mam Presented by P. S. O'Reilly, D. 0. COLLEGE OF OSTEOPATHIC PHYSICIANS AND SURGEONS LOS ANGELES, CALIFORNIA MANUALS FOB STUDENTS OF MEDICINE. CLEMENTS SURGICAL DIAGNOSIS" A. PEAECE GOULD, M.S., M.B. LOND., F.E.C.S. ENO. ; ASSISTANT-SURGEON TO THE MIDDLESEX HOSPITAL, LONDON; SURGEON TO THE LONDON TEMPERANCE HOSPITAL, AND TO THE EOTAI, HOSPITAL FOR DISEASES OF THE CHEST. PHILADELPHIA : HENRY 0. LEA'S SON & CO. 1884. IOIoYH L i PEEFACE. MY chief object in writing this book has been to state, so far as lies in my power, those principles of diagnosis which apply in all cases and under all cir- cumstances. The application of these principles to the diseases and injuries of various regions has been given as fully as possible. I have thought it best to separate the diagnosis of injuries from that of diseases. While aware that this course is not in strict accordance with the ways of Nature, it has yet seemed to possess the advantage of gi'eater simplicity, and I trust that it will not interfere with any usefulness the book might other- wise have. I have great pleasure in acknowledging the able assistance I have received from my friend, Dr. Angel Money, who has kindly revised the proof-sheets, and made many valuable suggestions. In view of the importance and difficulty of the subject, it is with great diffidence that I venture to submit this manual to students and practitioners of surgery. A. PEARCE GOULD. 16, Queen Anne Street, W. CONTENTS. CHAPTER PAGE I. INTRODUCTION . 1 II. GENERAL DIAGNOSIS OF INJURIES OTHER THAN WOUNDS . .26 III. GENERAL DIAGNOSIS OF WOUNDS ... 38 IV. DIAGNOSIS OF THE CONSTITUTIONAL EFFECTS AND COMPLICATIONS OF INJURIES AND OPERATIONS 49 V. DIAGNOSIS OF INJURIES OF THE HEAD . . 75 VI. DIAGNOSIS OF INJURIES OF THE SPINE . . 98 VDT. DIAGNOSIS OF INJURIES OF THE FACE . . ill VIII. DIAGNOSIS OF INJURIES OF THE NECK . . 115 IX. DIAGNOSIS OF FOREIGN BODIES IN THE PHA- RYNX, (ESOPHAGUS, AND AIR PASSAGES . 119 X. DIAGNOSIS OF INJURIES OF THE CHEST . . 124 XL DIAGNOSIS OF INJURIES OF THE ABDOMEN . 146 XII. DIAGNOSIS OF INJURIES OF THE PELVIS . . 163 XIII. DIAGNOSIS OF THE SPECIAL INJURIES OF THE UPPER LIMB 169 XIV. DIAGNOSIS OF THE SPECIAL INJURIES OF THE LOWER LIMB 198 XV.- -GENERAL DIAGNOSIS OF SWELLINGS AND TUMOURS . . 239 XVI. DIAGNOSIS OF GENERAL TUMOURS . . . 279 XVII. DIAGNOSIS OF FLUID OR FLUCTUATING SWEL- LINGS 290 XVIH. DIAGNOSIS OF PULSATING SWELLINGS. . . 296 XIX. DIAGNOSIS OF SWELLINGS IN CONNECTION WITH BONES 308 XX. GENERAL DIAGNOSIS OF ULCERS .... 319 XXL DIAGNOSIS OF SINUS AND FISTULA . . 339 viii SURGICAL DIAGNOSIS. CHAPTER PAGE XXII. DIAGNOSIS OF GANGRENE 341 XXIII. DIAGNOSIS OF DISEASES OF JOINTS AND BURS.*: 353 XXIV. DIAGNOSIS OF DISEASES OF THE HEAD . . 379 XXV. DIAGNOSIS OF DISEASES OF THE JAWS AND GUMS 387 XXVI. DIAGNOSIS OF DISEASES OF THE SPINE . . 393 XXVII. DIAGNOSIS OF DISEASES OF THE LIPS AND FACE 405 XXVIIL DIAGNOSIS OF DISEASES OF THE NOSE . . 110 XXIX. DIAGNOSIS OF DISEASES OF THE MOUTH, TONSILS, FAUCES, AND GULLET . . .417 XXX. DIAGNOSIS OF DISEASES OF THE TONGUE . . i23 XXXL DIAGNOSIS OF DISEASES OF THE XECK . . 430 XXXII. DIAGNOSIS OF DISEASES OF THE BREAST . . 440 XXXHX DIAGNOSIS OF DISEASES OF THE ABDOMINAL WALL ... . . . 454 XXXIV. DIAGNOSIS OF CASES OF INTESTINAL OBSTRUC- TION 456 XXXV. DIAGNOSIS OF ABDOMINAL HERNIA . 463 XXXVL DIAGNOSIS OF THE DISEASES OF THE ANUS AND RECTUM 470 XXXVII. DIAGNOSIS OF DISEASES OF THE PENIS . . 4S9 XXXVHI. DIAGNOSIS OF DISEASES OF THE FEMALE GENITAL ORGANS 499 XXXIX. DIAGNOSIS OF DISEASES OF THE SCROTUM, TESTICLE, AND SPERMATIC CORD . . .501 XL. DIAGNOSIS OF INGUINO-SCROTAL TUMOURS . 519 XII. DIAGNOSIS OF DISEASES OF THE GROIN . . 524 XLH. DIAGNOSIS OF DISEASES OF THE URINARY ORGANS .533 XLin. DIAGNOSIS OF DISEASES OF THE HAND . . 555 XLJV. DIAGNOSIS OF DISEASES OF THE FOOT . 553 SURGICAL DIAGNOSIS. CHAPTER I. INTRODUCTORY. THE art of diagnosis is that by which different things are distinguished from one another. The use of the term " diagnosis " is almost limited to medical literature, and there it is employed in two senses : first, to signify the process whereby we arrive at the distinc- tion between different morbid states ; and, secondly, to signify the result of that process. Hence the "diagnosis " of a case is oftentimes synonymous with the name of the disease or injury from which the patient is suffering. In this book an attempt is made to study the process of diagnosis, and to put the student in possession of knowledge, the application of which to any given case will enable him to determine the nature of the patient's ailment. There is no natural distinction between medicine and surgery, but a separation of medical and surgical affections is so convenient, and is so generally understood and approved, that no excuse for dealing with the subjects of medical and surgical diagnosis in two volumes need be given. It has been thought best to limit the subject of sur- gical diagnosis by excluding reference to surgical affections of the eye, ear, larynx, and the female pelvic viscera, partly because this is in accord with a prevailing custom, and mainly because it would B 13 2 SURGICAL DIAGNOSIS. [Chap. i. require too much space to discuss the various special means of diagnosis, instrumental and other, which have been introduced by those who have devoted themselves to the study of these diseases. My aim is to afford a guide to the diagnosis of those cases of injury and disease which may be met with in the surgical wards and out-patient rooms of our hospitals. If some of my readers are disposed to cavil at the limits I have assigned myself, I would remind them that all sound principles of diagnosis are of general, not merely of local, application, and may be employed with as much confidence in the special surgery of the eye, ear, larynx, and pelvis, as in what is known as the general surgery of the trunk and limbs, and that all that is required in any case, in addition to the principles of diagnosis, is correct anatomical and physio- logical knowledge, aided by acquaintance with the methods of investigation of the particular organs. At the outset I would urge upon the student the importance of grasping the fact that the principles of diagnosis are of more value and importance than any given application of them, and that he should endeavour always to look through and behind the application to the principle itself. In other words, the knowledge of why certain signs or symptoms justify or compel a given diagnosis, is the key to correct diagnosis, and is the essential point for students to grasp. For this reason I shall make but very scant reference to so- called " pathognomonic signs " or " diagnostic tips," which are of value, if at all, only to the experienced, and to the beginner are both sources of danger and the promoters of evil habits of mind. Similarly, tables of comparative diagnosis have been discarded. It is impossible to sketch Nature in parallel columns ; and although such a method may be useful for showing in a graphic manner the resemblances and the differ- ences of allied affections, it is an artificial and, in my chap, i.] INTRODUCTORY. 3 opinion, a false method when applied to the purposes of practical diagnosis. Upon the importance of diagnosis it is only necessary to say a word. Viewed in its wide and true sense, diagnosis is the essential preliminary both of successful treatment and of a just prognosis ; and, although the present want of correla- tion between it and therapeutics forms a strong temptation to carelessness in diagnosis, it is evident that this correlation, so earnestly desired by every true surgeon, is only to be secured by a patient and pains- taking study of the facts of each of these sciences. The fact that a surgeon's treatment is the same for two or more similar affections affords no justification for his failure to distinguish between cases of such affections. The art of diagnosis can be carried to very various degrees of perfection ; it is therefore necessary to re- mind the student that merely to assign a name, even when it is correct, to a disease or injury, may fall far short of a satisfactory diagnosis. It may be admitted that there are certain refine- ments of diagnosis, the practical value of which is not at present appreciated, at any rate by the majority of surgeons, and in reference to which two remarks seem called for : all such " refine- ments," when expressions of truth, are to be valued, and even when their practical bearing upon thera- peutics and prognosis is not apparent, they must be followed out, with confident assurance that their practical benefit will become evident ; but they must be carefully regarded as "refinements" and not as " essentials " in diagnosis, and only those who are masters of the art should draw them, for it is as dis- astrous as it is foolish for mere tyros to attempt " to run before they have learned to walk." One of the most important points to be constantly borne in mind, is the fact that the surgeon has not simply 4 SURGICAL DIAGNOSIS. [Chap. r. a disease or injury to diagnose, but a diseased or in- jured man. There is a great tendency to concentrate the thoughts solely upon some local lesion, and to ignore the individuality of the patient ; and there is the greater tendency to this from the extreme difficulty of esti- mating in many cases the "personal equation" of patients, and from the close attention that must of necessity be given to the features of all local lesions, as well as from the fact that our clinical dis- tinctions and nosological names depend in nearly all cases upon local manifestations of disease. This leads me to observe that a complete diagnosis in most cases includes three elements. There is first the recognition of the anatomical features of local lesions ; then their physiological or pathological character- istics; and, lastly, the constitutional change either leading to or resulting from the local lesion. For example, to take such a simple case as an enlarged gland in the groin. The first step in the diagnosis will be the recognition of the anatomical nature of the swelling present, the fact that it is an enlarged gland and not a hernia, a varix, or a fatty tumour, etc. But this must be complemented by an inquiry into the nature and cause of the enlargement, whether it be inflammatory or neoplastic, whether the result of the absorption of irritating matters from an in- flamed urethra, a chancre, or a sore on the foot, or the result of syphilitic or of cancerous infection, or, again, a part of the local manifestation of erysipelas, or a primary affection of the gland, as in Hodgkin's disease. When the pathological nature of the lesion is known, inquiry must still be prosecuted to ascertain how far the general system is implicated, whether primarily or secondarily, as by fever, exhaustion, anaemia, etc. These three parts of a diagnosis do not require to be separately followed out in all cases, but they are so intimately connected together that the chap, i.] INTRODUCTORY. 5 threefold nature of a complete diagnosis is, for that very reason, in danger of being lost sight of. The general method of diagnosis varies with different surgeons ; some prefer to obtain first a complete history of the case, and then to make their examination of the lesions presented ; while others first make their examination, and then investigate the history of the case. There is much to be said in favour of each plan, and probably each is specially suited to certain forms of disease and injury, and he will be the best diagnostician who knows when and how to employ either as may be most desirable. For beginners, however, the former and more laborious plan is much the best, as otherwise important points will be overlooked ; and it is only safe to practise the more direct method when clinical experience has developed that instinct which enables a surgeon to elicit just those points in the history of a case that have a real bearing upon the diagnosis. The particular methods of diagnosis vary with the general character of the case, and with the locality of the affection. I shall try to indicate these in their proper places, and would here only mention that there are many plans which may be adopted, and possibly with equal advan- tages. The same case is approached in different ways by different minds, and the student must nob look for uniformity among his teachers, nor can the author claim anything more for the methods and schemes advocated in this book than that he has found them to be practical and reliable. Nothing will conduce more to the formation of habits of correctness in diagnosis than the practice of note-taking and of committing to writing the diagnosis of a case and the reasons to be urged in support of it. I would venture to press this point upon the attention of students, and to assure them that any time so spent will yield them a full reward in the 6 SURGICAL DIAGNOSIS. [Chap.i. reatlir.ess, confidence, and accuracy in diagnosis it will produce. But of far greater moment than the method em- ployed is the precision and soundness of the data on which the diagnosis rests, and it is to this that students must first and chiefly direct their attention. Books and didactic instruction can give them but little aid here, and they must rely upon practice and the education of their senses. Care is required in making even the simplest observation, such, for instance, as counting the pulse or measuring the length of a limb. Students from the first should form the habit of taking single precise observations, and not trust to mere repetition for ensuring accuracy. It is only too common to see the manipulation for the detection of fluctuation repeated several times before the observer is sure of the result ; similarly, a patient with a scrotal tumour is made to cough several times, before it is decided whether the act causes any impulse in the swelling or not ; and many other similar examples might be given. All this is bad, and the student from the first should set his face against it, and endeavour as far as possible to obtain a thoroughly trustworthy result from a single observation ; not only does this save time, but it often saves pain to the patient, and, by demanding a concentration of attention, does much to secure the condition most of all necessary to ensure accuracy of observation. It is not intended that where a single observation leaves a doubt upon the observer's mind it is not to be cleared up by a repe- tition of the observation, but only to insist upon the great value and importance of forming the habit of relying upon a single observation, and so of reducing to a minimum the occasions when its repetition is necessary. It is well always to bear in mind that clinical data vary widely in value. Thus, as a rule, positive Chap, i.] INTRODUCTORY. 7 data are of more importance than negative ; for instance, the detection of fluctuation in a swelling is proof of the presence of fluid in it, but the failure to detect fluctuation cannot always be accepted as proof that the swelling is wholly solid ; similarly, the detec- tion of translucency in a scrotal tumour will prove it to be a collection of serous fluid, but its opacity is not an absolute proof that it is not a hydrocele, for there may be some special condition preventing the transmission of rays of light. This applies with even more force to the facts stated by patients or their friends than those observed by the surgeon. The fact that pain has been experienced or complained of, or that swelling, or discoloration, or some functional disturbance such as lameness, or nutritive change such as wasting, has been observed, must be accepted as of distinct and positive value. But the absence of any such history is of very different import, for it may depend not only upon the absence of these conditions, but also upon failure to observe them, upon forget- fulness, or even upon a wilful concealment of the truth. For example, it is not uncommon to find patients suffering from secondary syphilis quite uncon- scious of the existence of the rash or of the sore throat, and, such patients, questioned years after as to the occurrence of such phenomena would of course reply in the negative, and might therefore mislead the surgeon. Still more must such a distinction be drawn be- tween objective and subjective phenomena, between those which can be ascertained by the surgeon himself and those for which he has to rely upon the word of the patient alone. With due care, skill, and some prac- tice, the surgeon should in nearly all cases be able to determine the objective phenomena without doubt or error. Patients are rarely content to state subjective phenomena without either some exaggeration, or, more 8 SURGICAL DIAGNOSIS. [Chap. i. often, an attempt to interpret them. It may be quite im- possible to eliminate the error arising from conscious or unconscious exaggeration, but the surgeon should always be careful so to form his questions as to conceal, so far as may be, his object in asking them, and so as to elicit the simplest statement of facts without any added interpretations ; and in every case he will, of course, reject such interpretation unless his own inde- pendent investigation of the phenomena convinces him that it is correct. Care should be taken also to distinguish between what maybe called "common" and "skilled" evidence, and upon the class of facts which may be accepted on the strength of the one or only on the strength of the other. By this it is not meant that all evidence derived from a patient and his friends is " common," and only that afforded by a medical examination is "skilled." With the degrees of intelligence there are corresponding degrees of value to be attached to lay as well as to medical evidence, and the astute observer will not only be enabled to make the most trustworthy examination himself, but also to put its right value upon the evidence given by the patient, and will be able to distinguish between those statements which he may accept as valid and trustworthy, and those which he must take with the proverbial " grain of salt." To refuse to receive evi- dence on technical points from laymen, would be to make a mistake as great as to accept without question all evidence on technical points from every medical observer. The capacity of the observer to make the particular observation in point must be always con- sidered and estimated. By practice in questioning, it is easy to obtain corroboration or the reverse of state- ments made by patients on technical points, and this should, of course, never be neglected. It is not possible in the space at our disposal to go further into the rules of evidence and other allied chap, i.] INTRODUCTORY. 9 questions. We have, perhaps, stated enough to indi- cate the importance of the subject and the necessity of acquiring proficiency in the art of obtaining the data upon which to found a diagnosis. One other remark may be made here, and it is to urge upon students the importance of appreciating the significance of individual data. There is a danger lest this should be overlooked, and the deplorable habit formed of resting a diagnosis upon a mere com- bination of signs and symptoms rather than upon the anatomical or physiological facts of which they are but the expression. An illustration will perhaps serve to make my meaning clear. Fluctuation is a sign obtained only when there is fluid contained in a cavity of some size, and it indicates little or nothing as to the character of the fluid ; and yet it is not infrequent to find beginners resting their diagnosis of abscess solely upon this one sign. The observer must look behind and beyond any symptom or sign to its explanation, meaning, or cause, and diagnosis must rest not upon symptoms, but upon the con- ditions of which they are the expression. This may seem a trite remark, but experience in the out- patient rooms and wards, not to mention examination halls, soon shows that, like many other trite obser- vations, it needs to be enforced. Diagnosis rests first upon accurate observation and then upon a correct ap- preciation of the true significance of clinical data.' Before passing on to consider the diagnosis of indi- vidual affections, it will be well to speak in somewhat fuller detail of the various chief classes of clinical data on which we have to rely. These may be spoken of under the heads of. family history, personal history, history of the cause or first onset of the affection, its course or progress, the "present state " of the patient when first seen, and the subsequent progress of events, including the effects of treatment. io SURGICAL DIAGNOSIS. [Chap. i. Family history. The influence of heredity upon pathological processes is both varied and occult. While in some instances we seem justified in assigning very great importance to it, in others its influence is wholly unrecognised, and between these two extremes we meet with all possible degrees of difference. It is, therefore, not a matter upon which it is possible to dogmatise or to write in a categorical manner, and it must suffice to indicate those constitutional states in the parents which are justly believed to influence disease or injuries in their offspring. Of these by far the most important is Syphilis. It admits of no doubt that the syphilitic taint may be inherited, but it is no less certain that all the children of syphilitic parents are not themselves the subjects of syphilis, and all degrees of intensity of the inherited taint are met with and can be recognised in practice. To ascertain that a patient is the subject of inherited syphilis 'is of the utmost importance ; for not only may it at once determine the diagnosis, but it will exert a distinct influence upon the treatment, and in very many instances form the sole guide to the ma- nagement of the case. The manifestations of acquired syphilis vary so much in kind and in intensity that it is quite impossible to state positively what does and what does not constitute a history of syphilis in the parents of an individual, and experience will alone enable the surgeon to determine upon what evidence such a conclusion may be allowed to rest. But this may be mentioned, that one objective sign of the disease observed by the surgeon is of more value than much unsupported evidence of the patient or his friends. As already mentioned, the discovery that a patient's parents were the subjects of constitutional syphilis before his birth does not of itself warrant the conclusion that he has himself inherited the dia- thesis, and in all such cases the supposition must be Chap. L] FAMILY HISTORY. n corroborated by evidence derived from the history or condition of the patient before it can be ac- cepted. It has been clearly proved that the syphi- litic taint is most often and most intensely inherited soon after it has been acquired by the parents, and that with successive pregnancies the chance of inheri- tance and the intensity of the inherited taint diminish. It is, therefore, of importance to get evidence upon this point, and to learn, if possible, not only whether the parents were the subjects of syphilis, but also when, in reference to the birth of the patient in ques- tion, they acquired the taint, and whether the syphi- litic dyscrasia was manifested in the products of the conceptions immediately preceding and following that in point. What is known as Colics' law, that the mother of a syphilitic infant is always herself the sub- iect of syphilis, leads us to rely more upon evidence of syphilis in the mother than in the father. In investi- gating a family history for inherited syphilis, two errors may be made : the infection may be assumed on insuffi- cient evidence, or we may fail to obtain the evidence of the taint which really exists. When it is remem- bered how mild some attacks of syphilis are, oftentimes how little there is to attract the patient's attention to his condition and to fix it in his memory, as well as how unobservant many patients are, it is not to be wondered at that years afterwards we fail to elicit an account of troubles long ago forgotten if ever noticed at all. Many of the characteristic effects of constitu- tional syphilis are simulated by other conditions. For example, a series of abortions is caused by local affections of the generative organs perhaps as often as by syphilis ; repeated attacks of sore throat, and " ulcerated " sore throat, are as often simple follicular tonsillitis as specific pharyngitis ; while it need hardly be pointed out that sores on the genital organs leaving behind depressed scars, are so often not syphilitic in 12 SURGICAL DIAGNOSIS. [Chap. i. nature, or at least not Hunterian or infecting chancres, that no weight whatever is to be given to the history or objective evidence of such sores unless supported by other facts. In some cases even one fact will render the existence of syphilis in the parents beyond all doubt, such, for instance, as the discovery of a per- foration of the palate; but in the majority of cases the most satisfactory evidence will consist of a series of facts in which the recognised course and progress of the malady can be traced : a single sore followed by multiple painless buboes, a papular rash over the trunk, sore throat, and perhaps mucous patches, and then, later on, sore tongue, periostea! pains and swellings and ulcerations, miscarriages, and other well-known syphilitic phenomena. The result of an examination may be given under one of four heads. Thus, in many instances we may be able to state positively, (1) that the patient's parents were the subjects of active constitutional syphilis at the time of his conception and birth; or (2) that the patient's parents were certainly not the subjects of active constitutional syphilis at the time of his concep- tion and birth ; but in many other cases, the evidence obtained will only warrant the statement (3) that the evidence is not sufficient to show that the patient inherited syphilis from his parents ; or (4) that the evidence is not sufficient to show that he did not inherit syphilis. Struma is another disease which is undoubtedly hereditary, although often acquired. Evidence of the existence of struma in a family is usually readily obtained from its characteristic effects. Phthisis, diseases of bones and joints, lupus, and lymphatic glandular enlargements, are too obvious, too chronic, and too serious in their results, to be overlooked or forgotten. A family history of Gout is not so easily obtained among the humbler as among the upper chap, i.] PERSONAL HISTORY. 