred should always deter the surgeon from trephin- ing, because the opposite side of the brain has probably been injured by transmitted force (Contre-coup). Profound motor paralysis indicates, as a rule, a lesion which affects deeper parts than the cerebral cortex, and the chances for surgical relief are extremely doubtful DISEASES OF THE BRAIN AND ITS ENVELOPES. 505 Paralysis of any of the cranial nerves in connection ivith body paraly- sis should be regarded as a contra-indication to the use of the tre- phine. Cheyne-Stokes respiration, vomiting, and choked disc, indicate lesions at the base of the brain which cannot be reached by any surgical interference. Aphasia, when following immediately after an injury, is probably due to depressed bone or a blood-clot over Broca's centre ; if it occurs within a few weeks after an injury, an abscess of that region probably has developed. Both of these causes might be relieved by surgical aid, the trephine being employed directly over the base of the third frontal convolution (see guides given by the author in his " Treatise upon the applied anatomy of the nervous system" ). Monoplegia in any of its varieties, when dependent upon traumat- ism and not accompanied by anaesthesia, affords the surgeon a reli- able guide to the seat of the lesion, and a reasonable hope of success in removing the cause by trephining. 506 SURGICAL DIAGNOSIS. PAEALYSIS FEOM COETICAL PAEALYSIS FEOM NON-COE- CEEEBEAL LESIONS. TICAL CEEEBEAL LESIONS. Consciousness. Is seldom lost at the onset of pa- A sudden loss of consciousness ralysis, unless the lesion be extensive usually accompanies the develop- or due to traumatism. ment of tlie lesion or its manifesta- If ushered in with an epileptic tion in the form of paralysis. attack, consciouness is of course Convulsions are not usually pres- lost. ent during the " paralytic attack." Pain. Local pain within the head is The patient is usually unconscious often complained of at the time of at the time of the attack and for the attack. some time after ; and (even after the attack) pain in the head is a less constant symptom. Percussion. Percussion over the seat of the lesion often elicits pain. Monoplegia (in any of its forms) is typical of this condition. Special groups of muscles are par- alyzed, and some more than others. The paralysis is often transitory, if the lesion be slight or superficial. The group of muscles, which is the last to show improvement, may be a valuable guide in localizing the seat of injury. Sensibility is usually unimpaired. Negative in its results. Hemiplegia or hemianmthesia, more or less profound, follow the de- velopment of the lesion, as a rule. Both may coexist in some cases. It is slow in recovery. The improvement is compara- tively uniform, so far as special groups of muscles are concerned. More or less anaesthesia usually coexists with the motor paralysis. Paralysis. DISEASES OF THE BRAIN AND ITS ENVELOPES. 507 PAEALYSIS FEOM COETICAL PAEALYSIS FEOM NON-COE- CEEEBEAL LESIONS TICAL CEEEBEAL LESIONS (continued). (continued). Muscular Eigiditt. The paralyzed muscles often ex- Early rigidity of the paralyzed hibit rigidity at an early date. muscles is rare in central cerebral disease. Choreiform Movements. Infrequent as a sequel to the pa- Frequently follow the develop- ralysis. ment of the hemiplegia or hemian- aesthesia. Electro-Contractility. The paralyzed muscles exhibit Usually impaired or modified. normal electro-contractility. SYMPTOMS IN COMMON. Both are associated with motor paralysis. " may be associated with post-paralytic rigidity of muscles. " " " " sudden advent, " " " " traumatism. " " " " convulsions. 508 SURGICAL DIAGNOSIS. lEEITATIVE LESIONS OF THE DESTEUCTIYE LESIONS OF CEEEBEAL COETEX. THE CEEEBEAL COETEX. (Jacksonian Epilepsy.) History. Syphilis is by far the most fre- Syphilis is only one of many quent cause of this condition. causes of this condition, and by no means the most common (see page 477). Convulsions. The patient is seized with con- Convulsions are usually absent. vulsive attacks of the epileptic type, which are followed by tran- sient paralysis. The part which first shows rigid- ity during the convulsion points toward the motor centre for that part as the seat of greatest irrita- tion. It may thus assist in localiz- ing the seat of the lesion. Paralysis. The paralysis is somewhat of the A well-marked "monoplegia" is "monoplegic" type, but is usually developed, which is more or less transitory. It is not so well de- permanent according to the charac- fined as in the case of destructive ter of the lesion. It affects the side lesions. It exists on the side oppo- opposite to the lesion. site to the lesion. The groups of muscles affected with paralysis will aid in deciding as to the seat and extent of the lesion. Prognosis. Good—on account of its syphilitic origin. Depends entirely upon the char- acter of the lesion, its seat, and ex- tent. DISEASES OF THE BRAIN AND ITS ENVELOPES. 