13 classes of society, where the distinction between it and rheumatism is carefully drawn. Repeated attacks of inflammation in the joint of the great toe is the sign that we have chiefly to rely upon. One of the hereditary affections most interesting and important to the surgeon is Haemophilia, and where this exists in the family, evidence of it is usually readily obtained, as the repeated and often fatal haemorrhages are facts which strongly impress the laity. It must be remembered that inquiry is to be mainly directed to the male members of the family, as it chiefly affects them, although it is trans- mitted through the females. Cancer. The heredity of cancer, including un- der that head all malignant tumours, is of much less importance than was at one time supposed. Oc- casionally we meet with striking examples of it, as in the family of a patient recently under my care for scirrhus of the breast (the patient had lost her mother, two maternal aunts, and at least two cousins on the mother's side, from cancer) ; or the well-known " Middlesex Hospital case," in which a woman and five of her daughters had cancer of the left breast. The absence of all hereditary influence is very frequently observed, and this factor will scarcely influence in any way the diagnosis of the nature of a tumour. Personal history* By this is meant the history of the patient previous to the occurrence of the affec- tion presented for diagnosis. This is of importance in two ways, either as indicating the existence of some dyscrasia or constitutional taint, or as revealing some habit, practice, or occupation, rendering the patient liable to particular accidents or forms of disease. When the family history shows the existence of some heritable affection in the parents or brothers and sisters, inquiry should at once be made to ascertain 14 SURGICAL DIAGNOSIS. [Chap. i. whether there is positive evidence of this clyscrasia having been transmitted to the patient. As already mentioned, when a history of syphilis has been made out in the parents, that alone is not a proof that the children are syphilitic, and evidence of the existence of this taint must be sought in the patients themselves. This holds true to some extent also in the case of the other heritable diseases we have mentioned, but there will be nothing to indicate the existence of the can- cerous or gouty dyscrasia until the occurrence of a tumour or an attack of inflammation in the great toe, and this may be postponed for many years ; but the other dyscrasise (syphilis, struma, and haemophilia) manifest themselves much earlier. In reference to habits and occupations, mention may be made of kneeling, mining, working with phosphorus, mercury, or lead, the handling of hides or horses, alcoholism, exposure to wet and cold, occupations involving con- stant standing or contact with soot. History of the affection. This must be made out with great care and precision, and all dates accu- rately fixed, and stated in the days of the month (not of the week) when committed to writing. The earliest symptom noticed should be first recorded, and then inquiry should be made with a view of tracing out its cause, whether an injury of any kind (blow, fall, strain), over use, exposure to changes of tempe- rature or to contagion of any kind, or the ingestion of food or medicine. The student must not accept the patient's view of the cause of his affection unless it commends itself to his own knowledge and judgment. Having obtained an account of the supposed origin of the affection, note carefully its exact course, and the order, mode, and time of development of any changes in it, together with the effects of any plan of treatment that may have been adopted. The bearing that these facts has upon dap. i.] HISTORY OF THE AFFECTION. 15 diagnosis varies much in different cases, and will have to be discussed in succeeding chapters ; but we may here make a few brief general remarks upon the subject. And first, as of most moment, comes the influence of injury of every kind ; this is most apparent in a large class of cases such as wounds, fractures, sprains, etc., which will be dealt with apart from so-called " diseases " in the earlier chapters of the book. But there are cases in which the influence of traumatism is less certain : first, because we do not know how far slight injuries may act as exciting causes of the growth of tumours or of some other diseases; and next, because such an injury may be merely the means of attracting the patient's attention to a pre-existing morbid state. For instance, a blow is often alleged to be the exciting cause of a tumour of the breast, when it may merely have led a patient to make an examination of the part and detect a lump, which, not being painful or protuberant, had previously escaped observation. The only way of avoiding this error is to ascertain as accurately as possible the succession of events and the relation as to time of the injury and any signs or symptoms of disease. The mode of progress of the disease may be an important factor in diagnosis ; for while pjiy disease may steadily advance, only certain foruis are capable of spontaneous reces- sion, or of an intermittent or remittent course. It is a marked characteristic of all forms of malignant growths that they continuously and generally rapidly increase ; and while simple tumours may run a similar course, yet they not unfrequently remain stationary for an indefinite period, or recede. The mere duration of an affection may in the same way exclude some forms of disease, as, for instance, malignant growths and acute inflammation. The sequence of symptoms is sometimes of importance, as, for example, where renal colic is followed by signs of vesical calculus, or where 1 6 SURGICAL DIAGNOSIS. [Chap. i. the apparent reduction of a hernia is attended with no relief to, but rather an increase in, the severity of the signs of strangulation of the bowel. The rela- tive intensity of various symptoms may aid in the diagnosis ; thus, the absence of pain may exclude acute inflammation, or the frequency and amount of vesical haemorrhage may clearly connect any other urinary symptoms with the presence of a tumour in that viscus. Lastly, the relation of any constitutional state, such as ansemia, wasting, jaundice, or other cachexia, may indicate whether it is the cause or tho result of some local morbid state. The examination of the patient will now follow, and should in all cases be as complete and careful as possible, no point being omitted because of its apparent want of bearing upon the case ; for it must always be remembered that we have to deal with patients, with men and women, not with diseases : we must not, therefore, limit our attention to some merely local lesion, or even some constitutional change, but must try to view each patient as a dis- ordered man. The interest and practical importance of local lesions or of general diseases is so great, that there is a grave danger lest in our view of the disease we lose sight of the subject of it. The re- sults of our examination of the patient are, of course, the most important for purposes of diagnosis ; for the evidence so obtained may be mostly, if not wholly, objective, and will also be entirely skilled evidence. To show how the data thus obtained, combined with others, enable us to diagnose various morbid states is the chief burden of the following chapters. What has been said as to the progress of the case as stated by the patient himself in relating its history, applies equally to the changes, or lack of change, observed by the surgeon himself. In refer- ence to the results of treatment, special significance is Chap, i.] EXAMINATION OF PATIENT, 17 to be attached to the influence of what are known as " specifics," such for example as mercury, iodide of potassium, and quinine ; but scarcely less important are the results of general tonic treatment, or of rest, counter irritation, and of surgical operations. It remains but to add a few words upon the general method of examination. First of all it should be systematic and purposive; the investigation of symptoms should be conducted in some regular order, and each question, each manipulation, each part of the examination, should have some definite object or objects in view. To conduct an ex- amination in this way not only promotes accuracy of diagnosis, but it tends also to facilitate and expedite it, because it necessitates the surgeon using his mind and his senses together. Its value is often conspicuously seen in the way two men will examine a tumour, one of whom in a few brief moments will have learnt all its characters, while the other, after a more prolonged examination, will have ascertained little or nothing about it, and will be unable to speak definitely and with assurance as to its nature ; and this may not be so much from want of absolute know- ledge, as from ineptitude and the want of a definite aim and purpose in his examination. Similarly, pre- cision in result must be attained whenever possible ; there are many cases where it is unattainable, but it is safe to say that this should neither be taken for granted, nor admitted until an attempt has been made to eliminate all elements of doubt and inaccuracy ; whenever the results of examination can be stated in numbers, this should be done, as in the case of the temperature, pulse, respiration, measurements of all kinds, number of fits, frequency of micturition, etc. As far as possible, objective and subjective phenomena should be separately investigated, and the latter must be carefully analysed. Patients will freqiiently C 13 1 8 SURGICAL DIAGNOSIS. [Chap. i. describe their sufferings or their sensations by inac- curate language, and the surgeon must seek by careful questioning to obtain objective evidence of subjective phenomena. For instance, a patient's state- ment that he cannot swallow must not be accepted until his attempt and failure to do it have been seen ; in this, as in many other like cases, pain in an act is often spoken of by the sufferer as inability to perform it. Lastly, as already mentioned, the examination must be complete, and include the entire patient, with all his functions. It is only too true, that from various reasons this latter point is often neglected ; the omis- sion may be condoned, but never justified, and while it often results in serious error, it is never without some risk. Certain symptoms we shall have to speak of so often, and are so important, that they merit and must receive separate consideration. Of these, swelling, ulceration, and gangrene, will be dealt with in sub- sequent and separate chapters ; redness and pain may be discussed here. Redness. The first point to be settled in regard to redness of a surface is the cause of the discolora- tion, whether it is dependent upon excess of blood in the vessels of the part (hypenemia) or upon extravasa- tion of blood from the vessels. This is easily as- certained by noticing the effects of gentle pressure upon the part ; when the condition is one of hyper- semia, such pressure displaces the blood in the vessels and causes a momentary blanching, while it has no effect whatever upon petechise or larger blood extra- vasations. By observing also the rapidity with which the blanching produced by pressure passes off and the blood returns into the emptied vessels, an estimate of the freedom and rapidity of the local circulation can be formed. In acute inflammation, for example, the redness generally entirely disappears on pressure, but Chap, i.] REDNESS. 19 quickly returns when the pressure is removed. In the congestion of a part approaching gangrene the redness may still be made to disappear on pressure, and then only slowly reappears. The eruption of purpura or the discoloration of a bruise, is entirely unaffected by pressure. Cases may of course occur where the red- ness of a surface is merely the result of the applica- tion, of a dye, such as magenta, either accidental from the contact of dyed stockings or other clothing, or in- tentional on the part of malingerers. In the one case its position and extent will suffice to prevent error, while in both cases alike the peculiar colour, unlike that due to hyperaemia or hemorrhage, its superficial character, the fact that it is at the same time bright, intense, diffused, uniform, and yet unaffected by pres- sure, together with the absence of local heat or swel- ling or other signs usually attendant upon such marked hyperaemia, and the results of a diligent application of soap and water, will reveal the true nature of the case. This is the most important of all the particulars to be noticed in reference to redness. Next in importance in the cases of hyperaemia comes the colour of the redness, which depends upon the state of oxyge- nation of the blood in the vessels ; a purple or livid colour may depend upon a general de-arterialisation of the blood from structural or functional derangements of the heart or lungs ; upon local conditions, the hyperaemia being mainly or entirely venous, or the circulation in the part retarded, and the regular inter- change of gases greatly increased in amount. Very important deductions, therefore, can be made from the colour of a hypersemic surface ; its lividity may prove a measure of general systemic failure reacting upon the heart and lungs ; while in other cases similar lividity may indicate local obstruction to the return of blood from the part. The difference between this local lividity from obstruction and that from venous 20 SURGICAL DIAGNOSIS. [Chap. i. hypersemia without obstruction, such as is seen in the final stages of inflammation, in venous nsevus, and in some other cases, is that the effect of pressure is slowly recovered from in the former case, and very rapidly in the latter ; and in the latter case, too, the individual dilated veins are oftentimes to be seen. Closely con- nected with this is the temperature of the part ; where hyperaamia is combined with increased heat it indi- cates that there is a rapid circulation, and a rapid renewal of the blood in the part ; where, on the other hand, a hypersemic part is cold, it shows that the cir- culation is torpid, and that the blood travels so slowly through the superficial vessels that it loses a consider- able amount of its heat. The intensity of the redness and the extent of tissue affected are points easily ob- served, and the significance of them is quite obvious. It should also be noticed whether the redness is as- sociated with swelling, and an attempt be made to gain an estimate of their dependence one upon the other. Marked hypersemia may be quite unattended with appreciable swelling (a familiar example of this is afforded by blushing) ; it may be attended by slight swelling, as in cutaneous erysipelas; or associated with intense swelling, as in phlegmonous erysipelas or in cedematous intertrigo. Where redness is one of the phenomena of inflammation, swelling will always be found with it, it may, however, be so little marked as not to be noticeable as enlargement of the part so much as a certain increase in its tension, or a hardness of the tissue. It may be well to point out here what are the various associations of redness and swelling. (1) They may be joint phenomena of the process of in- flammation; (2) hypersemia, especially when passive or obstructive, leads to cedema or transudation of the liquor sanguinis; (3) by the growth of tumours the deep veins may be pressed upon, and the stress of the circu- lation thrown upon the superficial vessels may then chap, i.] PAIN. 21 cause hyperaemia, or the tissues around a tumour may participate in its extreme vascular engorgement ; (4) greatly swelled parts may become hypersemic, or even inflamed, as the result of friction or the preven- tion of cleanliness, or of the proper evaporation of irritating cutaneous secretions ; the patches of inter- trigo in connection with large pendulous tumours, scrotal hernias, or the oedema of Bright's disease, afford illustrations of this. Finally, the association of alteration of sensation with hyperaemia is to be noted. Inflammatory hyper- semia, indeed all active hypersemia, is always attended with pain and increased sensitiveness. When, on the other hand, there is a combination of numbness, or loss of the normal acuteriess of sensation, with hyper- semia, it indicates a failure of the local processes of nutrition, unless indeed the two phenomena own one common cause in some affection of the central nervous system, which will be shown by other signs, and espe- cially by motor paralysis. Pain is a symptom which more often than any other is presented to the surgeon, and the importance of which, from a diagnostic point of view, cannot be overrated. For a full and worthy consideration of the diagnostic value of pain, the reader is referred to Mr. Hilton's classic lectures on "Rest and Pain;" our space will only allow us to notice some of the principal features which should be noted in the investigation of pain. The first of these is its exact seat ; this is of value in two ways ; in the majority of cases it directs attention to the affected parts, and by localising the pain we are able to localise the disease; in other cases the pain is found to correspond to the distribution of a particular branch or trunk of nerve, and when this is the case it should lead us to look for the cause of the pain, not in the area of peripheral distribution of the nerve, but in some affection of the trunk or root of the 22 SURGICAL DIAGNOSIS. [Chap. i. nerve. The reason of this is that purely local (that is, peripheral) causes of pain are not limited by the dis- tribution of particular nerves; while causes of pain act- ing upon nerve trunks or their roots are referred to the exact peripheral distribution of the nerves affected. But it must also be remembered that an irritation acting upon one branch of a nerve may be referred as a pain to the terminal offsets of the nerve, and the pain ex- perienced in the knee in many cases of disease of the hip-joint is a "well-known example of this fact Hence, where the area of a pain does not correspond to the exact distribution of any given nerve or nerves, a local cause for it may be sought; but when, on the contrary, the painful area is sharply limited to parts supplied with sensation by a particular nerve or nerves, some cause acting upon this nerve trunk or its root, whether inflammatory, compressive, destructive, or reflex, must be sought. Much light is afforded by noticing whether hyper- cesthesia is associated with pain, and if so how this hypereesthesia is elicited. For example, the absence of all tenderness to pressure or movement in a painful part is strong evidence that the source of the pain is not local, but central or referred ; for instance, when pain is complained of in the knee, and the part is found free from all tenderness to pressure or movement, there will be no doubt that the source of the pain is not in that joint, and probably it will be discovered in the hip-joint. Other illustrations are afforded by the pain felt in the foot in cases of aneurism pressing upon the internal popliteal nerve, or the pain in the testicle in cases of renal calculus. The surgeon must make this examination with caution, because the association of pain and tenderness is so frequent, and probably in the patient's experience so constant, that he will thoroughly expect pressure or movement to give pain, and he may be so much on the alert to detect its first Chap. I.J PAW. 23 onset, that he may unconsciously deceive the examiner; his suspicions and his alarms must be allayed. The converse of the above statement does not hold good, for tenderness may be elicited where the cause is central or referred, as, for instance, in some cases of neuralgia, and in some cases of pain in the knee from disease of the hip ; but most markedly of all is this met with in hysteria. The manner in which the hy- peraesthesia is elicited greatly aids in diagnosis ; if, for instance, the lightest contact causes pain it indicates affection of the cutaneous nerves ; if the skin can be handled freely, perhaps pinched up without causing pain, while pressure upon the deeper parts (muscles or bones) excites pain, it shows in the same way that these deeper structures are affected ; this mode of diagnosis is constantly employed in the recognition of intercostal myalgia, and there are many similar in- stances. Where the hypersesthesia of the subcuta- neous tissues is very intense, and they lie superficially, as, for instance, in the case of periostitis over the inner surface of the tibia, the gentlest pressure upon the skin is at once transmitted to the inflamed peri- osteum, and causes pain, and great care must be used in applying this test. Very similar information is afforded by observing the effect of movement upon pain. The stretching or compression of any inflamed part, or the contraction of an inflamed muscle, is painful. Hence, if it is found that a certain active movement, e.g. abduction of the arm, is painful, but that the arm can be put into the same position by the surgeon without causing any pain provided the patient's abductor muscles are all kept relaxed, it will show that it is really the contraction of these par- ticular muscles, and not this position of the limb, that is painful ; the precise seat of the pain will thus have been determined. The same test may be applied in a similar manner to other muscles. 24 SURGICAL DIAGNOSIS. [chap, i, But it will further be found in these cases that placing the parts in such a position that the affected muscles are stretched will also elicit pain ; for instance, in a case of myalgia of the deltoid muscle, active abduction of the arm will give acute pain, passive abduction will be painless, and extreme adduction, whether active or passive, will be painful. Ligamentous pain is elicited by any movement, whether active or passive, that stretches the ligament. Hence by the careful and intelligent use of this sign we are able to distinguish between muscular and ligamentous pain. Take such a case as is presented in " stiff-neck," and we will sup- pose that the patient has pain on turning his face to his left shoulder, the pain being limited to the right side of the back of the neck ; if we find that the surgeon can turn the patient's head to the left without causing pain, but that when he moves the face far to the right he elicits sharp pain, the pain evidently is muscular ; but if the pain is just the same whether the face be turned actively or passively to the left, while no pain is produced on turning the face to the right, the pain is evidently situated in those ligaments which are stretched when the face is turned to the left, and not in the muscles. There is a considerable range of movement in all joints in which no ligament is placed on the stretch, but during which the articular sur- faces are in contact, and passing over each other with more or less pressure ; hence, if such range of move- ment be painless it is a good indication that the arti- culation itself is not the seat of the painful lesion ; while, on the other hand, if passive movement to any extent, and in every direction, is painful, it clearly shows that the interior of the articulation is affected. Quite similar principles find a somewhat different application in special situations, as, for example, in the bladder, where the pain in vesical calculus is specially caused by the. contraction of the bladder on the stone, and chap, i.] PAIN. 25 is relieved by the passage of some urine into the bladder to re-distend the viscus off the surface of the stone. In acute cystitis, on the other hand, the chief pain is produced by the contact of the urine with the inflamed mucous surface, and by the contraction of the inflamed muscular tissue, and it is relieved imme- diately after the act, to be again exaggerated as the urine accumulates. The knowledge of the way in which the pain is spontaneously produced or increased has for its object the same purpose. By the character of the pain something may at times be learnt ; the itching, burning, smarting pain of cutaneous and mu- cous inflammations, the deep boring and aching pain of bone inflammations, the shooting, lancinating pains of " neuralgic " origin, or of those due to central lesions, and to pressure upon and partial destruction or in- flammation of nerve trunks, and the " lightning-like " pains of locomotor ataxy, are all illustrations of this fact. Parsesthesia or anaesthesia with pain is most frequently due to central nervous lesions, but may be purely of local origin, as in the case of commencing gangrene. When there is a history of severe or of long- continued pain, it should be carefully observed whether there is any evidence of the constitutional influence of the pain. Pain exerts a depressing influence upon the central nervous system, and when intense or very pro- longed its ravages are always visible. If, therefore, the account of the pain given by the patient corresponds with the fades, it receives important corroboration. If, on the other hand, there be no correspondence between the two, if with cheerful face and healthy countenance a patient describe himself as in great suffering, or as having recently suffered severely, and for a long time, it will convince the surgeon that the statement is exaggerated, or that the pain is purely functional hysteria, not that it need be any the less real. Such a fact may render important aid in 26 SURGICAL DIAGNOSIS. [Chap. n. diagnosing hysterical pains, and may then usually bo corroborated by finding that when the patient's atten- tion is engaged elsewhere he permits of pressure, mani- pulations, and movements, which when his attention is directed to the part he would have described as " dis- tracting," or " intense," or " unbearable," or by some similar term. This correspondence of all the facts about a given pain is a point which may enable the surgeon to give an opinion even in otherwise very difficult cases. CHAPTER II. THE GENERAL DIAGNOSIS OP INJURIES OTHER THAN WOUNDS. IT is important to remember that more than one lesion may be produced by a single injury or accident, and that it is the duty of the surgeon not only to determine that a certain lesion, e.g. a fracture, has been produced, but also to exclude every other, e.g. a ruptured artery, severe sprain, and so on. Errors, sometimes of grave consequence, are made by failing to make a complete diagnosis. In con- ducting an investigation for this purpose it is best to examine each structure separately and in suc- cession, beginning with the skin and subcutaneous tissue. 1. Examine the skin and subcutaneous tissue, noticing especially discoloration and swelling. (a) If the skin be discoloured dark-red or reddish purple, and the colour be unaffected by pressure, there has been an escape of blood from several small vessels, a bruise. This effused blood goes through the well- known colour changes, and if seen late may cause Chap. II.] IfMAfATOMA. 2J merely a yellow stain. If the dark-red discoloration appear at some interval after an injury it points to a deep bruise, the blood escaping from deep vessels gradually reaching and staining the superficial tissues ; this phenomenon is sometimes witnessed in fractures of the neck of the femur. (5) If immediately or very rapidly after an in- jury a distinct fluctuating swelling be formed in the skin and subcutaneous tissue, and if the circulation in the part be not interfered with, the blood has escaped from torn vessels in such a manner as to form a blood tumour or Jwematoma. Two forms of hsematornata are met with, the circumscribed and the diffuse. In the former the swelling is circumscribed and tense; in the latter the swelling is much less tense and involves a larger area, and is due to the detachment of the skin from the deep fascia with effusion of blood between them ; in such a case the blood can be pressed from one part of the injured region to another. Thus, the author treated a case in which the whole scalp was separated from the pericranium without any wound ; blood was effused between these structures, and when the man lay on his back it all collected in a soft loose swelling at the back, but could be easily pressed forwards on to the forehead, or laterally as far as the attachment of the scalp. Haematoma is generally combined with a certain amount of superficial bruising. The collection of blood may long remain fluid, or it may coagulate, and the presence or absence of fluc- tuation will determine this point; occasionally such a swelling suppurates, or, more strictly, the tissues around it become inflamed and suppurate. This has to be distinguished from simple inflammatory oedema following the tissue laceration, and is recognised () by increased and progressive swelling; (#) by sur- rounding oedema; (7) by great heat and redness of the part ; (5) by severe pain of a throbbing character; 28 SURGICAL DIAGNOSIS. [Chap. u. () by pyrexia of a suppurative form, the temperature curve rising and falling daily ; sometimes there are chills or even a rigor, and sweating. (c) The presence over a bruised part of superficial blebs containing serum, which is usually stained deep red or brown in colour, is an important sign of frac- ture of a subjacent bone. These blebs are often ex- tensive, and to the uninitiated have a threatening look ; they do not really add materially to the gravity of a case. They must be distinguished from the blebs caused by burns, in which the clear serum quickly coagulates, and from those of gangrene, which are accompanied by other signs of tissue- death. 2. Next examine the bone or bones of the injured part. This should be done systematically and carefully. First compare it with the uninjured part, and look if there is any obvious deformity ; if there is, ascertain that the two limbs or parts were symmetrical before the injury. Next measure the length of the two opposite bones, being careful to take exactly the same points on the two sides, and to place the uninjured limb in the position assumed by the injured one. It has been shown that perfect symmetry in the limbs is not so general as was formerly believed ; and useful as is the detection of a difference in length between the two limbs, this sign alone must not be taken to prove the existence of a fracture or dislocation. Then run the fingers along the most superficial surface of the bone on the two sides (a) to compare the outline of the bones, and (b) to observe whether there be any very tender point in the injured bone ; a fracture may cause so much displacement that the break in the line of the bone as compared with the sound side is at once apparent, as in the case of the common fracture of the clavicle ; on the other hand, there may be no chap, ii.] INJURIES OF BONE. 29 displacement at all. The line of a fracture is generally the seat of pain and acute tenderness, and the detec- tion of a spot in a bone that is acutely sensitive is strong presumptive evidence of a fracture in that situation, but it may be due to a bruise of the periosteum. Lastly, examine for mobility in the length of the bone ; in so doing grasp the limb firmly with one hand close above, and with the other close below the supposed seat of the lesion, and first very gently attempt to move one hand independently of the other ; if any movement or crepitus is detected, it is enough, but if not, then more force may gradually be used, and the whole length of the bone explored, until it is ascertained that no part of it is movable on the rest. In different cases reliance is chiefly placed upon one or other of these signs of fracture, as will be pointed out in the diagnosis of individual fractures. THE INJURIES OF BONE ABE : Bruise. Fissured fracture Incomplete fracture Impacted fracture Complete fracture Separation of epiphysis. / simple 1 compound j comminuted \ multiple. If there be severe pain and marked local tender- ness in a part of a bone that has received a direct injury, and if there be no alteration in the axis of the bone, no irregularity in the outline of the bone, no shortening, no mobility in its length, no cre- pitus, it is a bruise of the periosteum and bone, or a fissured fracture. The distinction between these conditions is a matter of great difficulty ; but the more diffused and dull the pain the greater the pro- bability of its being only a bruise ; the more severe, and the more precisely localised the pain and tender- ness, and the longer these severe symptoms last, the 30 SURGICAL DIAGNOSIS. [Chap. n. greater the probability of its being a fissure of bone. (See also page 228.) If in a child, after an injury a bone be found bent and the direct distance between its two ends shortened, but there be no mobility at the bend, and no crepitiis, it is an incomplete fracture, or greenstick fracture. This is most common in the forearm and the clavicle, but is seen in other long bones ; it must be distin- guished from a rickety curve in the bone, which is chronic, gradually produced, and symmetrical. Rickets and incomplete fractures may be associated together. When, as the immediate result of direct violence to a bone, there is found to be some alteration in its contour and length, but no mobility at the seat of the supposed fracture and no crepitus, it is an im- pacted fracture. It is distinguished from incom- plete fracture by the age of the patient and the deformity (when this can be clearly made out) not being a round curve in the bone. The lower end of the radius and the upper end of the femur are the most frequent seats of impacted fracture, and the means of exactly distinguishing these injuries are detailed elsewhere. Where there is found mobility in the length of a bone, a complete fracture has been sustained ; the examination of such a case also shows some or all of the following signs : alteration in length, if there be overriding or separation of the fragments ; alteration of the contour of the bone at the seat of fracture, if there be any displacement of the fragments ; rough crepitus on movement, if these fragments are in contact ; localised pain and tenderness at the seat of fracture, at once greatly increased by any movement of the fragments ; and swelling. As bones are very vascular structures, their fracture is followed by a good deal of haemorrhage, and in a few hours this is suc- ceeded by a free serous exudation. These facts explain chap, ii.] FRACTURES. 31 the occurrence of the blebs mentioned above. In many cases the patient hears the sharp snap of the breaking bone at the time of the injury. If there is no wound of the soft parts associated with the fracture, or if there is a wound which does not lead down to the fracture, it is a simple fracture ; but if, on the other hand, there is a wound leading down to the fracture, whether it be through the skin or mucous membrane, it is a com- pound fracture. (See Wound of bone, page 43.) The direction of the fracture may be recognised by the deformity present, and by noticing the plane in which mobility is obtained. If mobility is obtained with great ease, and is accompanied with marked and readily- elicited crepitus, suspect a comminuted fracture ; and if manipulation shows that the bone is broken into more than two fragments (if, for instance, other frag- ments are felt separate from and movable upon the two main ones), this suspicion is converted into a certainty. If, however, the fragments are broken off by distinct fractures, it is called a double frac- ture ; this accident is rare except at the lower end of the femur and humerus. Comminution is gene- rally easily detected in compound fractures when the fragments can be felt, but is often overlooked in simple fractures, especially when small splinters or fragments are detached from the deep aspect of the bones. When a sharp-pointed fragment, not including the whole thickness of a bone, is detached, it is spoken of as a splintered fracture. If a fracture occur in the position and direction of the junction of an epiphysis with a diaphysis, in a person under twenty years of age, and if the crepitus be softer and less distinct than in a common fracture, and the projecting points of the fragments be smooth and rounded, or at least less sharp and angular than in or- dinary fractures, it is a diastasis or separation of an epiphysis. This is most commonly seen at the lower 32 SURGICAL DIAGNOSIS. [Chap. n. end of the radius and femur, and the upper or lower end of the humerus. It is a grave injury, as it is liable to arrest permanently the growth of the bone. 3. Tlii-ii examine carefully into the con- dition of tbe joint or joints. This examination should be systematic, and should determine (a) whether there is any displacement of the articular ends of one or other bone, and if so, to what extent; (6) whether there is any fracture of either bone at the joint ; (c) whether there is any laceration of ligaments, or (d) effusion into the joint. (a) Compare carefully the same joints of the two sides of the body and determine whether the articula- ting bones retain their normal relative position ; any modification of this is a dislocation, which may be complete or incomplete. The two signs of dislocation which are unmistakable are the absence of an articu- lar end of bone from its normal situation, and its presence in an abnormal position ; and the student must not forget that the diagnosis should be made to rest upon these phenomena, and not upon mere altera- tions in contour and measurement, which, although depending directly upon the displacement, may yet be simulated by other conditions. For example, finding the glenoid cavity empty, and the head of the humerus resting on the ribs just below the coracoid process, are absolute signs of a subcoracoid dislocation of the shoulder, and are of more value than a number of such observations as " flattening of the shoulder," " alteration of the axis of the arm," certain limitations of movement, and so on. These indirect evidences of dislocation are by no means unimportant, and it is not intended to disparage them, but, in view of the number of the indirect signs given by some authors, and the stress laid upon them, it is necessary to insist upon the primary importance and value of the two great essential signs of dislocation. For purposes of chap, ii.] FRACTURES INTO JOINTS. 33 diagnosis, what I have called the " essential " signs of dislocation are alone sufficient, and it is only where, from special conditions, they cannot be clearly and directly elicited, that their indirect evidences have to be relied upon. (b) The mode of investigating, and the signs of a fracture of the articular ends of bones, are those which have been already given in the previous section, and it is only necessary to add the special and characteristic features of fractures into joints, by which they may be distinguished from fractures near joints; these are (a) the position of the fracture, e.g. all complete transverse fractures of the patella must be into the knee joint ; (#) the size and shape of the detached fragment: by this we can determine whether there is an extra-arti- cular fracture of the internal condyle of the humerus, or whether the trochlear surf ace is broken off; or simi- larly, finding that an entire condyle is movable on the rest of the femur demonstrates a fracture into the knee joint ; (7) effusion of blood into the neighbouring joint, recognised by the position and shape of the swelling, and by its appearance quickly after the injury : this sign is somewhat equivocal, as the extra-articular swelling may conceal that within the joint, and the joint may be swelled independently of the fracture ex- tending into it ; (5) subsequently, inflammation of the joint ; (e) the nature of the fracture; some fractures are frequently complicated with fissures reaching into the adjacent joint, as e.g. those of the lower end of the humerus ; and in wounds of bones from conical bullets extensive fissuring frequently occurs ; ( ) in compound fracture synovia may be seen to escape from the wound. (c) If, after a sudden wrench or strain to a joint, it becomes swelled and painful, and movement is limited and very painful, while examination shows that there is neither fracture nor dislocation of the bones, nor D 13 34 SURGICAL DIAGNOSIS. [Chap. n. rupture, nor displacement of muscles and tendons, it is a sprain of the joint. These sprains vary much in their intensity. If there be an unnatural degree of mobility in a joint, as of lateral motion in the knee joint, it indicates rupture of the ligament normally limiting that movement ; if, on the other hand, with- out this unnatural extent of movement, a particular movement causes acute pain, it indicates a stretching and partial laceration of the ligament that is put on the stretch by the movement in question. When, however, slight movements, not extensive enough to stretch any ligaments, elicit sharp pain, and when there is effusion into the synovial cavity, as shown by a fluid swelling having the outline of that cavity, it indicates that the chief stress of the injury has been upon the synovial membrane, and that it is to be regarded rather as a bruise and laceration of the synovial membrane. These lesions are variously com- bined in different cases, and it is often impossible to arrive at an exact diagnosis of the injury sustained ; but in all cases great care should be taken to deter- mine that there is no displacement of any of the structures entering into or immediately surrounding the joint, bones, interarticular cartilage, or tendons. 4. Examine the muscles and tendons of the injured region. The injuries these structures may sustain are : (a) Bruise of muscle. I (e] Kupture of tendon. (b) Rupture of muscle. | (d) Displacement of tendon. (a) When, after a blow, strain, or prolonged and violent contraction, a muscle is found somewhat swelled, tender to pressure, with a sense of stiff- ness and weakness, and acute pain is produced on attempting to put it into action, the injury, is a bruise or strain of a muscle ; when produced by a blow it is called a bruise or contusion, and when caused by chap, ii.j INJURIES OF MUSCLES. 35 over use it is called a strain. This injury is most common in the deltoid, pectoralis major, biceps, pronator radii teres (lawn-tennis arm), adductor muscles of the thigh (rider's sprain), hamstrings, muscles of the calf, and the extensors of the spine. (b) When, during some sudden and powerful con- traction of muscle, there is experienced a sudden and sometimes very severe pain, followed by a notable sense of weakness, and on examination there is found a more or less marked gap in a muscle, with swelling from effused blood, a rupture of a muscle has occurred. Its production may be attended with an audible snap, and attempts to put the muscle into use are painful and futile. Subsequently the two ends of the rup- tiired muscle remain widely separated. (c) When, with symptoms exactly like those at- tending a rupture of a muscle (sudden pain and an audible snap, with sudden loss of power), there is not found any gap in a muscle or swelling over its fleshy part, unless it be some fulness produced by its retrac- tion, and yet it is impossible to make its tendon tense or produce its particular movement ; or if a distinct gap can be felt in the tendon, as in the case of rupture of the tendo Achillis, rupture of a tendon may be diagnosed. (d) When, as the result of some sudden strain or wrench, there is acute pain, with tenderness in the course of a tendon, swelling and ecchymosis, and con- traction of one or other of the muscles of the part excites severe pain, while its tendon is found not to occupy its normal position, a dislocation of a tendon has occurred. This is most frequently seen at the ankle, in connection with the peroneus longus tendon, which starts forwards over the malleolus, or at the knee, where the patella with its tendon is displaced on to the outer side of the joint, or one or other hamstring tendon is displaced. It is said also to be frequent 36 SURGICAL DIAGNOSIS. [chap. it. in connection with the long tendon of the biceps, causing the arm to be locked in the abducted position until set free by flexion of the shoulder and rotation of the limb. "When this injury is of old standing it is more easy of diagnosis, as there is no swelling and ecchymosis to conceal the displaced tendon. 5. Examine carefully the condition of the vessels of the part. Compare on the two sides the pulse in the arteries beyond or at the seat of the lesion, note the temperature of the part, and by com- pression of a superficial vein determine the freedom and rapidity of the venous circulation. (a) If there be no pulsation in the arteries below an injured part, and the limb become pale and cold, while the pulse in the superficial arteries of other parts of the body be plainly felt, and the colour and temperature of the injured part be normal, and there be no notable swelling or displacement of a bone compressing an artery, it is a case of partial laceration of an artery, urith occlusion, the torn inner and middle coats, together with blood clots, having blocked up the lumen of the vessel In such a case it may be possible to trace the pulse down to the seat of the injury, and there note its sudden disappearance. (6) Where, with similar symptoms, there is a frac- ture or dislocation, and the reduction of the displaced bone is followed by a return of pulse in the arteries below, the injury has evidently been compression of the artery. (c) Where, immediately after an injury, a fluid swelling is very rapidly developed, with oedema of the parts below, and impeded circulation, there has evi- dently been a rupture of a large vessel. If the arteries beyond the injury are quite pulseless, and the part notably cold, the swelling tense, with or without expan- sile pulsation, thrill and bruit, it is a ruptured artery ; it must be remembered that when the rupture of the chap, ii.] INJURIES OF VESSELS. 37 vessel is complete, and there is no form of sac around the effused blood, there is no pulsation and no thrill. Where, on the other hand, there is a pulse in the arteries beyond the swelling, and the part is not notably cold, while the tumour is without pulsation, bruit, or thrill, a ruptured vein may be diagnosed. (d) Where at some interval after an injury pulsa- tion is suddenly found to be lost in an artery, the vessel at this part feeling solid and firm, the parts be- yond being at first pale, cold, and pulseless, although they may subsequently recover, there has been a secondary occlusion of the artery, and where embolism may be with certainty excluded, owing to the absence of any source of an embolon, arterial thrombosis from contusion or inflammation may be diagnosed. (e) Where at some interval after an injury a vein is found to be occluded, forming a solid, round, firm cord, the veins opening into which are distended, thrombosis of a vein from contusion may be diagnosed. This must be distinguished from thrombosis due to a general enfeeblement of the circulation, which is cha- racterised by its wide extent. (See page 347.) 6. Examine the nerves of the injured part. Nerves may be contused, lacerated, or compressed by subcutaneous injuries, and later on may be in/lamed, or become the seat of tumours. The history of the case will determine whether the lesion be con- tusion from a direct blow, laceration from over-stretch- ing, or compression from the displacement of a bone, the formation of callus, or the extensive effusion of blood or other fluid. Where the injury is due to con- tusion, laceration, or displacement of a bone, as in a dislocation, the symptoms come on at once ; but where they are dependent upon the pressure of effused blood, or of an abscess, or to the implication of a nerve in callus, they come on later, at a time corresponding to the occurrence of these phenomena. Where there 38 SURGICAL DIAGNOSIS. [Chap. in. is any reason to suspect an injury to a nerve, the surgeon should carefully test the patient's power of contracting all his muscles, and the acuteness of the sensibility of the skin, comparing together the sound and the injured limbs. By noting the intensity of the paralysis, and of the anaesthesia or parsesthesia, the intensity of the lesion may be judged of, while the exact distribution of the motor and sensory paralytic phenomena will indicate the nerve or nerves that are involved. As already hinted, the symptoms vary with the intensity of the nerve lesions. But it is to be noted that motor paralysis is more frequent and more marked than are changes in sensibility. When, after an injury, there is found to be weak- ness or paralysis of certain muscles, which are not themselves injured, and, in addition, there is numbness or insensibility of a certain area or areas of skin, with a sense of tingling, formication, and weakness, there is an injury of the nerve or nerves supplying the affected muscles and skin. Later on the affected muscles waste, and the skin and other tissues may undergo the changes to be mentioned in reference to wounds of nerves. (See page 42.) Subcutaneous injuries of viscera are con- sidered in the chapters devoted to the diagnosis of the various regions of the trunk. CHAPTER III. GENERAL DIAGNOSIS OF WOUNDS. IN this chapter will be considered the signs by which we are able to determine the nature of a wound, the parts that have been injured and the subsequent progress chap, in.] WOUNDS. 