509 CEOSSED PARALYSIS. OLFACTORY NEEVE AND TEICEMINUS NEEYE AND BODY TYPE. BODY TYPE. Sensation in Face. Normal. Impaired or lost as far as the me- dian line. Conjunctiva, nostril, lips, gums, and tongue participate in the anaesthesia, as far as one lat- eral half of the head is concerned. Neuralgia may coexist with anaes- thesia, if it is not complete. Special Senses. Anosmia (loss of smell) will exist Smell may be impaired from an in the nostril opposed to the hemi- effect of the sensory paralysis upon plegic side of body. the mucous secretion of the nostril affected. Taste may be impaired or lost in one lateral half of the tongue for its anterior two-thirds. Chin. Normal. May be deflected away from the hemiplegic side of body, if the motor branches of the nerve are paralyzed. Mastication. Normal. Impaired, on account of paralysis of the temporal, masseter, and pterygoid muscles of the side ren- dered anaesthetic, if the motor root of the nerve is affected. Body Paralysis. Hemiplegia exists on the side of Hemiplegia exists on the side the body opposed to the nostril, in opposed to the symptoms described which the sense of smell has been above ; hence on the side opposite destroyed. to the exciting lesion. 510 SURGICAL DIAGNOSIS. CEOSSED PAEALYSIS OF CEOSSED PAEALYSIS OF THE OLFACTOEY NEEYE THE TEIGEMINUS NEEYE AND BODY TYPE AND BODY TYPE (continued). (continued). Situation of Lesion. Probably in the anterior fossa of Probably in the middle fossa of. the cranium. Sufficiently large in the cranium or in the region of the extent to simultaneously affect the pons Varolii. If in the latter, it olfactory nerve and the "motor may induce paralysis of the seventh tract" or the corpus striatum. nerve simultaneously. SYMPTOMS IN COMMON. Both are associated with hemiplegia. " may be associated with impairment of the sense of smell. DISEASES OF THE BRAIN AND ITS ENVELOPES. 511 CEOSSED PAEALYSIS. MOTOE OCULI NEEVE AND FACIAL NEEVE AND BODY BODY TYPE. TYPE. Face. Pupil dilated on same side as the lesion. External squint on same side as the lesion. Ptosis on same side as the lesion. Eye prominent on same side as the lesion. Eye cannot be closed on same side as the lesion. Obliteration of facial wrinkles on same side as the lesion. Nostril collapsed on same side as the lesion. Mouth. The lower portion of face is oc- casionally paralyzed on the side corresponding to the hemiplegia— hence on the side opposite to the lesion. Mouth is drawn toward hemiple- gic side. Tongue cannot be protruded in a straight line. Lips cannot be symmetrically puckered (as in act of whistling). Taste is sometimes impaired. Arch of palate is rendered straight on the paralyzed side. Uvula is deflected toward the hemiplegic side. Food accumulates in the cheek from paralysis of the buccinator. Saliva dribbles constantly. Special Senses. Not affected. The patient may see objects as if doubled (in certain attitudes of the head). Double images are obviated, however, by altering the position of the head so as to allow both eyes to focus upon the object. Hearing may be rendered exces- sively acute (tensor tympani muscle affected). Taste may be affected (chorda tympani nerve paralyzed). Smell is not impaired, if the nos- tril is held open. 512 SURGICAL DIAGNOSIS. CEOSSED PAEALYSIS OF CEOSSED PAEALYSIS OF THE MOTOR OCULI NERVE THE FACIAL NEEVE AND AND BODY TYPE BODY TYPE (continued). (continued). Body Paralysis. Hemiplegia exists on the side of Hemiplegia exists on the side of the body opposed to the eye deform- the body opposed to the facial de- ity ; hence on the side opposite to formity ; hence on the side oppo- the lesion. site to the lesion. Situation of Lesion. Within the crus cerebri of the In the pons Varolii, on the side hemisphere opposite to the side opposite to the hemiplegia, and pos- rendered hemiplegic. terior to a line connecting the roots of the Trigemini (Gubler). SYMPTOMS IN COMMON. Both are associated with eye deformity. " " " " hemiplegia. " may be " " paralysis of the lower portion of the face. DISEASES OF THE BRAIN AND ITS ENVELOPES. 