39 of the lesion. It will be convenient to take these points one by one. A. The nature of a wound, by which is meant the kind of injury which has been inflicted on the tissues ; the features of recent wounds only will be here spoken of. (1) If the wound be a simple clean cut through the skin or other tissues, bleeding freely from its whole surface, the appearance of the skin quite up to the edge of the wound being unaltered, and the surface of the cut being smooth, showing the different structures cut through, it is an incised wound. (2) If the wound have been inflicted with some blunt instrument, do not bleed freely from the whole surface, the skin for a varying distance from the cut- edge being livid, ecchymosed, more or less cold and numb, and the cut surface dark in colour and uneven, it is a contused wound. (3) If the surface of the wound be extremely irregular, with long shreds of tissue adherent to it, with very little haemorrhage, or none at all, it is a lacerated wound. Contusion and laceration are often combined, and the wound is then spoken of as a contused lacerated wound. Incised wounds are much the most painful, the pain being of a sharp stinging or burning charac- ter ; in contused and in lacei'ated wounds, the pain, much less severe, is of a dull, aching, or benumbing character. (4) The shape and superficial extent of wounds may vary within the widest limits ; but only two varieties require notice here, and one is where a distinct flap of tissue has been cut or stripped up. Such a wound is to be called &jlap wound, " incised " or " lacerated " being added as a prefix, according to circumstances. The other is where the depth of a wound is out of all pro- portion to its superficial extent, a punctured wound; 40 SURGICAL DIAGNOSIS. [Chap. in. and as these may be inflicted with sharp, clean-cutting instruments, such as daggers and bayonets, or with blunt weapons, such as bullets, they may have the characters either of incised or of contused wounds, and this fact should be expressed by a prefix. (5) In case of contused and torn wounds it is im- portant to determine whether the tissues have been injured beyond all recovery. If, after the patient has recovered from the primary shock, and the general circulation is re-established, there be no signs of cir- culation in the part, if compression make no altera- tion in its colour, and if it remain cold and quite senseless, it may be decided that the part is actually dead; but these signs must be unequivocal before such a diagnosis is to be made ; where they are not thus plain, time will soon show whether the tissues retain their vitality or not. (6) If the local or the constitutional effects of a wound are not explicable upon the extent and severity of the wound, it is a poisoned wound. The particular symptoms vary of course with the poison ; in one case it may be coma from morphia ; in another, tetanic convulsions from strychnia ; in a third, paralysis from curare ; in a fourth, septicaemia ; in a fifth, local suppuration with lymphatic inflammation ; in a sixth, convulsions from hydrophobia ; in a seventh, local induration and the constitutional effects of syphilitic infection. B. The parts injured. (1) Injury to the skin or mucous membrane, as the case may be, is obvious ; if the wound extend through the whole thickness of the skin, it gapes, and allows the subcutaneous fat to be seen. If muscular tissue, known by its deep red colour, or tendons (glistening white bands) are seen in the wound, the deep fascia has been divided. A cut into muscle is also obvious. Complete division of a tendon is determined by noticing chap, in.] WOUNDS OF VESSELS. 41 (a) that the patient is unable to execute the particular movement accomplished by the muscle in question; (>) that he is unable to make the tendon tense ; (c) in some cases, that the retracted muscle makes a distinct swelling ; (d) and sometimes that the divided tendon, one or both ends, can be plainly seen in the wound, the proximal end being drawn upon when the patient puts the muscle in action. (2) If there be an oozing of bright blood from the whole surface of the wound it is capillary hcemor- rhage. (3) If, in addition to this, there be a rapid con- tinuous flow of dark blood from one or more points of the wounded surface, it is venous haemorrhage. Venous haemorrhage is not attended with local blanching, nor with interference of the pulse in the arteries beyond, when compared with those of the opposite side ; it is lessened or stopped by moderate pressure on the distal side of the wound, and increased by moderate pressure on the cardiac side ; firm pressure on the cardiac side, by stopping the arterial flow to the part, of course stops, but not instantly, loss from a wounded vein. If a large vein be opened, such as the axillary or jugular, the blood may spurt from the wound, but the flow, however rapid, is continuous. (4) If, at the same time that a vein is wounded, a sucking or hissing sound be heard, and the blood be noticed to be frothy, air has entered the vein. This only takes place through the veins close to the heart, especially the innominates, jugulars, and subclavians ; if the air enter in any quantity it produces sudden death or severe symptoms of cardiac failure, i.e. pallor, dyspnoea, very rapid weak pulse. (5) If there be a rapid flow of bright red blood from a particular spot in the wound, the blood being forced out in a jet and per saltum, it is bleeding from a wounded artery, arterial haemorrhage. If the 4? SURGICAL DIAGNOSIS. [Chap. in. patient be inhaling ether or nitrous oxide gas, the blood even from an artery will be dark in colour, but will be readily distinguished from that coming from a vein by its remittent flow. Arterial haemorrhage may, however, lose this character under two circum- stances : (a) if the blood do not escape directly from the ai-tery, but flow along a more or less narrow or sinuous wound, its jetting flow is lost, and (b) in the case of small arteries, where, from loss of blood or from obstruction in the flow above, the arterial tension is considerably lowered, the flow may become continuous ; it is, however, distinguished then from capillary oozing by its escape from definite spots in the wound, and from venous haemorrhage by its colour, its control by pressure above, and the failure of distal pressure to stop it Where a large artery is wounded, such as the carotid, femoral, or axillary, the blood issues with a distinct hissing noise. In the case of an artery wounded in its continuity, it may be possible to determine what vessel is injured by noticing (a) if there be blanching of any part, as e.g. of the sole of the foot in division of the posterior tibial artery during tenotomy ; (6) loss of pulse in the artery beyond ; thus, if with a wounded artery at the root of the neck, the pulse in the carotid or facial artery and the brachial or radial is unaffected, it proves that neither the carotid nor subclavian artery is the one injured ; similarly, in the case of a stab in the thigh, if the pulse in the tibial arteries is equal in the two sides, it shows that the femoral tnink is not wounded. In many cases the position of the wound is enough to determine what artery is wounded ; but in many others it is uncertain until the bleeding vessel is actually found, and its euact relations to surrounding structures are seen. (6) The division of nerve trunks is best shown by the anaesthesia of parts beyond the wound, and also chap, in.] WOUNDS OF BONE. 43 by paralysis, but care must be taken to exclude the direct effects of the wounds of muscles when estimating the latter. In such a case as the division of the great sciatic nerve in the buttock, the palsy of the muscles of the toes (quite at a distance from the injury) is very characteristic. A divided or partially divided nerve may be visible in a wound. (7) Complete division of a bone in a wound is evidenced by the usual signs of fracture, i.e. mobility in the length of a bone, crepitus, irregularity of the outline of the bone, and one of the fragments may be visible ; but where a bone has been only partially severed, a so- called wound of bone, the fact can only be detected either by the eye, or by the finger or probe feeling the cut in the bone, while the signs of complete fracture are absent. The association of a fracture of a bone with a wound of the soft parts is a very important one, for if the latter extend down to the broken bone it forms a compound fracture. To determine whether this is the case is usually quite easy, as one or other fragment may pro- trude from the wound, or be visible in it, or the finger introduced into the wound may at once detect the fracture. In other cases it is equally apparent that the wound is quite superficial, perhaps a mere abra- sion, or at some distance from the fracture, the latter not being " compound." In a third series of cases the student may be in doxibt, and then the amount of haemorrhage from the wound will be the best indica- tion ; bone is a very vascular tissue, and if from a small wound, over and complicating a fracture, there be a free trickle of bright blood continuing for some hours, it is very strong evidence of the fracture being compound ; a probe may be carefully introduced to detect the bone, but great care should be xised lest the wound be deepened or haemorrhage renewed. (8) If a clear tenacious fluid be seen to flow from a wound, either pure or mixed with the blood, which 44 SURGICAL DIAGNOSIS. [Chap. in. can be drawn out into " strings," a synovial cavity has been opened. If the wound be immediately over a bursa or synovial sheath, and the fluid small in amount, and especially if a tendon be exposed in the wound, it may be diagnosed as a wound of a bursa, or synovial sheath ; but if the wound be directly over a joint, and the quantity of fluid be more than a drop or two, it is probably a wound of the joint. In exten- sive wounds there is no difficulty in determining whether a joint is injured or not, as the articular surfaces may be exposed, or may project, or portions of articular cartilage may be chipped off and be found free in the wound. It is in the case of small punctured and incised wounds that the difficulty arises. In no case must a probe or any similar instrument be passed into a wound over a joint to determine its depth, as it may actually tear the synovial membrane, and inflict the injury most of all to be avoided. Whenever there is doubt, the case must be treated as a wounded joint, and if the part swell out with effusion into its articular cavity, the diagnosis of a wounded joint may be considered to be established ; similarly, where a bursa becomes distended, evidence is afforded of a wound extending into it. The exact position and direction of a wound, together with the amount of synovia escaping, are the best guides in deciding between a wound of a bursa and a wound of a joint. (9) Woimd of a serous cavity is only certainly determined by the protrusion of one or other of the contained viscera. A few drops of serous fluid may be seen to escape, but only in the cases where the wound is so small and clean-cut that this cannot have been expressed from a clot of blood will this aid in the diagnosis ; where a dropsical accumulation has been opened the amount of the flow may be decisive. Here, again, any attempt to explore the wound to determine its depth is to be earnestly Chap, in.] WOUNDS OF SEROUS MEMBRANES. 45 deprecated, as liable to do great mischief; and in doubtful cases, which are to be treated as in- juries of the serous membranes, subsequent inflam- mation of the membrane confirms the diagnosis of such a wound. In the belly the omentwn is the viscus that most often protrudes, and it must be dis- tinguished from the subcutaneous or the subperitoneal fat by its peculiar granular appearance and feel, its distinct circumscription, and in some cases its redu- cibility ; or it may be irreducible and strangulated, when its livid colour will be very distinctive ; next to it the small intestine most often protrudes. In the scrotum, the smooth, glistening testicles may protrude. Injury of the serous cavity of the head is in some cases characterised by a continuous flow of the cerebro-spinal fluid, and occasionally by a peculiar symptom, viz. a spurting forth of the cerebro-spinal fluid when the jugular veins are compressed. (See page 83.) Wound of the pleura without wound of lung only rarely occurs, and is extremely difficult of diagnosis unless there be prolapse of unwounded lung. (See page 136.) (10) The diagnosis of wounds of viscera is considered in the chapters devoted to local injuries, as it is impossible to generalise with any advantage the symptoms caused by injuries to the various viscera. (11) The diagnosis of wounds of the ducts of glands rests upon the position of the wounds and the flow from them of characteristic secretion (such as saliva or milk or urine). (See chapters on Local injuries.) 0. The subsequent progress. The constitu- tional complications attending wounds are considered in chapter iv., and therefore only the local pheno- mena attending their healing, and their local compli- cations, will now be dealt with. 46 SURGICAL DIAGNOSIS. [Chap. in. (1) A wound may be found not to undergo any change whatever, even for many days after its inflic- tion ; a little dark blood oozes from it, but the natural appearance of the severed tissues is in no way obscured, and there is no union between adjacent surfaces. This delayed healing is only occasionally seen, and arises from severe constitutional debility. As a late symptom, delay in healing, or even the breaking down of union already accomplished, may attend erysipelas, pyaemia, and some other severe constitutional affections. (2) If it is found that the cut surfaces are in apposi- tion and adhering together by a soft, yellowish material, that there is no purulent discharge, and at the most a thin scab of dried blood or of soft yellowish lymph over the wound ; that there is no (or very trifling) redness and swelling about the edges of the wound ; that there is no pain, and only slight tenderness, such wound is healing by first intention. (3) If the edges of a wound are found adhering as above described, or have been united by the surgeon, but the skin around shows a blush of redness, some- times slight and at others deep, with marked swelling and even superficial redema, and there be severe pricking, stabbing, or throbbing pain, considerable tenderness, with fever, the temperature perhaps ranging as high as 104, and accompanied with a chill, there is retained discharge, a condition of tension ; this, if unrelieved, will quickly run on to abscess, which will then burst through the softly united edges of the wound, or through the skin, and if the wound be not aseptic may lead to septic poisoning. The retained fluid may be blood or serum, the former accumulating within the first few hours after the dressing of the wound, the latter within the first two days, as a rule. (4) If the cut surfaces do not directly adhere, but the tissues composing them become obscured by a chap, in.] HEALING OF WOUNDS. 47 translucent layer of coagulated lymph, this state is called the glazing of a wound. The lymph becomes opaque, then pink, then florid and uneven on the surface, from the formation of minute conical eleva- tions, and these gradually grow towards the surface, their growth being attended with the secretion of laudable pus, the wound healing, it is said, by granu- lation, or second intention. (5) If opposing granulating surf aces become directly adherent in place of the cavity between them being filled up by the growth of granulating surfaces, it is called healing by third intention. This is known by the sudden diminution of the pus secreted, and by direct observation of the union. The diseases of granulating wounds are considered in the chapter on Ulcers. (6) If a wound be wholly or in part filled up with a blood clot, and this clot do not soften and flow away, but remain firm and fixed ; and if after several days a thin dry layer of it separate and show a soft delicate cicatrbc below, it is called organisation of, or more cor- rectly in a blood clot. This is the process which has long been familiar in small wounds as healing under a scab. In clots of larger extent, only the deeper part of the coagulum may become organised, the upper part breaking down. (7) For gangrene occurring in a wound see page 345 ; and for erysipelas, septicaemia and pyaemia, see pages 65 et seq. (8) Bleeding recurring from a wound during re- action, i.e. within forty-eight hours of its infliction (most common within the first eighteen hours) is called intermediary or recurrent haemorrhage. But if the bleeding occur later than this, it is secondary Jicemorrhage. If, while dressing a wound, a little trickle of bright blood be seen to come from the deeper parts of the wound, and if this be not caused by any 48 SURGICAL DIAGNOSIS. [Chap. in. movement or manipulation of the wound breaking down some granulations, and especially if it recur spontaneously, it is probably the forerunner of an extensive secondary haemorrhage. (9) If with acute febrile symptoms with or with- out an initial rigor, the parts about a wound impli- cating a bone are found much swelled, and the soft parts, including the periosteum, retracted, leaving the bone dry and bare ; and if in a case of amputation a soft fungous mass protrude from the end of the medullary canal, and the probe passed into this meet with no resistance and possibly liberates some pus, acute osteomyelitis is present. (10) If afterthe healing of awound a part below con- tinue insensitive and cold, and especially if its muscles are paralysed and wasted, with loss of irritability to the faradaic current, it indicates that a severed nerve has not united. This has to be distinguished from the immobility of a part from division of a tendon or a muscle. The position of the scar (in the one case over a nerve, and in the other over a muscle or tendon) ; the extent of the paralysis (in the one case affecting all the muscles supplied by the nerve below the scar, in the other affecting only the muscles wounded); and the accompanying electric and sensory phenomena are sufficient to establish the diagnosis. If the skin of the affected part be rough and covered with dry, scaly epidermis, the nerve or nerves are completely divided. In cases where the skin is smooth, glossy, devoid of hair, with patches of livid red colour, or herpetic eruption, smart burning pain, and the muscles have wasted rapidly, there has been incomplete division of the nerve. (11) If a scar remain painful and tender, the con- dition is spoken of as neuralgia of cicatrix. Of this it is necessary to distinguish two varieties. Where the pain is localised, and is especially excited by pressure chap, iv.] DISEASES OF SCARS. 49 on a particular spot, the neuralgia may be considered to be of local origin, and this diagnosis will be con- firmed if there be an induration, or adhesion of the scar to a bone at the tender spot If, on the other hand, the pain is more widely diffused, and especially if it be attended with marked superficial hypersesthesia, be intermittent in character or attended with spas- modic jerkings of the part, and if the patient be anaemic, or subject to neuralgia in other situations, the disease may be diagnosed as of constitutional origin ; the latter form is more common in women. (12) When a cicatrix enlarges, becoming thicker, prominent on the surface, wider, remaining firm, smooth and of a delicate pink or purplish colour, it is called a keloid scar. This disease may attack a scar at any time after its formation, and after a certain advance may remain stationary, or the growth may be absorbed. It may attack a large scar in several situations. Its smoothness, firmness, slow growth, and its not ulcerating, together with its spontaneous recession or disappearance, distinguish this disease from epithelioma attacking a scar. (See pages 286, 337.) V CHAPTER IV. THE DIAGNOSIS OP THE CONSTITUTIONAL EFFECTS AND COMPLICATIONS OF INJURIES AND OPERATIONS. IT is extremely important to recognise with as much accuracy as possible the constitutional condition of patients suffering from injuries or surgical diseases. The importance of and the interest attaching to the diagnosis and treatment of local surgical maladies may tend to concentrate the attention too exclusively upon E 13 50 SURGICAL DIAGNOSIS. [Chap. iv. local conditions at the expense of neglect of the con- stitutional. Such tendencies should be carefully re- sisted. The constitutional effects of local surgical conditions vary from the most trivial to the most severe, and this makes it impossible to do more than discuss the diagnosis of certain typical forms ; but if the student will notice carefully the steps in the dia- gnosis of these chosen types, and grasp the meaning or the explanation of the different symptoms of constitu- tional disturbance, he will be able to appreciate the sig- nificance of combinations or degrees of these symptoms other than are here mentioned. Here, as elsewhere in diagnosis, it is important not to rest content with learning that a certain group of symptoms charac- terises a certain injury, or disease, or constitutional condition ; but the surgeon must go beyond, and arrive at the meaning or the cause of each symptom, and understand why a certain conjunction of symp- toms must indicate a certain morbid state. It is im- possible in the space at our disposal to discuss in any detail those symptoms upon which the diagnosis of systemic conditions depends, the temperature, the pulse, respiration, state of digestion, general nutrition, and the various manifestations of the functions of the nervous centres. Such discussions are found in works on physiology and to some extent in works on medicine, and to these I must refer my readers, and must content myself here with the following brief notes. Fever, by which is meant pyrexia, or increase of body-temperature, is produced (a) by the absorption of the products of inflammation, inflammatory fever ; (b) by the introduction of special substances into the blood, as in so-called " septic intoxication," the infec- tive septic fevers and malaria ; (c) perhaps by the abstraction of certain materials from the blood, as in hectic fever ; (d) possibly as a reflex effect of the irrita- tion upon nerve terminals : in this way some explain Chap, iv.] FEVER. 5 \ the pyrexia attending tension in a -wound, but a better illustration is the fever sometimes caused by a tight stitch ; (e) possibly also as a reaction from the depres sion caused by the shock of an injury or operation ; in this way may be explained the initial transient rise of temperature after all operations or injuries of any moment, the fever which alone should be designated " traumatic," as signifying its dependence upon the injury, and nothing else. It must be borne in mind that the intensity of a fever depends partly upon the intensity of its cause, as e.g. the dose of poison ab- sorbed, and partly upon the constitutional peculiarity of the patient. As a rule, children respond more readily than adults to all causes of fever, and some adults present what, for want of more exact knowledge, can only be called an "idiosyncrasy," which makes them peculiarly intolerant of all causes of febrile ex- citement. The author recently had under his care a lady on whom he operated for anal fistula, in whom emotional disturbance (a fit of crying) was on several occasions found to raise the temperature several degrees. In the same manner the type of the fever is modified by the nature of the exciting cause, and occa- sionally also by constitutional peculiarity; as an exam pie of the former may be mentioned the asthenic type of septic fevers, and of the latter the influence of pre- vious malaria upon subsequent febrile attacks. In the study of fever attention should be directed to its mode of onset, whether gradual or sudden, attended with marked pyrexial phenomena, such as rigors, headache, etc. ; the exact time of it& onset in relation to other morbid symptoms ; its course, duration, the height of the temperature, its modifications at different times of the day, and the manner and extent to which the other vital functions of the body besides that of animal heat are interfered with. The pulse. The observer should note the 52 SURGICAL DIAGNOSIS. [Chap. iv. frequency, the rhythm, and the size of the pulse-beat, together with the fulness and tension of the artery. It is well known that the rapidity of the cardiac contrac- tions is greatly affected by mental impressions, and care must be taken to eliminate this source of error as far as possible. With tkis exception, the chief causes of quickening of the pulse met with by the surgeon are collapse, haemorrhage and fever, while it is notably slower in compression of the brain. The size of the pulse, or the degree to which the artery is affected by the wave passing along it, is dependent upon the ten- sion of the artery and the force of the heart's contrac- tion. The tension of the artery is measured by pass- ing the fingers across the vessel in such a manner as to feel its contour without compressing it, at the same time noting its fulness or the reverse, and also by noting what amount of compression is required to obli- terate the pulse ; the tension of an artery is a measure of the blood-pressure in the vessel, and as the blood pressure is very largely dependent upon the muscular tone of the vessels, its chief importance is as an indica- tion of the latter : thus, a soft compressible pulse, such as is met with in hectic fever or in septicaemia, indi- cates a loss of tone in the small vessels or more or less advanced vaso-motor palsy, while the hard wiry pulse of acute peritonitis indicates spasm of the muscular walls of the arterioles and vaso-motor stimulation. In certain cases coming before surgeons the pulse has a special significance in diagnosis ; thus, it may be absent in some particular vessel owing to its rupture or occlu- sion, or it may be smaller and later in one artery than in its fellow on the opposite side of the body, owing to an aneurismal dilatation of the trunk above. Lastly, in middle-aged and elderly persons the nutritive condition of the arteries should always be observed, whether it is tortuous, moving freely in their bed with each cardiac impulse, and presenting a perfectly smooth or irregular Chap, iv.] RESPIRATION. 53 outline to the fingers passed over them longitudinally ; the first two phenomena are signs of loss of elasticity, while the detection of irregularities in the vessels point to calcification of the middle coat in the form of calcareous rings. Respiration. The frequency, absolute and re- lative to that of the pulse, and the fulness of the respiratory movements, have the same significance for the surgeon and the physician; but the former is especially concerned to notice whether the movements of the chest are uniform on the two sides, as in the diagnosis of fractured ribs and of impaction of a foreign body in a bronchus, and whether they are both thoracic and abdominal ; in peritonitis the respiration is characteristically thoracic only, while in cases of crush of the spinal cord at or just below the fifth cervical vertebra it is as charac- teristically abdominal only. Mention should also be made of the falling-in of the soft chest-walls of children, and of the epigastrium and supra- sternal and supra-clavicular regions in adults and in children in cases where there is great obstruction to the entrance of air. In these cases, it is impor- tant to observe whether the larynx moves up and down in the throat with the exaggerated respiratory efforts. When it does, it indicates that the obstruction to the passage of air is above or in the larynx ; when, on the other hand, the larynx remains fixed, it shows that the obstruction is below the larynx. The digestive system. There are no special points in connection with the digestive system to which reference need be made here ; the state of the appetite and thirst, the condition of the tongue, the ease and painlessness of deglutition and of digestion, freedom from vomiting, flatulence, consti- pation or diarrhoea will, of course, engage the atten- tion equally of the surgeon and the physician. Of 54 SURGICAL DIAGNOSIS. [Chap. iv. much importance as an indication of great vital de- pression is a dry brown tongue, protruded with diffi- culty, and exhibiting marked fibrillar tremor, and usually accompanied with sordes on the teeth and lips. In works on medicine the student will find discussions on the causes of vomiting and the diagnosis of its different forms. The causes of vomiting most often met with in surgical practice are (1) the circulation in the blood of certain toxic agents, such as chloroform, morphia, and the poison of erysipelas; (2) reflex nervous irritation, as in rupture of the liver, intestinal obstruction or strangulation, peritonitis, uterine and ovarian congestion ; (3) and, less often, affection of the brain, as meningitis and] tumour, the vomiting occur- ring during the reaction from collapse should be ranged in this class. The urine is an important aid in determining the state of general nutrition, as well as a valuable guide to the correct diagnosis of diseases of the urinary organs. The excretion of a small quantity of water, while the usual quantity, or even an excess, is taken into the body, there being also no unusual loss by other sources as the skin and the bowel, is an indication of retention of water within the body, one of the most marked effects or accompaniments of fever. Excessive excretion of water by the kidneys is similarly due either to excess in absorption of water, lessened excre- tion by other channels, to the excretion of sugar, to the disease called diabetes insipidus, or to a chronic disease of the excreting portions of the kidney by which in- creased filtration of urine is permitted. Similar mo- difications in the amount of urinary ttolids excreted are observed ; their increase shows an excessive oxi- dation within the body, while their decrease may be due either to diminished oxidation, or to a lessened power of excretion by the kidneys. This subject is again referred to on page 541. For remarks on the chap, iv.] EFFECTS OF INJURY. 55 diagnostic value of disturbances of the nervous system, see pages 87 et seq. , The constitutional effects of injuries or operation are either immediate or more remote ; either primary, produced directly and solely by the injury, or secondary, both in point of time and also in the influence of causes other than the mere injury. Of the former, collapse may be taken as a type ; and, of the latter, septicaemia or tetanus. Injuries may cause general disturbance by affecting seriously one or more of the great vital functions, especially those of circula- tion, respiration, and of the central nervous system. These are intimately interdependent ; mere stoppage of the heart will abolish all the functions [of the nervous system, and arrest respiration ; and a lesion in the floor of the fourth ventricle will at once stop the action of both the heart and the lungs. Similarly an in- sufficient supply of blood to the brain will induce a feeble performance of all its functions ; while any in- fluence upon the nerve-centres reducing their activity, may enfeeble and impair the action of the heart. Hence it comes about that the final effects of severe injuries, damaging the brain or the organs of circula- tion or of respiration, may be closely alike. While, however, injuries can only tell primarily upon the functions of circulation and respiration (except through the nervous system) by direct inter- ferences with those functions, in the one case, by loss of blood or stoppage of the heart's action by pressure, laceration of its walls or incompetence of its valves ; and, in the other case, by obstruction to the passage of air or arrest of respiratory movements ; they can affect the nervous ' centres both directly and indirectly ; directly, as when the brain is concussed or com- pressed ; indirectly, by an impression made upon a nerve terminal being conducted up to the centre, and then exerting its influence, as when a crush of the 56 SURGICAL DIAGNOSIS. tchap. iv. great toe causes collapse or syncope. When an injury affects the nerve-centres by an impression conveyed up to them by afferent nerves, the injury is said to be attended with " shock " to the nervous system. Shock is sometimes used to designate both the ascending nervous impression and the symptoms resulting from it ; it should be employed in the former sense only ; and for the latter, or the effects of shock, the term " collapse " should be used. Shock and its consequent collapse may be caused by other conditions than in- jury, e.g. depressing mental emotions. The intensity of shock varies with the intensity of the injury, and with the part injured, that due to visceral lesions is particularly severe ; while the resulting collapse varies with the intensity of the shock, and what may be termed the " stability of the nerve-centres." Children, " nervous " women, and old persons show the effects of shock more markedly than robust men, while the influence of pre-occupation or intense mental excite- ment or concentration in opposing the influence of shock, is instanced by the numerous accounts of severe injuries received upon battle-fields without any collapse being produced at the time. It is further to be observed that, in consequence of the rapidity of all nervous processes, the effects of shock and of direct injury to the nerve-centres, are instan- taneous, although when the injury increases, as in subcranial or meningeal haemorrhage, the symptoms vary or increase in proportion. On the other hand, the constitutional effects of direct injury to the respi- ratory and circulatory organs are nearly always more or less gradually induced. Every injury produces some degree of shock, and the impression in every case exerts a depressing in- fluence upon the nerve - centres. The resulting collapse varies from a systemic disturbance un- noticed and transient, up through all grades, to chap, iv.] SHOCK COLLAPSE SYNCOPE. 57 an intensity such as to cause instant death. When the constitutional symptoms are due to failure of the heart's action, and the consequent anaemia of the brain, the condition is called syncope ; this may be produced by shock, being, indeed, one form of collapse, as when it is caused by the passage of a catheter, or by fright; or it may result from direct interference with the circulation, as from haemorrhage and the toxic effect of chloroform. Like collapse, syn- cope varies between the wide extremes of brief insensi- bility and sudden death ; when pronounced and severe it may be indistinguishable from collapse. In addition to constitutional states, primarily resulting from in- juries, the association of recent injuries with condi- tions quite independent of them, such as apoplexy, alcoholism, and epilepsy, must be borne in mind ; and it will be well, therefore, to consider the diagnosis of all these together : Collapse. Syncope. Concussion of brain. Compression of brain. Apoplexy. Epilepsy. Alcoholism. 1. If a patient be pale, with blanched cheeks and lips, sunken features, dull motionless eyes, cold skin, with beads or drops of sweat on the brow or other parts, with a frequent small very compressible pulse, or even a pulse imperceptible in the radial artery, with shallow noiseless respiration, muscular relaxation, so that the limbs are flaccid and fall about under the influ- ence of gravity, while no resistance is offered to move- ments at the joints, the relaxation of the sphincters being attended with involuntary escape of faeces or urine ; and if there be mental apathy, which may be exaggerated up to complete unconsciousness ; the condition is said to be one of collapse. In a typical case all the vital functions are equally depressed, 58 SURGICAL DIAGNOSIS. [Chap. iv. and the recovery is gradual and slow. As a varia- tion may be mentioned a state in which, with ex- treme pallor, coldness, feebleness or absence of pulse and muscular relaxation, consciousness is preserved intact ; this is especially, but not exclusively, observed in cases of collapse from haemorrhage. In collapse from this cause it is to be noted that the circulatory pheno- mena precede the nervous and muscular. 2. If a patient suddenly becomes quite unconscious, with general muscular relaxation, and either sudden stoppage of the heart or great diminution in the force of its contractions, with pallor, dilated pupils, insensi- tiveness of the conjunctiva, weak superficial respi- ration, and these symptoms quickly pass off and end in recovery ; or, on the other hand, if sudden death ensues from the sudden arrest of the heart's action, the condition is generally known as syncope. The distinctions between syncope and collapse are not absolute, and individual surgeons employ the terms somewhat differently ; the main point is to discover whether the symptoms are due to a general failure of nerve force, or to a primary arrest or enfeeblement of the circulation ; from true collapse there is never the sudden or rapid and complete recovery that is witnessed in some cases of syncope. 3. When a patient presents the above general symptoms, but it is observed that the mental pheno- mena are out of proportion to the feebleness of the circulation, there being perhaps apparent complete unconsciousness, the patient only being roused to mutter when shouted at, or severely pinched, while the pulse is plainly felt at the wrist, concussion of the brain is to be suspected ; and if there be no signs of paralysis or convulsions, while a history of a blow on the head, or of a general shake of the body with im- mediate onset of the unconsciousness, can be obtained, the diagnosis is established. As will be mentioned chap, iv.] UNCONSCIOUSNESS REACTION, 59 later on, the symptoms of concussion vary greatly in intensity, from slight vertigo up to instant death; but they are always sudden in their onset, immediately succeeding the injury causing them, and the cerebral phenomena are the most marked and the most enduring, unconsciousness often lasting for many hours after the pulse has fairly recovered. (See also page 91.) 4. As the diagnosis of conditions of unconscious- ness associated with injury is considered separately in the chapter on injuries of the head, page 91, it is only necessary here to point out that the distinguishing features of compression of the brain and of apoplexy are the completeness of the unconsciousness and the attending paralysis ; those of epilepsy are the occur- rence of tonic succeeded by clonic convulsions. 5. Alcoholism to a degree short of prodiicing unconsciousness may complicate the diagnosis of the constitutional effect of an injury. Unfortunately, its features are almost too familiar to need description, but special notice should be taken of the flushing of the face and surface generally, the unsteadiness of all mus- cular actions, as seen in the tremor of the tongue and the stumbling gait, and the mental inco-ordination, as seen in the incoherent talk, often foul or foolish, the inability to grasp an idea, or the obstinacy with which a false idea is held. The surgeon must not forget the possibility of the entrance of air into a vein, or the occurrence of cardiac or pulmonary thrombosis, complicating an injury or an operation. Collapse, unless fatal, after a time passes off, and is succeeded by reaction. The earliest signs of reaction are increased fulness and strength with lessened fre- quency of the pulse, sighing respiration, a return of warmth to the surface, slight voluntary movements, and vomiting. Reaction is complete when the surface is warm, and consciousness is restored and it is 60 SURGICAL DIAGNOSIS. tchap. iv. generally attended with restlessness, heat and dryness of skin, and abiding quickness of pulse. If, however, the patient be restless, unable to sleep, and even delirious, with hot dry skin, anxious flushed face, quick bound- ing or sharp compressible pulse, with weak tremulous movements, thirst and frequent vomiting, and hurried respiration, the condition is known as prostration with excitement. These symptoms are sometimes met with after severe haemorrhage, and if they do not end in re- covery, the pulse becomes fluttering and very quick, the skin cold and clammy, and convulsions and coma usher in death. The secondary constitutional effects of injuries or operations and diseases are : Fever. Fat embolism. Pulmonary thrombosis. Delirium tremens. Exhaustion. Tetanus. Hydrophobia. The existence of pyrexia, or increased body-heat, is the essential and pathognomonic sign of. fever. This is usually accompanied by increased frequency of pulse and respiration, and disturbance of the cerebral, cutaneous, and other functions. It is not sufficient to recognise the mere existence of fever, but an attempt must be made to determine the kind and degree of the constitutional disturbance, and then from this and other facts to decide as to its cause and nature. Fever varies very widely in different cases ; it may be a" mere transient pyrexia, accompanied by scarcely noticeable disturbance of function, while in other cases it may be fatal from the intensity of the body-heat or from extreme prostration. Two chief types of fever are usually described, sthenic and asthenic, and well- marked cases of either form are frequently to be recog- nised ; but there is a large intermediate class of cases exhibiting all the marked characteristics of neither of chap, iv.] FEVER. 61 these types, and which forms a continuous gradation between them. The student should carefully remem- ber that in the study of fever it is most of all im- portant to regard it as a general disturbance of vital function, and that to form a due estimate of any case it is necessary not simply to measure the rise of tem- perature and study the temperature curve, although that is of great value, but he must regard the patient as a whole, and estimate the kind and degree of dis- turbance of all the vital functions. In one case the temperature may be very high and out of proportion to the intensity of the other signs of illness, in another this due proportion will be observed ; in a third the frequency and softness of the pulse will indicate that the disturbance of the circulation is greater than that of other functions ; in yet a fourth case, the nervous symptoms will predominate, and so on ; and it is only when a good estimate is formed of the character and amount of the general systemic disturbance that is caused, or accompanied by, fever that a diagnosis of this condition in any true sense can be said to have been arrived at. In these days, when the thermometer is used as a matter of routine, and temperature charts are carefully drawn up so that the course of the pyrexia can be seen at a glance, there is a temptation to rely too exclusively (not too much) on this one manifestation of the febrile condition, and to neglect an equally careful and painstaking examination of the others. If with pyrexia the skin be hot and dry, the patient experiencing a "burning " sensation, and com- plaining of great thirst, restlessness, and frontal head- ache, with inability to sleep, and the face be found flushed, the eyes suffused, the pulse full, bounding, quickened to 90 or 110, the respirations proportionately increased, the tongue moist and coated with a white fur, digestive disturbance being further indicated by 62 SURGICAL DIAGNOSIS. [Chap. iv. complete anorexia, obstinate constipation, and some- times by nausea and vomiting, and the urine is scanty, high-coloured and deposits lithates in abundance on cooling, the case is described as one of sthenic fever. This form is met with in adults who were previously healthy, and accompanying acute sthenic inflamma- tions ; the temperature range is generally between 1028 and 105 Fahr. ; if there be delirium, it assumes the active, noisy, or violent type. If with pyrexia the skin be pale or livid, harsh and dry, or bathed with a clammy sweat, the features sunken, the pulse frequent (120 or more) soft, per- haps dicrotous, fluttering or irregular, respiration being hurried and shallow, the tongue dry, cracked and brown on the dorsum, with sordes about the teeth and lips, the appetite entirely lost but thirst not urgent, the motions dark and foetid, and possibly loose and frequent, with great muscular weakness, the patient lying flat on his back and slipping down in his bed with, in severe cases, muscular twitchings, subsultus tendinum, carphology, mental obscuration, or a low, muttering delirium, the case is one of asthenic fever, and the condition is known also as the typhoid state. The temperature may be high or low ; the urine is less markedly " febrile " than in sthenic fever, and not unfrequently contains albumen, in the later stages, when the nervous system becomes profoundly depressed or narcotised, it may be retained in the bladder. It is impossible to give more than a mere out- line of the diagnosis of many forms of fever which have received distinctive names according to the views held in regard to their etiology. It is not certain what part " septic " processes play in causing surgical fevers, nor how many several kinds of " septic " fevers there are, nor how far they can be distinguished from one another. A few years ago "inflammatory" and chap, iv.] TRAUMATIC Ie absolutely excluded, and these are to be attributed to irritative lesions of the spinal cord ; but whether they depend upon vaso- motor changes, or injury to special " trophic " centres, or are to be ascribed to unusual impulses passing along the nerves, is still a matter for discussion. Similarly the changes in the urine, its alkalinity, decomposition, turbidity, and admixture with muco- pus, may be attributed to the decomposition of the urine started by and dependent upon micro-organisms introduced by the catheter passed to relieve the retention ; and where care is taken to exclude this chap. vi. j SPINAL MENINGITIS. 105 accident by aseptic catheterism, such decomposition of the urine can be obviated. But in other cases, there seems to be evidence that in spite of all such pre- cautions, and at an early period after the spinal lesion, nephrO-cystitis is set up, with subsequent decomposition of the urine : and this is then to be regarded as a trophic effect. These are the most common nutritive lesions ; others less often met with are arthritis and unilateral acute bed-sore dependent upon an irritative lesion of the brain. As in the case of the brain, injuries of the spinal cord may be attended with symptoms of irrita- tion as well as of paralysis. These are pain, hyper- custJiesia, muscular spasm, and excessive reflex irritabi- lity. Where these symptoms occur at and from the time of the injury, they indicate some irritation caused directly by the injury ; this may be meningeal haemorrhage, but it is more often some displacement of bone causing pressure upon a nerve in the inter- vertebral canal. Coming on at a late period, these symptoms point conclusively to inflammatory irrita- tion ; they are more marked in meningitis than in myelitis, while paralysis quickly results from the latter process. These inflammatory processes vary much in intensity, and often involve both the mem- branes and the spinal medulla, but the observation of the following signs will enable a diagnosis to be made. When after an injury the patient experiences severe deep-seated pain in the spine, which shoots down the limbs and round the trunk, the pain being increased by movement, and with this the muscles whose nerves come off from the affected part of the cord are spasmodically contracted, the limbs being rigid, with occasional clonic spasms excited by contact or voluntary attempts at movement, while there is marked hyperaesthesia of the skin, traumatic meningitis is to be diagnosed. io6 SURGICAL DIAGNOSIS. [Chap. vi. When, on the other hand, the pain is less marked, and not increased by movement, but the limbs are paralysed and cold, and rapidly waste, the skin is in- sensitive, and the superficial and deep reflexes are lost, while bed-sores rapidly form, and the urine becomes putrid, the symptoms are due to traumatic myelitis. The chief feature is the paralysis both of voluntary motion, sensation, and reflex action ; this is not pro- duced instantaneously, as in crush of the cord ; nor very quickly after the injury, as in haemorrhage into the cord ; but more slowly, after an interval to be measured by days, and there is accompanying it general fever, as in other inflammations. Haemorrhage into tJie meninges, when extensive, may lead to compression of the cord, and so to paralysis ; but from the large size of the cavity into which the blood is poured, the paralytic phenomena are gradually and not suddenly induced, while the paralysis ascends, affecting first the lower limbs and reflex centres, and gradually spread- ing upwards ; this condition is to be distinguished from myelitis by the paralysis being less marked and complete, as well as by the period of onset and the absence of fever. When at some interval from an injury the patient complains of pain in the spine, extending round the trunk and down the limbs, accompanied by spasmodic contractions of muscles and painful startings, and various alterations in sensation, numbness and formi- cation, with increase of the reflexes, and these symptoms are gradually succeeded by motor and sensory palsy and loss of reflexes, which slowly creep higher and higher up, the phenomena are those of chronic meningo-myelitis. 2. Injuries of the vertebrse. It must not be forgotten that some cases of sudden death from injury are due to crush of the upper part of the cervical spinal cord from fracture-dislocation of the boiies, and Chap, vi.] FRACTURE OF THE SPINE. 