513 BILATEEAL FACIAL PAEAL- UNILATEEAL FACIAL PAEAL- YSIS. YSIS. (Facial Diplegia.) (Bell's Palsy.) Mouth. The mouth cannot be closed. The mouth is drawn toward un- affected side. Cheeks. Both cheeks are flaccid. The cheek is flaccid on the af- fected side. Mastication. Mastication is impossible, if the Mastication is difficult if the mo- diplegia be complete. tor branches of the nerve are para- lyzed ; but it is still slowly per- formed. Deglutition. Deglutition is impossible, with- Deglutition is normally per- out the aid of the finger. formed. The Expression. The features are fixed and im- One lateral half of the face is mobile. immobile. The opposite half is dis- The alae nasi and cheeks collapse torted. with each inspiration and are puffed One nostril is collapsed. out with each expiration. Voice. The voice is nasal. No vocal changes are developed. Speech. Speech becomes almost unintelli- Speech is not markedly altered. gible. Act of Eating. The food is pushed into the phar- The finger is employed to empty ynx by the fingers. the food from the cheek of para- lyzed side. 33 514 SURGICAL DIAGNOSIS. BILATERAL FACIAL PAEAL- UNILATEEAL FACIAL PARAL- YSIS YSIS (continued). (continued). Uvula. Is flaccid and paralyzed, but still The arch of the palate is unsym- symmetrical. metrical; one side being curved and the other straight. Hearing. May be rendered excessively acute May be rendered more acute in in both ears. the ear of the paralyzed side than on the opposite. Causes. Basilar tumors. Cranial or cerebral lesions affect- Exostoses of the basilar process. ing one facial nerve. Aneurisms. Lesions of temporal bone of paral- Meningeal exudations inducing yzed side. atrophy of the facial nerves. Traumatism. Necrosis, caries, or suppurative Surgical operations. diseases of both temporal bones. Severe cold. Rheumatism. Diphtheria. Syphilis. SYMPTOMS IN COMMON. Both are associated with facial deformity. " " " " immobility of the features. " " " " difficulty in eating. " J. Corpus Striatum, Caudate Nucleus of, 504 * Effects of destruction of, 505, Functions of, 504. 505. Lenticular Nucleus of, 504. lesions of, 504. Cortical paralysis, 476. Cranio-tabes, 107. Cranium, Exostoses of 116.132, 4.4. Tumors of the, 422. Cellulitis, Pelvic, 451. Cephaltematoma, 427. Cerebral Hernia, 340, 341, 345. Cirsocele, 277. Cloacae, 112. Chordee, 328. Colic. Biliary, 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. Cremaster reflex, 561. Crossed paralysis, 478, 479, 486, 487, 488, 489, 491. Symptoms of, 5C9, 510, 511, 512. Types of, 478. Cryptorchidism, 261. Cyclocephalic deformity, 461, 4U3. Cystic disease of Prostate, 308. Sarcoma, 258. Cystitis, Acute, 288, 304. Chronic. 288, 306. Cystocele, 341, 345. Cysts, Congenital, 407. Extravasation, 407. Exudative, 407. Fibro-uterine, 442. Mucous, 407. of Antrum, 130. of the Breast, 432. of Broad Ligament, 407. of Kidney, 407. 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. of Ganglion cells of anterio? horns, symptoms of, 579, 580, 581. of spinal cord, 539. Delayed Sensation. 480. Descending Sclerosis due to cerebral lesion, 576. Diaphragmatic Hernia, 374. Diathesis, Aneurismal, 9. Direct Cerebellar Column, 545. Pyramidal tract, 544. Disease, "Cystic, of Prostate, 308. Diseases affecting Calibre of Vessels, 3, 7. of Arterial Coats, 4, of Brain, 461. 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. 600 INDEX. Diseases of Male Genitals, 257. varieties of. 2.">7. of Penis, 32". of Prepuce, 326. of Prostate Gland, 307. of Rectum, 338. of Spinal Cord, 539. 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,t70. Surgical, of Abdominal Cavity,335. Tubercular, of Axillary Glands, 420. Dislocations, 135,253. causes of, 135. classification of varieties, 135. congenital, of Jaw, J38. 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, 162, 163, 164, 165. of Clavicle, 143. varieties of, 148. of Elbow Joint, 149. Table of, 159.' of Femur, "Dorsum Ilii,*' 169. "Pubic," 171, 172,240. "Sciatic notch," 109,170, 239. "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 O.- 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, In. lateral, 178. rotary, 178. of Ulna, backward. 