107 when an explanation of the death is not elsewhere found, this region should be carefully explored ; very free mobility of the head, with or without crepitus, will further point to this injury. Where the symptoms of paralysis coming on imme- diately upon the receipt of an injury to the spine point to crush of the spinal-cord, a, fracture-dislocation of the bones opposite the injury to the cord, the upper part of the spine passing forward upon the lower, may be inferred. If the lesion be in the cervical or dorsal re- gion, a thorough examination of the spine will not be justifiable, as the injury of the bone is unimportant compared with that of the spinal marrow, and the manipulations requisite to determine the state of the bones are attended with the danger of rendering the crush of the cord more extensive, and of exciting myelitis, which, spreading up, will cause still further and may be fatal paralysis. When, however, the injury is in the lumbar or sacral region, a careful examina- tion of the spine should be made, for there we have the resistant cauda equina occupying the spinal canal ; if any displacement of the bones is detected it will be justifiable to attempt its correction. In such a case, then, the patient should be carefully turned well over on to his side or even his face, and the surgeon should pass his fingers steadily down the vertebral spines to determine whether there is or is not any break or dip in their line ; and if a marked deformity be detected, efforts may be made to replace the bones. It must be borne in mind that regularity of the line of the spines is no proof of the absence of fracture-disloca- tion in the face of evidence of crush of the cord or nerves, for the displacement of the bones may have been but momentary, or reduced by subsequent movements. In cases, however, in which there is no evidence of crush of cord, but where a severe blow has been received on the spine directly, the examination may io8 SURGICAL DIAGNOSIS. [Chap. vi. be made more deliberately. The patient standing up, the surgeon should examine the lines of the spines and transverse processes to determine whether there is any irregularity, depression or marked lateral deviation, at the injured part, and seizing the spinous processes between fingers and thumb, he should attempt to move each of them laterally to determine whether any one of them is detached. It is in cases of injury to the cervical spine, and especially of the higher part of it, that the examination becomes most critical ; where the cord is crushed the symptoms are unequivocal ; but where there is, or is suspected to be, a fracture or a dislocation without crushing of the cord, a complete examination is precluded by the danger of its leading to further displacement with crushing of the cord, and sudden death or rapidly fatal paralysis. Such cases, then, are only to be investigated with the utmost gentle- ness ; pain and rigidity are the symptoms suggesting such an injury, and where the face is turned to one side and fixed in that position, it points very strongly to dislocation forwards of a cervical vertebra on the opposite side. Subsequently, when ankylosis is obtained, the parts may be freely examined, and irregularity of the spines and transverse processes, with perhaps thickening from masses of callus, may confirm the previous diagnosis of a fracture. Fracture and dislocation of the coccyx may be produced by direct violence, falls, kicks, and possibly also in parturition. There is great pain in walking, coughing, and defecation, any act in which the muscles attached to the coccyx come into play. On examining the part externally, irregularity or ci'epitus may be detected ; but if not the finger should be passed into the rectum and the anterior surface of the bone explored ; if now a part of the bone be found movable upon the rest, with crepitus, it shows that the bone is Chap. VI. J SrAAfWS Of THE SPINE. 109 fractured ; while, if a marked transverse projection at the base of the bone is felt, it indicates a dislocation ; it must then be noted whether the prominence is the lower end of the sacrum or the upper end of the coccyx, and this will decide whether the coccyx is dislocated backwards or forwards. 3. Injuries of the ligaments and mnscles are often combined with the more serious lesions wo have been considering above ; but they are not un- frequent quite apart from them, as a result of sudden and violent twists, blows, and strains of the spine. They are the cause of pain and a certain amount of rigidity of the spine, which often lasts for some time, especially in the case of railway accidents. Immediately after the accident the symptoms are localised pain and tenderness, with pain on attempting to move that part of the spine, and often some swelling and ecchymosis ; neither irregularity nor mobility of the spines or transverse processes ; no paralysis or hyperaesthesia of distant parts, unless there is also some lesion of the spinal medulla or nerves. It is, however, later on, when the first effects of the injury have been recovered from, and the pain continues, that the diagnosis becomes of most importance, and Ijie surgeon has to determine whether there is a simple sprain of the muscles and ligaments of the spine or disease of the bodies of the vertebra, or chronic meningo-myelitis. In any case where an action for damages is pending the examination must be made with the utmost care and circumspection, as the patient may under these circumstances be self-deceived, or malingering. The general appearance and behaviour of the patient should be carefully noticed, as well as his movements while his attention is diverted into some other channel. In the absence of muscular spasms or paralysis, no SURGICAL DIAGNOSIS. [Chap. vi. hypersesthesia, paraesthesia, or anaesthesia, at a distance from the injured part, and of increased or diminished reflexes, meningo-myelitis may be excluded. If the pain have continued for many months and there be no projection of a spine or spines (angular kyphosis), and if there be a certain amount of movement of the vertebrae one on another, while pressure down the spine from the head or the shoulders does not excite severe pain, caries of the spine may be excluded. It must be remembered that caries of the spine may be set up by a sprain. If, in the absence of these signs, there be a localised pain in the back, made worse by movement, with some tenderness along the spines, or the muscles by the side of them, and limitation of movement owing to pain, a sprain of the spine may be diagnosed. If the muscles are found wasted, and if the spine can be bent painlessly* to a moderate degree, while the effort to straighten it causes pain referred to the attachments of the erector spinae, the injury is mainly confined to that muscle. If, on the other hand, the muscles be found fairly well nourished, and the pain in moving the spine be not in straightening it, but in bending it beyond a certain slight extent, it points to sprain of the vertebral ligaments. A muscular sprain is recognised by the pain caused by the contraction of the muscle ; a ligamentous sprain is characterised by the pain on stretching the ligament ; it must, however, be noted that pain is caused when a sprained muscle is stretched to the full Occasionally, after severe sprains of the spine, especially of the neck, as in othei joints, the part is left too movable, the ligaments being loose and lengthened. A severe wrench of the spine without fracture or dislocation may be followed by haemorrhage around the cord, or by suppuration in the spinal canal, and suppurative meningitis. 4. Wounds of toe spine. Mere skin or flesh Chap, vii.] INJURIES OF THE FACE. in wounds of this region do not present anything ab- normal. If, however, a deep wound, such as a stab, be attended with a free flow of a clear watery fluid, it shows that the theca vertebralis is injured, and that the subarachnoid cavity is opened. For the chemical characters of this watery fluid, see page 83. Such an injury is likely to be followed by acute meningitis. If a wound of the spine be immediately followed by paralysis of sensation or motion, it shows that the spinal cord, or one or more of the spinal nerves, is injured. The distribution of the paralysis will enable the observer to determine the nerve lesion ; division of a nerve, causing paralysis of the parts supplied by that nerve without any effect upon the parts below ; divi- sion of any part of the spinal cord paralysing all the parts below in those functions for which that parti- cular section of the cord is a conductor. (See also page 99.) Wounds of the spinal cord are prone to excite myelitis. CHAPTER VII. THE DIAGNOSIS OF INJURIES OP THE FACE. THE greater number of the injuries of the face are too obvious in. their nature to require notice here ; but it may be pointed out that wounds must always be care- fully examined for foreign bodies, that bruises must be examined for signs of fracture of the subjacent bone, and that the swelling following lacerations of tissue is often more marked in the face, particularly the lips and eyelids, than in other regions. When from a wound of the cheek there is a great flow of a watery fluid during mastication, the fluid being alka- line in reaction, and " amylolytic," or possessing the i T 2 SURGICAL DIAGNOSIS. [Chap. vn. power of converting starch into sugar, it indicates a wound of the parotid gland or of Steno's duct. And if, when the rest of the wound heals up, a sinus remains which continues to discharge saliva, it is called a salivary fistula. The alkaline reaction of the fluid, and its intermittent flow, which is always excited by mastication, are usually alone relied upon to decide the nature of the fluid ; but if, on adding some of the fluid to a small quantity of a watery decoction of starch, and maintaining it at a temperature of about 100 Fahr. for an hour, it be found that the addition of a drop of tincture of iodine fails to give the character- istic deep blue reaction, and that a brown colour is produced, or no effect at all, the diagnosis is rendered certain. If the wound or the fistula be behind the middle of the masseter muscle, the saliva is escaping from the parotid gland ; but if in front of that line Steno's duct is wounded. If, in addition to an ordinary bruise of the face, such as a "black-eye," there be a distinct swelling, circumscribed, prominent, fluctuating, and dull on percussion, it is a hcematoma. Such a swelling may become solid from coagulation of the blood, or may suppurate. If, immediately after a blow upon the nose, a smooth, tense, rounded, glossy purple swelling be found blocking up one nasal fossa and fixed to the septum of the nose, it is a htematoma of the nasal septum. If after a blow upon the face there be a pufiy swelling, soft, crackling under the fingers, resonant on gentle percussion, it is due to emphysema, and indi- cates a fracture extending into one of the air-contain- ing cavities of the face. The position of the earliest swelling will indicate whether the fracture is into the frontal sinus, the nose, or the antrum. For the detection of fractures of the facial bones, each bone should be carefully examined to determine chap, vii.i FRACTURES OF FACIAL BONES. 113 whether there is any marked deformity. Thus, run the forefinger along the bridge of the nose to see if there be any sharp break in it ; then, in the same manner, with the two forefingers examine the sides of the nasal bones and the nasal processes of the superior maxilla? ; to deformity may be added mobility and crepitus, and in that case there can be no doubt in the diagnosis ; the point or line of deformity and mobility will determine the position of the fracture. Then examine the upper row of teeth and the alveolar pro- cess, see if its line is unbroken, and if any part of it can be moved ; with the eye and finger examine the hard palate to determine that it is regular and symmetrical, and that the two halves are not separated. Then throw back the patient's head, and gently everting the nostril, examine the septum nasi on each side ; it may be found fractured and displaced vertically or later- ally, with depression of the tip of the nose. But care must be taken not to mistake a natural deflection of the septum for a fracture in it ; when the mucous membrane over the septum is unaltered in colour and not swelled, the curvature not tender, and there is no unwonted obstruction to the passage of air along the nose, it may be considered a natui-al deflection of the septum ; but when, on the other hand, the curvature is abrupt, the part swelled, discoloured and tender, and there is unwonted obstruction to nasal respiration, along with flattening or deflection of the nose, it must be regarded as a fracture. Then compare the two malar bones and note any irregularity, flattening, or mobility of the one struck ; and from these pass the fingers back along the zygomatic arches to determine whether either is broken across, which will be indi- cated by irregularity of the bone and mobility of the fragment. In some cases the fracture of the bones of the face is so extensive that the fragments can be seen and felt to move with the utmost ease ; in other 113 ii4 SURGICAL DIAGNOSIS. [Chap. VIL cases again there is so much swelling and bruising of the soft parts that a thorough examination and diagnosis cannot be made until after the lapse of a few days. The lower jaw must be examined in a similar manner. The surgeon should first run his fingers along the outer and under-surf ace of the body of the bone to detect any irregularity or want of symmetry of the two sides. Then let him look at the line of the teeth, and if any irregularity in it be seen, let him grasp the bone, with one hand on each side of the deformity, and try whether there be mobility and crepitus, and note whether the fracture extend through the alveolar pro- cess alone or through the body of the bone as well. If the fracture be opposite or behind the canine tooth, the sensibility of the lower lip on the same side should be tested, to ascertain whether there is also injury of the inferior dental nerve. The surgeon should carefully note whether all the teeth are in place, and if not, he should make sure that one has not slipped down be- tween the fragments. The ramus of the bone must then be carefully examined ; by seizing the angle mobility can be tried for, the contour of the posterior border as well as of the surface through the masseter muscle should be determined. Should these parts be sound and yet the patient complain of great pain in opening and closing the mouth, while he can himself feel and hear crepitus, the coronoid and articular pro- cesses should be carefully examined. Place the fore- fingers, one immediately in front of each pinna, to feel the condyles in their normal position, and carefully com- pare them to make certain whether they are or are not symmetrical, and look closely at the position of the chin, noting whether the space betwen the lower central incisor teeth is vertically below that between the upper ; should there be deformity of one condyle, while the chin is displaced to the same side, a fracture Chap. viii.] DISLOCATION OF LOWER JAW. 115 of the neck of the jaw on that side is to be diagnosed. The coronoid process is to be explored by the finger in the mouth, which may detect that it is immovable, or that it is movable on the rest of the bone, and some- times a sharp projecting edge or point of the fracture can be detected. If, however, on placing the finger immediately in front of the tragus, the firm, slightly projecting condyle of the lower jaw is not to be detected, but, on the contrary, a hollow (the glenoid fossa) is felt, while there is a fulness of the temporal fossa just above the zygoma, there is a dislocation of the jaw. This maybe unilateral, in which case the chin is displaced to the opposite side, or bilateral, when the mouth is open and the chin protruded, and there will be 'the usual signs of pain, with dribbling of saliva, and pain in speaking or attempting to swallow. CHAPTER VIII. THE DIAGNOSIS OP INJURIES OF THE NECK. THE injuries of this region may be divided into wounds, contusions, the impaction of foreign bodies in the respiratory or alimentary passages, and the local effects of heat and caustics. Sprains and fracture and dislocation of the cervical spine have been considered under the head of injuries of the spine (chapter vi). Wounds of the neck, inflicted from the out- side, are, of course, obvious, but they vary from the most trivial, through all grades up to those which are almost instantly fatal, and it is neces- sary both for purposes of prognosis and treatment, to determine what parts have been severed. The question of primary interest is that of wounds of n6 SURGICAL DIAGNOSIS. [Chap. vin. vessels and haemorrhage, and the ordinary rules will here guide the surgeon ; the main vessels lie so deeply that they are comparatively rarely severed. If the wound is in front above the hyoid bone, the tongue may be implicated. An incision in the thyro-hyoid space may sever the epiglottis, and so open into the pliarynx. Wounds opposite the thyroid cartilage, and severing that structure, may traverse the larynx above, at the level of, or below the rima glottidis. Still lower down, the crico-thyroid membrane, or the tracJtea, may be implicated. A wound of the air- passage will be shown by the escape of air from the wound, and oftentimes also by the escape of mucus and frothy blood, and by the loss of voice. The pharynx is readily opened through the thyro-hyoid space ; but below that, it and the gullet can only be injured by a wound on the front of the neck if it have first com- pletely severed the larynx or trachea ; where the wound is thus very deep it may in some instances be obvious that the alimentary canal is opened or severed ; but where there is doubt it may be cleared up by passing a soft catheter or oesophageal tube through the mouth, and observing whether it be visible through the wound ; the surgeon should not give the patient food to swallow to see if it escape through the wound in the neck, as it may pass into the air-passages, and do serious harm ; and only when he is assured that the pharynx or oasophagus is not wounded should he allow the patient to eat or drink. In cases of gunshot wound or stab in the neck, where the injured parts cannot be so well and so easily explored, the diagnosis has to be more largely infer- ential. If a soft, puffy, crackling swelling forms, which increases on attempts at coughing, it is evidently subcutaneous emphysema from wound of the air passage ; such a wound is also to be diagnosed if the patient cough up frothy blood. A stab or gunshot Chap. VIII.] WOUNDS OF THE NECK. 117 wound of the oesophagus may pass unnoticed ; but if the patient vomit blood, or if deglutition be very difficult or painful, and especially if on drinking some milk some of the fluid appear at the external wound, such an injury is to be diagnosed. Injury of the nerves of the neck will be shown by limited paralysis ; in the posterior triangle the great cords of the brachial plexus may be severed, and there will then be motor and sensory paralysis of parts of the upper limb ; or the phrenic nerve may be injured as it lies on the scalenus anticus, this will be shown by paralysis of the diaphragm, causing difficulty in taking a full inspiration, and inability to force down the abdominal viscera, and protrude the belly-wall fully on the same side. If, after such a wound in the neck, the pulse be found irregular and quick, and the action of the heart turbulent, it would point to injury of the vagus nerve; while if the pupil on the same side be small, and do not dilate when both eyes are shaded, it would in- dicate an injury of the cervical sympathetic. If there be loss of voice or dyspnoea, not otherwise explained, the larynx should be carefully examined with a laryngoscope, and if one of the cords be found in the cadaveric position, and unmoved when the patient at- tempts phonation, or takes a deep inspiration, paralysis of the muscles of that side of the larynx from division of the recurrent laryngeal nerve must be diagnosed. In regard to wounds inflicted from tJie inside, it only needs to be pointed out that an exact diagnosis may be quite impossible ; haemorrhage may show that a vessel has been wounded, but there may be nothing to indicate what particular vessel is injured, especially where the wound is out of sight. Contusions of the neck may be instantly fatal. Where this is not the case the examination should be conducted with the view of determining whether the hyoid bone, or any of the cartilages of the larynx or n8 SURGICAL DIAGNOSIS. chap. vin. the trachea, have been injured. The arch of the hyoid bone should first be examined to see if there is any irregularity in it, or whether on compressing the two cornua crepitus is obtained, or great pain caused, or whether the bone yields with the normal elasticity ; where the bone is broken there is usually great pain in deglutition and in any movement of the tongue, so that speech is difficult and painful ; there is also inability to turn the head, and on looking into the mouth ecchymosis of the mucous membrane may be observed. Dislocation of the hyoid bone, in which the cornu of the bone catches against the cornu of the thyroid cartilage, has already been described. Next examine the cartilages of the larynx, and if they be found flattened, or the pomum Adami dis- placed to one side, or unduly movable, or there be distinct crepitus, a fracture of one or other of these cartilages may be diagnosed. There may be so much swelling from effused blood or from emphysema that no precise diagnosis may be possible. The symptoms may be nil or very severe dyspnoea, cough, and pain. The trachea is very rarely ruptured ; but if after a blow on the lower part of the front of the neck there be severe dyspnoea, with cold, livid countenance, weak or lost voice, emphysema of the neck, and the larynx can be felt to be normal, this injury may be suspected, and the diagnosis will be established if the state of the patient and of the parts permit of an examination of the trachea by the finger, and a gap be found in its continuity. CHAPTER IX. THE DIAGNOSIS OP FOREIGN BODIES IN THE PHARYNX, OESOPHAGUS, AND AIR PASSAGES. CASES in which foreign bodies have passed from the mouth, and in some instances from the stomach, into the oesophagus or air passages often present great difficulties in diagnosis, while they are never without grave importance. They naturally divide themselves into two groups : one, in which there is a distinct history pointing to such an accident, and the other, in which no such history is forthcoming, and in which the surgeon has to trust alone to the result of his examination ; these latter cases may be very obscure. The history that may be volunteered, or that should be inquired for, is that of a sudden inspiration or effort while food or some other substance is in the mouth or held between the lips, of vomiting, or of hurried swallowing of only partially masticated food, elc., followed immediately, even suddenly, by symptoms of obstruction to respiration, to deglutition, or to both. In young children there may be an entire absence of history, or it may be known only that the child had something in its mouth when the symptoms suddenly sxipervened, and if it be cherries or plums that the child was eating, the fact becomes additionally significant. In older persons the symptoms may come on during sleep, from the slipping of a plate of artificial teeth, and the surgeon in any case of sudden symptoms of obstruction should satisfy himself that this accident has not hap- pened. In vomiting during unconsciousness from alcohol, chloroform, etc., some of the vomited matters may pass into the air passages. 120 SURGICAL DJAGNOSIS. [ci.ap. ix. In addition to these positive facts, there are some of a negative character that may be of use ; these are the absence of fever, of any previous cough, of change of voice or dyspnoea, and of membranous pharyngitis ; in this way croup can be excluded. The symptoms vary within a very wide range. They may be constant or intermittent, threatening and even causing instant death, or slight and con- tinuing for months or years. They may be enumer- ated as pain and difficulty in deglutition, pain and difficulty in respiration, spasmodic attacks of cough- ing, loss or change of voice, obstruction to the entrance of air into a part or the whole of one lung, purulent expectoration, etc. The chief characteristic is the sudden abrupt onset of the symptoms. The diagnosis* In cases of extreme urgency, with sudden dyspnoea threatening life, and aphonia, the surgeon will at once thrust his finger to the back of the mouth to feel for and to dislodge any body that may be over or in the upper orifice of the larynx, and failing this will proceed to open the larynx or trachea, without waiting to make an exact diagnosis of the cause and actual position of the obstruction. In cases of less urgency, where there is time for deliberation, the first step in the diagnosis is to deter- mine whether the foreign body be present in the air or the food passage. For this purpose give the patient some water to swallow, and if that be taken easily then try some bread, and if a bolus of bread be swallowed without difficulty or pain it may be con- cluded that the phaiynx and oesophagus are free. If the result of the trial is inconclusive, an cesophageal bougie or probang may be passed, which will at once determine the presence or absence of obstruction in that tube. Foreign bodies in pharynx or cesophagus. The usual mode of procedure is for the surgeon to chap, ix.] FOREIGN BODIES IN (ESOPHAGUS. 