156,158. forward, 158. lower end, backward, 166. Dislocations, of Ulna, 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. Duchenne's disease, 492. Symptoms of, 520. Dysphagia, 492. Elephantiasis Arabum, 394. Emboli in Veins, 3. Embolic Abscesses, 467. Embolism, 15, 22, 44, 461. cerebral, 466. Symptoms of, 518. Emphalocele, 426, 427. Encephalitis, 461, 470. Encephalocele, 461, 463. Enchondroma, 99, 114, 406, 407. of Testicle, 260. Enterocele, 341. Entero-epiplocele, 341. Entozoa of Bone. 100, 118. Epididymitis, 208. Epigastric Hernia, 340. Reflex, 562. Epilepsy, Symptoms of, 534. Epileptiform attacks, 492. Epiphyses, Separation of the, of Radius and Ulna, 230. Epiplocele, 341. Entero-, 341. Epithelioma, 288, 326, 418, 429. Epulis, 118. Erysipelas, 392. Cutaneous, 394, 404. Internal, 384. Phlegmonous, 394, 404. Exomphalos, 340, 372. Exostoses, 99, 115. causes of, 116. of Cranium, 116,132,.424. Eyes, Conjugate Deviation of, 480, 497. F. Face, Tumors of the, 422. Facial Anaesthesia, 490. Diplegia, Symptoms of, 513. Neuralgia, 491. Nerve, lesions of, 491. Paralysis, 491. Fatty degeneration of Arterial Coats, 3. of Vessels, 5. Flatfoot, 89, 92, 93, 95. Focal lesions of cervical region of spinal cord, 5C7, 568, 569. of dorsal region of spinal cord, 569, 570, 571. of lateral "half of spinal cord. 572, 573. of lumbar region of spinal cord, 571, 572. Foot-clonus, 562, 563. Formication, 479, 481. Fracture, at the Elbow, 219. varieties of, 219. at the Hip. 232. 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, 226. ... . ,, varieties of, 226. of the Ankle, 243. varieties of, 243. of the Clavicle, 209. inside of Coracoid Proc- ess, 211. INDEX. 601 Fracture of the Clavicle, 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-capsular, 235. Extra-capsular, simple, 237. Extra-capsular, with impac- tion, 236. Intra-capsular, 236. Intra-capsular, simple, 237. Intracapsular, with impac- tion, 2:15. 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, 222. Intra-capsular, simple, 213. near Shoulder, 212. near Shoulder, varieties of, 212. Neck of, 141, 207, 216, 217. Outer Condyle of, 222. of the Jaw, Lower, 202, 204. of the Jaw, Upper, 202. of the Leg, in vicinity of Knee, 241. of the Malleolns. Internal, 244. of the Patella, 212. 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, 200. of the Skull, 193. Base, 199. complete, 193. Inner Table, 197, 198. Outer Table, 193, 197. of the Sternum, 246. 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 Vertebra, 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. Varieties of, 189. Fragilitas Ossium, 108 Fieces, Impacted, 348,365. Femoral Canal, Lipoma of, 3,1. r emui Tumors in region of, 412. Femoral Hernia, 340, 349, 367, 368, 369. 370, 371, Fem4ur,-Disease of the Trochanter, 81. FeSur -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. Fistula;, Urethral, 317. Foot. Fracture of the Femur, with inversion of the. 170, 239. Fossa?, Iliac, Tumors in, 412. Front-tap Contraction, 563. Furuncle, 397. G. Ganglia, 407. Gangrene, 467. Dry, 403. Hospital, 403. Moist, 403. of Bladder, 288. General Paralysis of the insane, 283. Gland, Axillary, Cancer of, 420 Tubercular disease of, 42C. Enlarged, 349, 367. Lymphatic, Tumors of, 409. Parotid, Tumors of, 409. Prostate, Atrophy of, 308. Cancer of, 308. Cvstic disease of, 308. Diseases of the, 307. 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. Glosso-pharyngeal Nerve, lesions of, 492. Gluteal reflex, 561. Gonorrhceal Inflammation, 313. Gout, 50. Rheumatic, 58, 66. Groin, Tumors of, 412. Gubler's line, 491. Gummata, 327, 406. Gums, Tumors of the, 408. H. Haematoma of Dura Mater, 468. Symptoms of, 525. Haematocele, 272, 286, 348, 407, 411. of Testicle 259,362. Pelvic, 452. Haemorrhage of Spinal cord, 539. Half-vision, 482. Head, Double, 461, 463. Tumors of the, 408, 422. Hearing, Centres of, 487. in Optic Thalamus, 502. Modifications of, in Bell's paralysis, 491. Hemianesthesia, 480, 495. cerebral, 481, 488. Hemianopia. 482, 483. Hemianopsia, 479, 482, 483, 486, 488. Uncomplicated, 489. Varieties of, 483. with crossed paralysis, 489. nemiparaplegia, 574, 575. Hemiplegia, 477, 478 cerebral, 495. Diagnosis of, 530- Spinal, 573, 574. Diagnosis of, 530. Hemorrhage, Prostatic, 309. Hemorrhoids. 338. ' External, 352. Internal, 352, 354. Hernia, 340. anatomical classification of, 340. classified as to conteuts of sac, 341. cerebral, 340. 341, 345. condition of Bowel in, 346. conditions of sac of, 341. congenital, 284. 341. 346, 375, 276. " cough impulse " of, 345. Diaphragmatic, 340, 345,347, 374. differential diagnosis of, 348. 