121 pass his right forefinger into the pharynx, and with it to explore the fauces, tonsils, upper orifice of larynx, and as far down the pharynx as he can reach ; in many cases this will suffice to determine the presence and position, and even to dislodge a foreign body ; but it is imperfect in result, and disagreeable to the patient. A better plan is to trust to the eye. With the mirror used for the laryngoscope throw a strong light into the pharynx, and explore it well, then introduce the laryngeal mirror, and with it examine the upper orifice of the larynx, base of tongue, and lower part of pharynx. Should the obstruction or impaction be below this, as it usually is, the cesophagoscope, an instrument which as yet has been but little used, may be passed, and the lower end of the pharynx and the oasophagus explored, or an ivory-ended probang on a whalebone stem may be slowly and gently passed down into the stomach ; one of full size should be chosen. With this a foreign body of any but a small size may be felt, and if thought desirable, may be pushed on into the stomach. Pins and small fish- bones, however, will not be thus detected. For them it is best to use an " umbrella probang," by which they may be removed. If, however, after repeated trials, nothing be removed, and the patient complain of a pricking pain in a part beyond the reach of the eye or finger, it is a difficult matter to determine whether the symptoms are due to a sharp body actually impacted, or to a scratch or abrasion made by such on its way to the stomach, which often feels to the patient during swallowing like a sharp prick. Time will help most of all in clearing up the matter, for if it be an abrasion or wound of the gullet, and only soft food be taken and be carefully swallowed, the pain will gradually and quickly subside ; whereas if the foreign body be still impacted, the pain will continue, and the patient may hawk up a little blood and pus. It is oftentimes a 122 SURGICAL DIAGNOSIS. [Chap. ix. very difficult matter for the surgeon to assure himself or the patient that some small sharp body is not really impacted in the gullet. (See page 18.) When large bodies, such as a set of false teeth, are impacted in the lower part of the pharynx or upper part of the'gullet,'they may be plainly felt in the neck, bulging out the wall of the tube behind the larynx or trachea. Foreign bodies in the air passages. If the symptoms to which reference has already been made lead to the belief that there is or may be a foreign body in the air passages, the case becomes one of grave importance, demanding a most careful examination. It must be remembered that while such an accident may induce the most distressing and alarming or even quickly fatal symptoms, in other cases the symptoms may be very slight, and further, that, having been severe at first they may quickly subside and give the impression that the foreign body has been expelled : this latency of symptoms must not deceive the surgeon. The evidence on which reliance must be placed is that which shows the actual seat of the foreign body, rather than the general symptoms of the ingress of some solid substance. The examination, whenever possible, should be systematic. First examine the larynx, note the voice, the character of the dyspnoea and cough, and whether there is any local pain or tenderness ; but reliance must be placed chiefly on the results of a careful laryngoscopical examination, which should be as thorough and systematic as pos- sible, the observer first exploring the ventricles and the parts above the rima glottidis, then the rima, and subsequently the parts below the cords. Should the body be veiy small, as, for example, a pin which has transfixed the tissues, and has become almost entirely buried in them, it may be overlooked if great caution be not exercised. In favourable cases the trachea Chap, ix.] FOREIGN BODIES IN AIR PASSAGES. 123 can be examined in the same way, and any foreign body in it seen ; in other cases, however, we have to rely rather upon symptoms ; if attacks of severe spas- modic dyspnoea recur from time to time as the result of a cough or effort, and the patient feel something moving in his trachea, and even perhaps striking the cords above, and still more if on ausculting over the front of the neck the foreign body be heard moving up and down in the trachea with respiration, we are justified in diagnosing the presence of a body which lies loosely in the trachea, and is occasionally forced up violently against the cords, exciting intense spasm of the glottis-closers. Should the trachea be found free, the lungs must be carefully examined, attention being directed to the expansion of the two sides re- spectively, and to the results of percussion and auscul- tation. Should one side of the chest be found immovable during respiration, while the opposite side moves excessively, and the immovable side be found to yield a resonant percussion note, the opposite side being hyper-resonant, and on ausculting the chest there be an absence of vesicular murmur over the one side, or a loud musical or sibilant rale, loudest over the root of the lung, while on the opposite side the breath sound is exaggerated, and without rale unless that on the immovable side be conducted across; if these signs are made out, there can be no hesi- tation in diagnosing the impaction of some foreign body in the bronchus of the side on which the chest is immovable. It should be remembered that in such cases there may be no dyspnoea or distress while the patient is quiet, but movement will at once be attended with dyspnoea. Should an absence of breath sounds or a loud sonorous or sibilant rale be detected over only a part of one lung, the symp- toms may be attributed to the impaction of a foreign body in one of the secondary or tertiary 124 SURGICAL DIAGNOSIS, [Chap. x. bronchial tubes. In some cases a diagnosis has only been made, and has only seemed to be possible, when the foreign body has been actually extruded, either through the mouth or through an abscess in the chest walls. Cases where foreign bodies have lodged for some time, and have set up suppuration, will probably be overlooked unless the history of the onset of the affec- tion be elicited ; unusual localisation or exact limita- tion of the physical signs, however, should always suggest inquiry as to the possibility of the cause being an impacted foreign body. There are other cases of injury from foreign bodies getting into the air passages or gullet, viz those due to hot liquids or caustics. In either case the lips, mouth, and tongue may show signs of scalding, or of the caustic effects of acids or alkalies or of carbolic acid. But in other instances the rapid onset of laryngeal obstruction in a child who has shown no previous symptoms is the first and only evidence of the scald of the larynx. CHAPTER X. THE DIAGNOSIS OP INJURIES OP THE CHEST. INJURIES of the chest are of very frequent occurrence, and from the great importance of the contained viscera they are of special practical interest. They may be classified into contusions and wounds, which will be separately considered ; and as the sequelae of these two groups of injuries are to some extent the same, only the immediate and direct effects of con- tusions and wounds will be considered at first, and in a concluding section of the chapter, the diagnosis of chap, x.] CONTUSIONS OF THE CHEST. 125 all the sequelae or. secondary complications of chest injuries will be given. Many of these latter are inflammatory affections, which, when idiopathic, come under the care of physicians, and much fuller information concerning them will be found in works .on medicine. A, Contusions. A patient having received a contusion of the chest, the diagnosis may be best arrived at by the surgeon's attempting to answer the following five questions : (1) Is there a bruise ! The presence or absence of the well-known ecchymotic discoloration will decide this point. If a purple or yellowish stain appear in the skin after an interval of a few days, it indicates a deep bruise ; ecchymosis and blood-staining of the skin or loin appearing after two or more days have been said to be pathognomonic of hsemothorax, but reliance must not be placed on this sign, as blood in the pleural cavity does not always cause ecchymosis in the loins. The extent of the bruise is, of course, an indication of the number and size of the vessels which have been torn, or of haemophilia. (2) Is there rupture of a muscle ! From a blow or sudden severe strain there may be more or less extensive rupture of a chest muscle, especially of the pectoralis major. If there be inability to raise the arm in front of the body, while on the patient's making the attempt to do this a gap is seen or felt in the pectoral muscle, this lesion is to be at once diagnosed. Similarly, a gap in any other muscle, with pain, and inability to contract the muscle effectively, may enable the diagnosis of ruptures of other muscles to be made. If contraction of a muscle cause acute pain, and no fracture be present, and pressure on the painful part elicit tenderness, bruise of the muscle, with slight rupture, is the probable lesion. The pain of 126 SURGICAL DIAGNOSIS. [Chap. x. this injury may continue for some time, and when it implicates the intercostal muscles, the symptoms simu- late those of broken rib, as there is pain with all the respiratory movements, and some local tenderness; but the diagnosis is established by recognising the absence of irregularity in the rib, of crepitus or of mobility, . by failure to elicit pain by pressure on the rib at a distance from the tender spot, and by the absence of local emphysema. (3) Is there a swelling over the ribs ! The eye, and especially the hand placed flat upon the chest, will decide this question at once. Such a swell- ing may be due to (a) ffcematoma ; blood outside the chest. (6) Emphysema; extravasation of air in the cel- lular tissue. (c) Pneumatocele ; hernia of the lung. (a) Notice whether the swelling be well denned, whether it fluctuate or not, if it pit on pressure, or give a soft, crackling sensation to the fingers, whether it be resonant or dull on very light percussion, and whether it vary in size with inspiration, expiration, and coughing. If it fluctuate, or if without fluctua- tion it be ill-defined, dull on very superficial percussion, unvarying in size with respiration, and non-crepitant, it is a licematoma. These collections of blood vary much in size ; if large and quickly formed, they are due to the rupture of a large vessel, such, for instance, as an intercostal artery near the spine, or a large thoracic branch of the axillary trunk. Haematoma will be distinguished from abscess by its early appear- ance after the injury, and the absence of the usual signs of acute inflammation. (b) If the swelling be ill defined, gradually ex- tending, soft, even pitting on pressure, crepitant, resonant on very superficial percussion, and either unaffected by deep respiration, or if increased by a chap, x.] SUBCUTANEOUS EMPHYSEMA. 127 deep expiration or a cough not lessened by a deep inspiration, it is siibcutaneous emphysema, air having escaped from the lung into the cellular tissue of the chest-wall. This may arise in one of three ways : (a) the lung may be ruptured by severe pressure upon the chest while the glottis is closed, the air passing under the pleura to the root of the lung, and thence spreading up to the neck and over the chest ; in this case the swelling is first noticed about the neck and at the back, and not at a point which is the seat of considerable pain ; (0) or a fragment of a broken rib may lacerate the subjacent lung, and the air escape into the pleural cavity (pneumothorax), and thence at each expiration into the superficial cellular tissue ; (7) or should the fracture occur at the seat of an old pleuritic adhesion, the air passes into the subcutaneous tissue without previously filling the pleural cavity. In either of these latter cases the emphysematous swelling appears first over the broken rib, at the seat of an acute stabbing pain, and not at the neck or back. In the one case there will be great dyspnoea, displace- ment of the heart, absence of breath-sounds, or am- phoric respiration, with metallic tinkling, indicating the presence of pneumothorax ; while in the other case, the vesicular murmur will be plainly audible and quite superficial all over the chest. In either case the presence of this local form of emphysema indicates a fracture of a rib, with wound of the lung. The surgeon must not be misled to the diagnosis of pneumothorax by the existence of a tympanitic per- cussion note, as the presence of air in the superficial tissues may give that sign. (c) If the swelling be clearly defined in outline, soft, non-crepitant, resonant on percussion, swelling out on expiration or coughing (which latter gives a distinct "impulse" to it), and sinking during a deep inspiration, it is a pneumatocele or hernia of lung, 128 SURGICAL DIAGNOSIS. [chap. x. and indicates an extensive and serious lesion of the wall of the chest permitting of the protrusion of the lung. This is a very rare complication of contusions, but is a more frequent attendant upon wounds of the chest (4) Is there an injury (fracture or dis- location) of the bony and cartilaginous wall of the chest! (a) After viewing the chest carefully, to discover whether there is any obvious de- formity, and whether the respiratory movements are general, uniform, and free, pass the hand down the sternum, and then along the ribs from before back, in order from above down, and notice whether there be any irregularity, depression or projection, in them ; at the same time any local tenderness will be detected. If there be an abrupt sharp projection across the sternum, the projecting edge being continuous with one part of the bone, xisually the upper, it will be from a fracture of the sternum, in which the lower fragment is generally displaced backwards beneath the upper. Should the projection be opposite the second costal cartilage, it will be from a separation of the ma- nubrium from tJie gladiolus. Care must be taken not to mistake the normal slight ridge across the bone at this level, which is smoother and more even than in frac- ture or dislocation ; nor the smooth depressions some- times met with in the lower part of the bone, which have no sharp angles or ridges about them. If there be no local bruising occasioning pain, tenderness, and considerable swelling, such a mistake should hardly be possible. Similarly an irregularity in the line of a rib carti- lage may indicate its fracture, or a projection where the rib joins the cartilage may show a separation of the rib from its cartilage ; care must be taken not to mistake for this the nodular enlargement of this part, so com- mon in rickets ; the diagnosis will be easily made by chap. X.] FRACTURE OF THE RIBS, 129 noticing that the rickety swelling is symmetrical, affects many of the ribs, and is smooth and rounded, while the projection from dislocation affects only one or two ribs, is more marked and irregular, and mobility may be detected between the two parts. A marked depression, or angular projection, in the course of a rib or ribs may clearly establish the pre- sence of fracture of ribs. (b) Should the result of the above be negative, place the hand firmly over the part where the patient experiences pain, and induce him to breathe deeply, and then to cough ; should crepitus be felt, it will de- termine the existence of a, fracture. Some prefer to place a stethoscope over the most painful part, and to listen for crepitus during movements of the chest. (c) Should this yield only negative evidence, with one hand over the suspected region, make firm pressure with the other hand along the ribs and over the sternum ; in this way crepitus may be elicited ; or if it be found that firm pressure on a rib causes a sharp pain at a distance from the point pressed upon, that may be taken as evidence of & fracture. (d) It has already been pointed out that the pre- sence of local emphysema or of a pneumatocele proves a, fracture of ribs. (e) In some cases the patient is able to give a clear history of hearing and feeling a bone snap at the time of the accident, and of feeling a grating sensation on taking a full breath ; the sharp stabbing pain will always enable him to localise exactly the position of a fracture. (/) The surgeon may be unable to detect any irregularity of a rib, or to elicit crepitus ; in such a case, localised sharp pricking or stabbing pain caused by any attempt to take a deep breath or flb cough, and by pressure upon the rib at a distance, with spon- taneous fixation of that part of the chest, will be the j 13 130 Sl'KGICAL DIAGNOSIS. iChap. X. signs upon which the diagnosis ot fracture will havo to rest. (5) Is there a lesion of the thoracic vis- cera 7 Cases of extensive lacei-ation of the lung with laceration of large vessels, of double pneumothorax, or of rupture of the heart or great vessels, are usually speedily fatal, death occurring before any exact dia- gnosis can be made. The observer should look for signs of shock, or of loss of blood (pallor, coldness of the surface, syncope), and should notice the amount of dyspnoea present, as each and all of these signs are important as indicating that the injury is not a simple contusion of the chest- walls, but is complicated with some more serious con- dition. There are two phenomena which at once enable a diagnosis of injury of the lung to be made, and they may, therefore be at once alluded to. One is sub- cutaneous emphysema, showing that a rupture or wound of the lung has been produced, allowing air to escape from the alveoli. The other is hemoptysis; if bright- red, frothy blood be coughed up, it proves beyond all doubt a lesion of some of the pulmonary vessels, the blood escaping into the bronchi ; the amount of the haemorrhage will be some guide as to the extent of the lesion in the lung or the size of the injured vessel. It may be pointed out here that in some cases a patient will cough up sooty or black sputa a few days after an injury to the chest ; this arises from a small bruise of the king, with haemorrhage into the alveoli, the altered blood only passing slowly into the bronchi, and being expectorated after an interval. The chest must then be examined thoroughly ; the relative size and amount of expansion of the two sides being first noted, then the percussion note, the respira- tory murmur, voice sounds, position of the heart's impulse, and character of the heart sounds. This ex- amination is to be conducted to enable the surgeon to Chap. X.] fNyURIES OF THE L.UNGS. "131 determine whether there is air or fluid in the pleural cavity, laceration of the lung, or deranged action of the heart. If there be normal resonance all over the pulmonary area, -with superficial vesicular respiratory murmur everywhere without rale, and normal voice sounds, with a regular action of the heart, and normal heart- sounds, the surgeon will be justified in deciding against any lesion of the lung or heart in the absence of any positive sign to the contrary, such as emphysema. If shortly after an accident the lower part of the pul- monary area be found to be dull on percussion, the dulness perhaps increasing in extent from hour to hour for a few hours, and over this area the vocal fremitus be weakened or abolished, while auscultation shows the respiratory murmur and vocal resonance to be weak and distant, or absent altogether; and immediately above the dull area the physical signs are normal or indicate compression of the lung, a diagnosis of hcamotliorax is to be made. If there bo much pleural haemorrhage there will be a corresponding degree of dyspnoea, and the usual signs of loss of blood. After two or three days a dark purple discoloration of the skin over the lower part of the chest behind and in the loins may be noted. The blood will almost certainly come from the lung, and its presence may be accepted as a proof of laceration of the lung ; where there is also haemoptysis, this fact is beyond all doubt. If one side of the chest is found to be expanded with obliteration of the depressions along the inter- costal spaces, giving a tympanitic percussion note, the breath-sound being weak, and distant, or inaudible, or amphoric in character with perhaps coarse, crepitant rales, "metallic tinkling" and the " bell-sound " being audible, while the heart is found displaced to the opposite side, and the patient experiences severe dyspnoea or even orthopnoea, it indicates pneumotfiorax 132 SURGICAL DIAGNOSIS. tchap. x. from rupture of the lung through the pleura, the ail- Laving escaped into the general pleural cavity ; this may or may not be combined with fracture of a rib, or with superficial emphysema. Occurring 011 the left side it may obliterate the normal cardiac dulness, and so displace that viscus as to render detection of the cardiac impulse impossible, and that of the heart sounds very difficult. These signs may be present over a limited area of one side of the chest, the physical signs over the rest of the lung being normal j in that case there is a pneumothorax limited by old pleuritic adhesions. If a combination of these physical signs be met with, a dull note and loss of voice and breath sound, and of vocal fremitus oA'er the extreme base of the chest, and tympanitic resonance, amphoric respiration, " metallic tinkle," and succussion fremitus over the upper part of the chest, it shows that there is hcemo- pneumotJiorax. In all cases of pneumothorax there will be some amount of blood in the pleural cavity, but it may be so small in quantity as not to give rise to any characteristic physical signs. In reference to the evidence of pulmonary lesions it may be well to draw the student's attention to the great importance of observing whether a patient the sub- ject of fractured ribs be also the subject of emphysema of the lungs and chronic bronchitis, the barrel-shaped chest, loss of power of expansion of the chest in inspir- ation, prolonged wheezing expiration, hyper-resonance, diminution of the area of cardiac dulness, prolonged expiratory murmur, and loud sonorous or sibilant rales will be the signs pointing to these conditions, which render serious an accident under other circumstances of small moment. Lesions of the heart from contusions of the chest are much less common than those of the lung. If, however, immediately after such an injury a murmur chap, x.] WOUNDS OF THE CHEST. 133 be detected in connection with either of the heart sounds, and there be evidence that this is a sequel of the accident, either by the surgeon's previous know- ledge of the patient or the onset from the time of the accident of marked signs of disturbance of the cir- culation, which find no other explanation, and are explicable upon the theory of interference with the functions of one or other of the cardiac valves, it would be proper to diagnose a rupture of a semilunar valve, or of chordae tendinece. The signs of circulatory disturbance to be sought in such cases are faintness, a quick, feeble, soft pulse, or the suddenly collapsing pulse of aortic regurgitation, irregular and turbulent action of the heart, palpitation, dyspnoea, venous dis- tension, and the signs of general pulmonary hyper- semia. For fuller information on these subjects refer- ence must be made to works on medicine. Ruptures of the large vessels of the thorax are very rarely caused by contusions of the chest, and are very rapidly fatal from internal haemorrhage. Injuries of the abdominal viscera are treated in chapter xi. B. Wounds. Wounds of the chest are of much less frequent occurrence than contusions, and they are usually produced either by stabs or bullets, and there- fore they often have a medico-legal as well as a surgical importance. In any given case the surgeon should put to himself and seek an answer to four questions, 'and we may discuss the diagnosis in the form of answers to these questions. (1) Is the wound penetrating: or 11011- pcnetrating. That is, is it limited to the chest walls 1 or does it extend into one of the three great serous cavities of the chest or into the mediastinum ? The surgeon should attempt to show that it is pene- trating, and only in the absence of all evidence to the contrary consider it non-penetrating; but in no 134 SURGICAL DIAGNOSIS. chap. x. case must the wound be explored for this purpose, either by finger or probe, for in so doing penetration may be caused ; reliance must be placed upon evi- dence of lesion of the thoracic contents. In some cases the wound is evidently quite superficial, and the question of penetration can hardly be said to arise. If there be no emphysema around the wound, no passage of air through it during respiration (trau- matopncea), no pneumothorax, hsemothorax, or prolapse of lung, no haemoptysis, no disordered action of the heart, and no dysphagia, there is no evidence to war- rant the diagnosis of penetration ; but even in these circumstances, when the nature of the injury makes penetration probable, it is only when no secondary in- flammatory complications (pleurisy, pneumonia, peri- carditis, or mediastlnal suppuration) arise that an absolute diagnosis of non-penetration can be made. (2) Is the wound attended with haemor- rhage ! If so, what is the source or the bleeding 1 Blood may escape externally through the wound, or be coughed up mixed more or less tho- roughly with air, and in either case its recognition is perfectly simple. But the bleeding may be internal and unrecognised unless a careful examination is made. The constitutional signs of loss of blood (pallor, vertigo, syncope) must be carefully noted, and search should be made for evidence of haemothorax, haemopericardium, and hsemomediastinuin. The signs of hcemothorax have been given already. (See page 131.) If , quickly after a wound, the normal cardiac dulness be increased, the im- pulse of the heart displaced upwards or lost, the sounds indistinct or inaudible, especially over the lower part of the dull area, with feeble or turbulent action of the heart as shown by the pulse, hcemopericardium may be dia- gnosed. If, with a se*nse of oppression across the chest and dyspnoea, there be found dulness behind the sternum and reaching outwards on each side, with loss of cardiac Chap. X.J INTRATHORACIC HEMORRHAGE. .135 impulse, and extreme weakness of the heart sounds, which maybe entirely iu&udi\>\e,hcemomediastimim may be diagnosed. These last two conditions may coexist, or the distinction between them may be very difficult ; the position and known direction of the wound may afford some aid in diagnosis ; blood in the pericardium leads to much more serious disturbance of the heart's action than when it is extra vasated in the mediastinum. It must be remembered that external and internal haemor- rhage may and often do coexist, and although in all cases a careful examination to detect the lattej.' should be made, the necessity for it becomes more urgent when the general signs of loss of blood are greater than can be accounted for by the external flow. Such examination must, however, be conducted with the greatest care, as undue movement or excite- ment of the patient may lead to a recurrence of haemorrhage which has been arrested by nature. The fact of haemorrhage being established, some attempt must be made to determine its source. The position of the wound, and of the accumulated or flowing blood, are important aids in arriving at a con- clusion. The intercostal vessels run along the lower border of the ribs ; the internal mammary vessels run vertically down behind the costal cartilages, half an inch from the edge of the sternum ; wounds therefore in these situations may involve those vessels, and if the bleeding be solely external, or escapes per sal turn, or be moderate in amount, and the blood escape un- mixed with air, and if on introducing a folded card into the wound the blood flow over the outside of the card and not within the fold, or if the bleeding can be stopped by pressure with the finger against the upper of the ribs bounding the wound, the hsemorrhage may be considered as coming from a parietal vessel. But when the haemorrhage is excessive, and gives rise to hsemothorax, or when it is thin, of a bright red colour, 136 SURGICAL DIAGNOSIS. [Chap. X. and mixed with air, while similar blood is expector- ated ; especially if the blood-flow varies with respira- tion, and is attended with traumatopnoea or extensive emphysema, it may be regarded as coming from the lung. Extensive haemorrhage from a wound over the area occupied by the heart and great vessels from a wound of those structures is attended with haemorrhage into the pericardium or mediastinum, and is quickly fatal. The position and direction of the wound may enable the distinction to be made between wound of the heart and wound of one of the great vessels. 