602 INDEX. Hernia, 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. incomplete, 363. nomenclature of, 342. region, 348. Inguino-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 svmptom of, 346. Perineal, 340, 345, 373. Poupart's Ligament (above1), 340. (below), 340. Pudendal, 340. reducible, 341. reducibility of, 346. special types of, 342. Sciatic, 345. strangulated, 311. Scrotal, 280, 281, 359, 360, 361. 362. symptoms'in general, 344. Testis, 260, 267. Thyroid, 373. Umbilical, 340, 372. Vaginal, 340. Ventral, 340, 346, 372. Herpes, 332. Progenitalis, 325. Hiccough, 492. 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. (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. Sun-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. Hydrocele, of the Cord, 285, 348, 366. of the Testicle, 348, 360. Hydrocephalus, 461, 463. chronic, 461. 469. Symptoms of, 536. Hydrops Articuli, 60. Hydro-Sarcocele, 274. Hydruria, 492. Hyperaesthesia, 479, 482. Hyperinosis, 465. Hypertrophy Hypoglossal of Prostate Gland, 307. nerve, lesions of, 492. I. Ichthyosis, 394. Ilium, diseases of the crest of, 84. Incoordination of Muscular movements, 557. Infarction, 466, 467, 472. Inflammation, 379, acute, 380, 381. symptoms of, 390. catarrhal, 388. causes of (exciting), 382. (predisposing), 381. classification of, 379. cellular, 300. constitutional effects of, 387. chronic, 380, 381. 390. chronic circumscribed, of Corpora Cavernosa, 328. constitutional symptoms of croup- ous, in general, 389. etiology of, 381. Exudation in, varieties of, 388. Fibrinous, 389. Gonorrhceal, 313. Heat of, its causes, 385. Hyperplastic, 380. Idiopathic, 380. 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. of Spinal Cord, 539. pain of, its causes, 385. pleuritic, 250. rational symptoms of, 385. redness of, its causes, 385. results of inflammatory proces« (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. Inguino-labial, Hernia, 340. -scrotal Hernia, 340. Injuries of Abdomen, 335. Internal Capsule of Cerebrum, 494. Intestinal Canal, foreign bodies in 336 Colic, 28. Obstruction, 337, 349, 351. causes of, 337. symptoms of, 337. T ± ,. ,. varieties of, 351. Intestine, diseases of the, 337. Involucrum, 112. Ischiatic Hernia, 340. 4 INDEX. 603 J. Jacksonian Epilepsy, 493. Symptoms of, 508. 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, 408. 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. complications in locomotor ataxia, 559, 560. Deformities of, 87. acquired, 88. or congenital, 49. 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, 163,173. congenital, 74, 77. Nelaton's guide, 168. Table of, 174. Fracture of, 233. (extra-capsular), 235. (simple extra-capsular), 237. (intra-capsular), 236. (impacted intra-capsular\ 235. (simple intra-capsular), 237. (with inversion of the foot), 239. Knee diagnostic points of tenderness on ' • pressure, 87. Dislocations at, 175. Fracture of bones of the leg in the vicinity of the, 441. Knee and Ankle, Fractures at, 241. loose Cartilage in, 49, 62. Malformations (congenital), 8.. 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. Joint, Wrist, Dislocation of, 160, 25S, 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. Kinesodic system of Spinal Cord, 539. lesions of, 540. Knee-jerk, 562. 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, 32. Line of Gubler, 491. Locomotor ataxia, 539, 555, 556, 557, 558, 559, 582, 583. Symptoms of, 515. Luy's Centre in Optic Thalamus, 501. Lipoma, 400, 407. of Femoral Canal, 349, 361. of Spermatic Cord, 278. of Testicle, 259. Lips, Tumors of, 408. Liver, Hernia of, 341. Lumbar, Hernia, 340. Lung, consolidation at apex of, 31. Hernia of, 340, 341, 411. Lupus, 395, 406, 429. Vulgaris, 395. Lymphatic Gland, Tumors of, 409. Lymphoma, 406. M. Malacosteon, 108, 124. Malformations, acquired ard congenital, 49. Mamma?, Hypertrophy of, 433. Tumors of, 410. Medulla Oblongata, absence of, 463. Compression of, symptoms of, 492. lesions of, 492. Meniere's disease, symptoms of, 534. Meningitis, spinal, 588. Merocele, 340. Metastatic abscess, 467. Microcephalic deformity, 463. Mollities Ossium, 99, 108, 124. Monoplegia, 477, 493, 495. a guide to the use of the Trephine, 506. Monopodia, 186. Monorchidism, 262. Morbus Coxarius, 70, 77, 78,79, 81 to 86. Acetabular, 72. symptoms of, 72. Arthritic, 72. symptoms of, 72. differential diagnosis of, 74. Femoral, 72. symptoms of, 72. symptoms of, 71. Morbus Coxae Senilis, 58. Motor Oculi nerve, lesions of, 489. Paralysis, 476. coexisting with convulsions, 505. symptoms of spinal lesions, 565. 604 INDEX. Motor Tract, course of, 476, 477. of Brain, 487. Mouth, Tumors of the, 422. Muscle, Cremaster, Spasm of, 279. Muscles, atrophy of, 540. Tumors of, 409. Myelitis, 539. central, 539, 554, 555. of anterior horns of spinal cord, 547. Spinal, of anterior horns, 539. Symptoms of, 588, 589, 591. Myoma, 406. Myxoma, 406. N. Xaevi, 39. Waevus, 7. Neck, Tumors of the, 409. Necrosis, 111. 120. changes in, 111. Nerve, Auditory, lesions of, 492. Fourth Cranial, lesions of, 490. Glosso-pharyngeal, lesions of, 492. Hypoglossal, lesions of, 492. Motor oculi, lesions of, 489. Olfactory, lesions of, 480. Optic, lesions of, 486. Phrenic, 566, 507. Pneumogastric, lesions of, 492. Recurrent Laryngeal, result of pressure upon, 13. Sciatic, lesions of, 571, 572. seventh cranial, lesions of, 491. Spinal accessory, lesions of, 492. Third cranial, lesions of, 489. Trigeminus, lesions of, 490. Ulnar, 506, 569. lesions of, 581. Nerves, Brachial plexus of, 566. Spinal. 566. Neuralgia, Articular, 49, 61. of Intestine, 28. of Rectum, 340. of Testis, 263. Neuroma, 406. Numbness, 481. O. Olfactory Nerve, lesions of, 486 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. Optic Nerve, lesions of, 486. Thalamus, atrophy of, 463. lesions of, 500. Physiological function of, 501, 502, 503. Special centres of, 500. Osteitis, 99, 100, 102, 119, 121. symptoms of, 101. Osteo-Aneurism, 113. Osteo-Arthritis, chronic, 58. Osteo-Cvstoma, 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. CSdcma, local, 398. (Esophagus, Tumors of Mucous Membrane of, 409. P. Pachydermia, 394. Pachymeningitis, 461, 468. Symptoms of, 526. Pains of Locomotor Ataxia, 556, 557. Papillomata, 405, 406. Paralyzed Muscles, Contracture of, 570, 571. late rigidity of, 498. Rigidity of, 493. Paralysis Agitans, 586. Symptoms of, 532. Bulbar, 492, 552. Complete, 479, 488. Cortical, 476. 493. Symptoms of, 507. Crossed, 478, 479. symptoms of, 509, 510, 511, 512. Facial, Bilateral, 513. unilateral, 513. from brain tumors, 474. 475. from cerebral Meningitis, 468- General axioms of, 540. General, of the Insane, 583. General syphilitic, 593. Glosso-labio-pharyngeal, symptoms of, 520. infantile, 86. Labio glosso-pharyngeal, 492. Motor, 462, 476. Motor, coexisting with Anaesthesia. 505. of profound, 505. non-cortical, symptoms of, 507. Ocular, 487. bilateral, 488. of Bell, 491. of Bladder, 305. of cerebral origin, symptoms of, 515. of Duchenne, 492, 520. of Face, 489. of Palate, 491. of special senses, 478. of Taste, 491. permanent, 493. Pseudo hypertrophic, 539, 550, 552, 553, 554, 584, 585. sensory, 462, 479. Spastic, 545. Spinal, 543. acute, 547. atrophic, 539. General symptoms of, 544. Infantile, 547. Tetanoid, 539. Transitory, 443. with Hemianopsia, 486, 487. with Muscular atrophy, 540. with Spasms, 540. Paraphimosis, 327. Paraplegia, Functional, 587. Hemi-, 574. 575. Organic, 587. Reflex, 591, 592. Tetanoid, 582. Parasites, 407. of the Brain, 474. Parotid Gland, Tumors of, 409. Patella, Dislocation upward, 180. lateral, 180. rotary of, 180. Reflex, 562. 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. INDEX. eos Perineal Abscess, 320. . Hernia, 340, 373. Periosteal Abscess, 99. t. ■ .... Thickenings and Nodes, 99. Periostitis, 99, 103, 121, near a Joint, 122. Syphilitic, near a Joint, 68. D -. ... tyP68 of* 103- Peritonitis, Pelvic, 451. Perityphlitis, 349, 350. Peroneal Reflex, 562, 563. Phlebaectasis, 20. Phlebitis, Adhesive, 3, 18, 22, 45. Diffuse, 3, 19. Suppurative, 19, 22, 45. Phlebolites, 21, 309. Plantar Reflex, 561. Pneumogastric Nerve, lesions of, 492. Pneumo-thorax, 251. Pregnancy, 449. extra-nterine, 452. Tumor of, 438, 439, 440. Prepuce, Diseases of, 326. Phimosis, 326. Poliomyelitis, acute, 547. anterior, 547, 548, 549. chronic, 548, 549. Subacute, 548. Symptoms of, 578, 579. Polypus. Fibrous, 218. Rectal, 239, 354, 355.1 Uterine, 443. Vaginal, 453. Pons Varolii, absence of, 463. Posthitis, 325. Post-paralytic rigidity, 477. Poupart's Ligament, Hernia above, 340. below, 340. Primary Lateral sclerosis, 545, 546. 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. Progressive Muscular atrophy, 539, 550, 551, 552, 579, 584, 585. Prolapse of Rectum, 338. Prostate Gland, Atrophy of, 308. Cancer of, 308. Diseases of, 307. (cystic), 308. (inflammatory"), 307. Hypertrophy of, 307, 312, 333. Tubercle of, 308. Tumors of, 410. Wounds of, 309. Pseudo hypertrophic Paralysis, 539, 550, 552, 553, 554, 584, 585. Prostatic Enlargement, 307. Prostatitis, acute, 307, 311. chronic, 306, 307, 311. Psoas Abscess, 401. Ptosis, 474. 489. Pudendal Hernia, 340. Pruritus Ani, 339. Pyaimia, 16, 50, 380, 465, 471. R. Radius, Fracture of upper end of, 225. of (transverse, above the wrist), 231. Separation of the Epiphyses, 230. Rannla, 407. Rectal Prolapse, 355. Rectocele, 341, 345. Rectum, Cancer of, 339, 356. Diseases of, 338. Fistula of, 33, 357. Nenralgia of. 340. Polypus of, 339. Prolapse of, 338. Stricture of, 339, 356. Tumors of, 410. Reflex Paraplegia, 591, 592. Reflexes, Spinal. See Spinal Reflexes. Reflex tests, 561, 502, 563. Renal Colic, 28. Respiratory Centre, 567. Rheumatism, 50, 64. chronic, 58. Ribs, Fracture of, 248, 250, 251, 252. Rickets, 106, 124. causes of, 106. symptoms of, 108. Robertson pupil, 559. 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. Scapular Reflex, 562. Sclerosis, Amyotrophic lateral, 539. Cerebro-spinal, 586. Lateral, Amyotrophic, 549, 550. Lateral, primary, 545. Lateral, secondary, 546, 547. - of Anterior Columns of Spinal Cord, 534, 544. of bone, 101. of Brain, 473. of Columns of Goll and Burdach, 539. of lateral columns of Spinal Cord, 539. of lateral columns of Spinal Cord, Symp- toms of, 576. of Posterior columns of Spinal Cord, 555, 556, 557, 558, 559, 560. of Postero-lateral columns of Spinal Cord, 545. of Spinal Cord, 539. Spinal, of Cerebral origin, Symptoms of, 576. Spinal, Primary, Symptoms of, 577. Spinal, Secondary, symptoms of, 577. Secondary lateral sclerosis, 546. Sensation, delayed, 480, 557. Sensory Paralysis, 479. Symptoms, 543. • axioms of, 540. of Spinal lesions, 565. Sensory Tract of Brain, 487. Shaking Palsy, Symptoms of, 532. Sight, centre of, m Optic Thalamus, 501. Smell, centre of, 496, 497. centre of, in Optic Thalamus, 500. Destruction of, 496. Softening of the Brain, 473. Spasmodic tables, 545. Spasm of Cremaster Muscles, 279. Spasm, Urethral, 318. Spastic Paralysis, 545. Special senses, Impairment of, with Paralysis, 480. in cerebral lesions, 496. Sprain, severe, 185. Separation of the Great Tubercle of Humerus, 144. Speech, Broca's centre of, 484. Spermatic Cord, diseases of Tunica Vaginalis and the, 273. 606 INDEX. Spermatic Cord, diffused Hydrocele of, 275. encysted Hydrocele of, 276. Lipoma of, 278. Varicocele of, and Testicle, 277. Spleen, Enlargement of, 40.', 421. Hernia of, 341. Sternum. Fractures of, 246. Spina Bifida, 454, 456, 539. Ventosa, 100, 125. Spinal Accessory Nerve, lesions of, 492. Spinal Cord, absence of, 463. Aesthesodic system of, 539. Anterior columns of, sclerosis of, 544. Cervical region of, focal lesions of, 567, 568. 569. Columns of, 541. Commissural fibres of, 241. Congenital abnormalities of, 539. Degeneration of, 539. Diseases of, 539. Dorsal region of, focal lesions of, 569, 570, 571. Focal lesions of, 539. 560, 561, 562,563, 564, 565, 566, 567. 568, 569, 570, 571, 572, 573, 574, 575. Gray Mutter of, 541, 542. Haemorrhage of, 539. Inflammation of, 539. Kinesodic system of, 539. Lateral half of, focal lesions of, 572, 573. Lumbar region of, focal lesions of, 571,572. Motor fibres of, 541. Non-systematic lesions of, 560 to 575 inclusive. Physiology of, 541. Posterior Columns of, sclerosis of, 555 to 560 inclusive. Postero-lateral Columns of, sclerosis of 545. Sclerosis of, 539. Sensory fibres of, 541. symptoms of lesions of, 543. Systematic lesions of, 539. Trophic centres of, 541. Tumors of, 539. Spinal Epilepsv. 569, 570. Hemiplegia, 530, 573, 574. Meningitis, Symptoms of, 588, 589, 590. Nerves as Guides in diagnosis, 266, 567. Paralysis, varieties of, 543. Reflexes, 540, 541, 543, 561, 562, 563. axioms of, 563, 564. deep, 562, 563, 564. Superficial, 561, 562. Segments, 541, 542, 561. Symptoms, axioms of, 540. 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. Hernia, 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. Strabismus, 474, 489,490. Svmpodia. 186. Svndactvhis. 186. Svnustosis, GO. Synovitis, 49, 50, 60, CI, 103. acute, 51. chronic, 53. Gonorrhceal, 55. Pyaemic, 55. Rheumatic, 54. Scrofulous, 53, 65. Suppurative, 52. symptoms of, 51. Syphilitic, 56. Syphilis, 50, 465, 471. Syphilitic, General Paralysis, 593. Orchitis, 264, 265. Testis, 290. Ulcers, 313. T. Tabes Dorsalis, 555, 556, 557, 558. 559. Symptoms of, 515. Talipes, 88, Calcaneous, 89. Calcaneo-valgus, 89, 92. Equinus, 9, 89. Equino-varus, 89. Spurio-valgus, 89, 92, 93, 95. Valgus, 89, 92, 93. Varus, 89, 90. Taste, centre of, 497. Traumatic Aneurism, 9. Tendo-Achilles reflex, 562. Tendon, Rupture of the Triceps, 224. Testicle, Cancer of, 267. Haematocele 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, Cysts of, 266, 283. Hernia, 267, 341. malignant, 270. Neuralgia of, 263. Sarcoma of, 270. Syphilitic, 270. Tubercular, 270. Tetanoid Paralysis, 539. Paraplegia, 545, 582. Tetanus, Symptoms of, 590. Tremor, 498. Trephine, Rules for use of, 505. Trephining, Contra indications against, 505. Tissues, Conditions of. inflammatory, 391. diseases of, 379. Emphysema of, 252. Gangrene of, 392. Induratitin of, 391. Suppuration of, 391. Tumefaction of, 391. Ulceration of. 391. Trigeminal Nerve, lesions of, 490. Tongue, Tumors of, 408. Touch, Sense of, centre of, 497. 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. Arterial, 461. Cerebral, 465. Symptoms of, 518. Venous, 461. Tubercle, 406. of Prostate Gland, 308. Tubercular Testis, 270. Tumor or Tumors. Abdominal, 27. Aneurism, effects of, pressure upon, 11, INDEX. 607 Tnmors, Anenrismal, growth of, 10. in general, symptoms of, 10, situations of, 10. Atheromatous, 407. Benign, 416. classes of, 405. Congenital, 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. in Iliac Fossa, 412. . in*region of Femoral Canal, 412. of Inguinal Canal, 412. Intra-cranial, 131, 425. Intra-thoracic, 30. Malignant, 416. Mediastinal, 374. of Antrum, 408. cystic, 130. malignant, 130. solid, 129, 428. of Axilla, 411. of Bladder, 288. of Brain, 408. 474. 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. non-malignant, 99. pulsatile, 34, 100, 113, 126, 128. Scirrhous, 100. of Cranium, 422. of Face, 422. of Groin, 412. of Gums, 408. of Head, 40s, 42C. of Integument, 409. of Jaws, 408. of Labia, 410. of Larynx, Mucous Membrane of, 40ft of Lips, 41)8. 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 (Esophagus, 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 Spinal Cord, 539. of Spine, 454. varieties of, 454. of Teeticje, 410. (fibrous), 259. of Tongue, 408. of Trunk, 410. Tumors, of Thvroid Gland, 409. of Uterus, 410, 436. fibroid, 438. of Veins, varicose, 3. of Vessels. 409. on Arteiy, 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. Tiirck's Columns, 541. Trunk, Fractures of, 246. Tumors of, 410. Typhlitis 349, 350. Ihyroid Gland, Tumors of, 409. Hernia, 373. \J. Ulna, Fracture of the, at the elbow, 220. at Conoid Process of, 223. Olecranon Process of, 223, 224. upper end of the, 225. Fracture (transverse) of, above the wrist, 231. separation of Epiphyses of, 230. Ulnar Aneurism, 18. Ulcer or Ulcers. Chancroidal, 313. Local, 313. of the Anus, 339. Syphilitic, 313. Venereal, 326. Ulceration, 288. Lupoid, 395. Urethra, diseases of the. 313. diseases of the, affecting structure of its 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 Ligament, 321. Rupture of the, within the Triangular Ligament, 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. Tumors, 317, 324. Urethritis, 313. Uterus, Congestive Hyperaemia of, 437. Inversion of, 436. Tumors of, 410, 436. (fibrous), 433. (fibroid), 439. Umbilical Hernia, 340, 372. Unilateral Spinal Sclerosis of lateral column, 576. Urine, conditions impeding the normal exit of, and independent of structural changes, 318. Incontinence of, 303. Retention of, 301, 302, 303. Suppression of, 302. Vaginal Hernia, 340. Varicocele, 277, 281, 348. 361. causes of, 278. of the Spermatic Cord and Testicle, 277. 608 INDEX. Varicose Aneurism, 8. Varix, 20. Aneurismal, 7, 8, 36, 41. Arterial, 7. of Saphenous Vein, 349, 369. Vegetations (venereal), 326. Vein or Veins. 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, result of pressure upon, 13. obstruction to, from Emboli, Thrombi, etc., 3. Parasites of, 3, 21. Tumors of (varicose), 3. Varix of Saphenous, 349, 369. Varices of, 22. Varicose, 20, 42. Venereal Sores, 326. Ulcers, 326. Venous Coats, Atrophy of, 3. Degeneration of, 3,17. Hypertrophy of, 3,17. Ventral Hernia, 340, 347, 372. Vertebnc, Fractures of the, 246. •,.,„« Vesical Calculi, appearance and consistency or, 292. diagnosis of, 291. etiology of, 291. number of, 293. shape of, 293. symptoms of, 293. Vesical Walls, Suppuration of, 288. Vessels, Atheroma of, 43. Degeneration of (cancerous), 43. (fatty), 5, 43. fibroid. 461. 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. Vomiting, 492. Symptoms of cerebral disease, 505. W. Warts, Venereal, 326. Wounds of the Abdomen, 335. I lllis * *' NLM005545719