'It must be added that the diagnosis between parietal and visceral haemorrhages may be impossible without exploration of the wound, and also that they may coexist. (3) Does the wound implicate a viscus ? This is the most important question in reference to wounds of the chest, as upon the correct answer to it the prognosis mainly depends. (a) If a wound of the chest be attended with moderate emphysema, or slight traumatopncea or pneumothorax and collapse of lung, and there be no evidence of external haemorrhage more than that accounted for by the external wound, and no haemo- thorax, and no haemoptysis, the diagnosis of ivound of tlie pleura without injury of the lung is to be made ; this lesion is rare, and is met with towards the ex- treme base of the lung, and as a result of wounds by not very sharp instruments. (6) If instantly or quickly following a wound of the chest, a soft, smooth, dark purple mass be found pro- jecting from the wound, elastic and crepitant to the fingers, it is a hernia of the lung due to a wound of the pleura. This is met with especially in wounds of the front of the chest, near the fissures of the lungs. - The appearance and feel of the lung are characteristic, but a protrusion of very congested omentum has been chap, x.] WOUND OF THE HEART. 137 mistaken for the lung, a mistake which may be avoided by noticing the lobulated condition of the omentum, and the smoothness and crepitation of the lung. (c) Where there is extensive emphysema compli- cating a wound, or marked pneumothorax, hsemo- thorax, free haemoptysis, or distinct traumatopnoea, and especially where two or more of these are met with together, a wound of lung is to be diagnosed. (d) If a wound over the region of the heart be followed by tympanitic resonance over the cardiac area, with (sometimes without) a loud ringing character of the heart sounds, and if after a short interval there be dulness over more or less of the lower part of the cardiac area, with a tympanitic note above, a raised position of the heart's impulse, dyspnoea, distress, epi- gastric pain and quickened feeble pulse, followed in a few hours by pericardial friction, the evidence warrants the diagnosis of wound of the pericardium, leading to pwumopericardiumy hcemopericardium and pericar- ditis. (e) If a'wound over the heart be immediately fol- lowed by considerable shock and syncope, with free external bleeding, or evidence of internal bleeding into the mediastinum or pericardium, with rapid weak pulse, and be quickly followed by the usual signs of pericarditis, a diagnosis of wound of the heart should be made. Should a foreign body be found in the wound, such as a long needle, and it be noticed to move with every pulsation of the heart, it may be assumed that it is embedded in the heart wall There is often considerable anxiety and fear in cases of wound of the heart ; they may be extremely difficult to dia- gnose, and some reliance must be placed upon the nature of the injury, the haemorrhage and the early onset of pericarditis. The position of the wound will enable the surgeon to determine approximately which part of the heart is wounded. 138 SURGICAL DIAGNOSIS, tchap. x. (/) A wound over the great thoracic blood vessels, followed by profuse hemorrhage and all the signs of ex- tensive hcemomediastinum, with collapse, syncope, and dyspnoea, is complicated with ivound of a great blood- vessel ; such injuries are with few exceptions certainly fatal in a few hours. (g) If after a wound of the chest there be spitting of blood, dysphagia, and liquids swallowed are found to escape at the external wound, a wound of the cesoj)hagus (a rare accident) is to be diagnosed. (7i) Where, after a wound in the chest, there is a flow of clear serous fluid which becomes milky in appearance after a full meal, and the fluid on exami- nation is found to consist of a very fine molecular base with globular nucleated corpuscles, and to con- tain much fat, a wound of the thoracic duct is to be recognised. This injury is very rare, and if the fistula continues open it leads to considerable ema- ciation and exhaustion. (4) Is there a foreign body in the wound 1 In some cases it is extremely easy to answer this question, but in many others it is quite impossible. A knowledge of the mode of infliction of the wound, whether by gunshot, stab, or prick, is important, and an examination of the clothes should always be made. In cases of stab wounds, the weapon used should be carefully examined for any evidence of recent fracture. In cases of bullet wounds, an inspection of the pistol may show how many bullets have been discharged, and they should then be sought [for where the shots were fired, and in the patient's clothes. By these facts it may be shown to be extremely improbable that any foreign body is lodged in the wound, or, on the contrary, practically certain that such is the case. The next step will be to examine the wound. A knife-blade may be found transfixing a rib, or the end of a needle projecting tluxmgh or under the skin, or a chap, x.] FOREIGN BODIES IN THE CHEST. 139 finger or a probe may detect a bullet in the wound, or the detachment of the part of a rib. Where there is a history clearly pointing to the lodgment of a foreign body, the onset of acute inflammation of the wounded part running on to suppuration confirms the suspicion. In some instances, when the collection of pus (empyema or pulmonary abscess) has been evacuated the foreign body has been discharged with the pus, or detected on an examination of the cavity with the probe, and removed. In the case of a needle or knife-blade or similar body transfixing the prsecordial region, if a movement is communicated to it by the contraction of the heart it shows that it is impacted in the heart. Where the history indicates the lodgment of a foreign body in the pulmonary region of the chest, and there are no indications of a wound of the lung, and acute pleurisy and empyema ensues, it points to the presence of the foreign body in the sac of the pleura. Where, on the other hand, the signs are those of wound of the lung, and especially if pneumonia and a pulmonary abscess suddenly bursting into a bronchus occur, it points to the lodgment of the body in the lung. A certain diagnosis is not always possible. 0. The secondary complications of in- juries of the chest. The sequels^ of injuries of the chest are, with one exception, inflammations of the various structures involved, which frequently termi- nate in suppuration. It may be useful to append a list of them : (a) Muscular rheumatism, (l>) Subpectoral abscess, (c) Peripleuritic abscess, (d) Pleurisy, (e) Empyema, (/) Pneumonia, (ff) Gangrene of the lung, (h) Mediastinal abscess, (*) Pericarditis, (k) Myocarditis, (I) Endocarditis, (in) Pneumocele. If the patient convalesce without pyrexia, pain, dyspnoea, syncope, palpitation, or other sign of 140 SURGICAL DIAGNOSIS. [Chap.x. respiratory or circulatory difficulty, it indicates an absence of these complications. But the accession of pain, or especially of fever, with or without an initial rigor, of increased dyspnoea, or of signs of cardiac failure should at once excite suspicion, leading to a careful examination of the chest, while a knowledge of the nature of the original injury will suggest the in- flammatory lesions to be especially anticipated. Thus simple fracture of the rib is not unfrequently followed by pleurisy, with or without effusion ; wound of the pleura and hsemothorax often runs on to empyema, wound of the lung to pneumonia, and a bruise may lead to muscular rheumatism. First examine the chest walls for any evidence of " rheumatism " or of swelling, and then make a systematic physical examination of the lungs and heart. (a) If after a contusion of the chest, or some sudden strain, the patient continue to suffer from a localised pain on taking a deep breath, or on coughing, or on attempting to contract any of the thoracic muscles, and if the painful part be also tender, with no evi- dence of a fracture of a rib (see page 142), or of pleurisy (see page 129), or other intrathoracic complication, i.e. if there be no friction and no dulness on percussion, muscular rheumatism, intercostal or other, must be diagnosed. (6) When with the general signs of inflammation the front of the chest is found swollen, the swelling being ill-defined, boggy, and cedematous in nature, attended with considerable pain and tenderness and great pain on raising the arm forwards; and further when it is known that this swelling did not immedi- ately follow the injury ; a snbpectorcd abscess is to be diagnosed. In these cases the pus is often too deep to give rise to fluctuation ; where there is doubt an exploring needle or trocar may be introduced : flxic- tuation will be earliest detected in the axilla. Chap. x.i PRRIPLEURITIC ABSCESS. 14! (c) If, after a contusion or small punctured wound of the chest which has healed, the patient become ill, feverish with high temperature, perhaps a rigor or rigors, with pain in the side, the site of the injury should be carefully examined. If, now, that part of the chest be found enlarged, with one or more inter- costal spaces widened and bulging, while the ribs above are even closer together than normal ; and if fluctuation can be detected in these bulging spaces, and if they are noticed to become less prominent during inspiration and more tense and full during ex- piration ; if this area be dull on percussion and vocal f remitus be abolished over it, and the respiratory mur- mur be weak, but there be no friction heard ; and, further, if the heart be not displaced to the opposite side, or the liver or other abdominal organs depressed, jjeripleuritic abscess should be diagnosed ; if on tapping the swelling pus flow out from the part more forcibly and rapidly during expiration, this diagnosis will be confirmed. Baiiels asserts that the pus from such an abscess is of a higher specific gravity than that from empyema, the latter not being above 1032, while the former, in one case observed by him, was as high as 1041. In such a case the diagnosis lies between em- pyema and peripleuritic abscess, and the attention must be directed especially to the following points. In empyema, the distension of the chest is uniform, and "pointing" is a late sign; while in peripleuritic abscess the distension is more localised, and "pointing" is noticed earlier. In empyema, the dull area nearly always involves the lowest part of the pleural sac, even if it rises high up, and its upper level may be modified by position. In abscess there may be a resonant area below the dull area in which the respiratory movements and sounds are normal, and the level of duliiess is quite unaffected by position. In empyema there is displacement of the neighbour- 142 SURGICAL DIAGNOSIS. rchap. x. ing organs, in abscess there is not; in empyenia a difference in tension of the swelling during inspiration and expiration is not observed, and on tapping the collection of pus, the flow is not at first affected by respiration, but only later on. Peripleuritic abscess is a very rare affection ; it may arise spontaneously as well as from injury ; it may burst into the pleura and set up purulent pleurisy, or spread to the medias- tinum and pericardium, involving those tissues in suppuration, (d) If, on ausculting the chest, a dry rubbing or creaking sound be heard with inspiration and expira- tion, limited to a certain area of the chest, and unattended with dulness on percussion, it indicates dry pleurisy. Such friction may be heard just above a pleuritic effusion or over a pneumonic lung. (e) If one side of the chest be found enlarged, with bulging of the intercostal spaces, and great lessening of the respiratory movements, and is dull on percussion, with loss of vocal fremitus, while the breath-sounds are inaudible, or are distant, weak, and bronchial in character, and the vocal resonance is distant and bronchophonic ; and if, further, there be displacement of the heart to the opposite side, and if on the right side, of the liver downwards with exaggerated breathing in the opposite lung, there can be no doubt that there is an accumulation in the pleural sac. These signs, found quickly after the injury, point to Jicemo- tlwrax ; coming on after an interval of a day or two, or increasing at that time, and especially when attended with fever and increasing dyspnoea, they clearly indicate pleurisy with effusion, while if the temperature continue to rise and remain very high, or if there are rigors with sweatings, and emaciation ; or if a localised fluctuating swelling form in any part of the chest wall, empyema is to be diagnosed. Wherever any doubt as to the nature of the fluid in the chest is chap, x.] PNEUMONIA. 143 entertained, a small exploring syringe should be introduced and a portion of the fluid withdrawn for examination. This method of diagnosis, the most certain of all, is justly coming more and more into use. (/} If the examination of the chest show localised dulness around the wound, with tubular breathing, fine crepitation, and bronchophony, and the patient be febrile, with sharp pain in the chest, cough, and rusty expectoration, traumatic pneumonia is to be diagnosed. This form is less severe and less extensive than the idiopathic. If combined with pleurisy, the physical signs will be modified, and reliance in the diagnosis of pleura-pneumonia will be placed especially on the combination of rusty expectoration, tubular breath- ing, and fine crepitation with loss of vocal fremitus, bulging of intercostal spaces and perhaps friction. Should the inflammation attack a portion of lung that has been wounded, coarse, moist rales may be heard. If, in a case of pneumonia, the patient sud- denly cough up a quantity of pus, it will point to an abscess in the lung, which has burst into a bronchus ; and if now the signs of a cavity are present where before there was evidence of pulmonary conso- lidation, this diagnosis and the exact position of the abscess will be established. (g} If, with or without evidence of traumatic pneumonia, the patient, some days after the injury, cough tip dark and extremely fetid sputa, and the breath have a horribly foetid odour, the diagnosis of gangrene of the lung is to be made. This may be confirmed by detecting shreds of pulmonary tissue in the expectoration, the elastic fibres having a charac- teristic clear defined outline under the microscope, and resisting the action of acetic acid. An at- attempt should be made to localise the gangrene for the purpose of treatment ; and if an area of dulness, 144 SURGICAL DIAGNOSIS. [Chap. x. with moist rales and hollow respiratory murmur bo detected, that may be regarded as the seat of the disease. Gangrene is a rare sequel to chest injuries, but is met with occasionally after contusions and wounds, particularly if the lung is much lacerated or a foreign body is retained. (/*) If in a case of pnewnw- or haino-media$tinum, or of severe blow or wound of the sternum, the dis- tress of the patient become considerably increased, and there be palpitation of the heart, and dyspnoea, or oadema and signs of venous obstruction in the head, neck, and upper limbs, and on percussion a dull area is found over the sternum and extending laterally over the costal cartilages, and if with this there be pyrexia, with, perhaps, rigors, the surgeon must suspect niediastinal abscess. Careful examination jof the suprastemal notch of the intercostal spaces close to the sternum and of the epigastrium should then befrequently made, and if at either of these situations a soft fluc- tuating swelling appear, which may have a pulsation transmitted from the heart, or become fuller and more tense during expiration, this diagnosis will be established. The diagnosis will probably not be made before the abscess " points ; " but when it is suspected, an exploring syringe should be carefully introduced. The abscess may suddenly burst into either the pleura or the pericardium, setting up acute inflammation. Death often takes place before pointing has occurred. (i) Even within a few hours after a wound of the pericardium, friction may be heard over the cardiac area, showing the development of pericarditis. Peii- cardial friction is to be distinguished from pleuritic friction by the place where it is heard, by its being unmodified by respiration, and accompanying both sounds of the heart ; and from endocardia! murmurs, by its creaking or rubbing character, its uniformity with both sounds of the heart, its strict limitation, its chap, x.] PERICARDITIS. 145 want of conduction along the vessels or round into the axilla, and in some cases by its modification by firm pressure with the stethoscope. If this be followed by an increase in the area of cardiac dulness which takes the shape of the pericardium, with displacement upwards and to the left of the heart's impulse (which, may be quite lost) increased frequency of the heart's action and loss of the heart sounds over much of the dull area, while the pulse is small and weak, and dyspnoea very marked, the patient sitting up in bed and leaning forward, and having a frequent dry short cough, pericardial effusion has occurred. Should rigors occur, and there be any tendency to "point" in any part of the dull area, pyopericardium may be diag- nosed ; an exploring syringe will at once determine the nature of the fluid in the sac. (k) When, in connection with pericarditis, the heart's action becomes extremely weak and irregular, leading to syncope on movement or sitting upright, the existence of myocarditis is to be inferred. There are no positive signs by which its presence may be demonstrated. (I) If the surgeon be able to recognise the develop- ment of an endocardial murmur after a contusion, strain or other injury of the chest, i.e. if he at his early examination find the heart sounds clear, and subsequently note a murmur, it is evidence of the occurrence of endocarditis. The time, place of greatest intensity, and the direction of conduction of the murmur will enable a precise diagnosis of the valvular affection to be made. For this, reference should be made to works on medicine. (ni) If, after a wound in the chest has healed, or after a severe contusion, a tumour slowly and gradually appear, which is circumscribed, smooth, soft, rounded, crepitant under pressure, resonant on light percussion, with an impulse on coughing, expanding with each K 13 146 SURGICAL DIAGNOSIS. [Chap. xi. expiration and contracting during inspiration, it is a consecutive prolapse of the lung, or a pneumocele. These tumours may appear rapidly and attain a large size ; they may be more or less reducible, allowing the outline of the aperture through which the lung escapes to be felt. CHAPTER XI. THE DIAGNOSIS OP INJURIES OF THE ABDOMEN. INJURIES of the abdomen, as of the head and chest, derive their chief interest from the importance, and usually great danger, of any lesion of the viscera con- tained within the cavity. Hence, the question which above all presses for an answer is, whether any given injury has merely bruised or wounded the parietes, or whether there is a visceral lesion as well ; and if the latter, which of the several viscera has been damaged. While visceral lesions are generally the result of the more severe forms of violence, the surgeon must always remember that even by apparently trivial blows fatal visceral ruptures may be caused, while recovery may take place after more severe contusions. In arriving at a diagnosis of a case of abdominal injury, it is well to consider that the patient is 'the subject of a visceral lesion until the contrary can be proved, and to employ the method of exclusion ; and further, when examining the patient, the utmost gentleness of manipulation must be employed, lest the surgeon's fingers or the patient's movements should convert an incomplete into a complete rup- ture, or induce a renewal of haemorrhage that Nature has arrested. Abdominal injuries are to be divided into con- Chap, xi.] CONTUSIONS OF THE ABDOMEN. 147 tusions and wounds, of which the former are much the more common in civil practice, and form an ex- ceedingly serious and highly fatal class of cases. The sequela of each group will be considered separately. Exact diagnosis may be impossible when the patient is first seen. The absence of all acute symptoms, or of symptoms distinctly pointing to a visceral lesion, is not enough to justify the surgeon in proclaiming the injury unimportant ; but he should wait to see whether any severe symptoms, especially inflammatory symptoms, set in. For example, there may be nothing to indicate soon after the injury even such a severe lesion as a rupture of the intestines, but in a few hours the onset of acute peritonitis will reveal the gravity of the case. The same holds good in the case of wounds. It is only if the patient con- tinue to be free from severe symptoms that a diagnosis of a simple superficial lesion can be made. A. Contusions. There may be no indications whatever on the exterior of the severity of internal lesions ; but no case, however trivial it may appear, is to be dismissed without a careful consideration of all the circumstances, and without waiting to see whether serious symptoms do or do not quickly ensue. Some assistance in diagnosis is to be obtained by a precise knowledge of the injury inflicted, whether a fall or blow or crush, and of the exact spot struck, and of the condition of the abdominal viscera at the time, especially whether the stomach or bladder was full. Attention is to be particularly directed to the general condition of the patient, to any evidence of shock or collapse, or of internal haemorrhage, and to local signs, pain, tenderness, vomiting, emphysema and hsematuria. Pain is, of course, a symptom of all injuries ; but when it is intense, and increases spontaneously, i.e. without any movement on the part of the patient, or is fixed in one spot, and 148 SURGICAL DIAGNOSIS. [Chap. xi. from that gradually radiates over the belly, it becomes of very serious portent. Similarly, shock may be pro- duced simply by contusion of the solar plexus and its branches ; it is most intense immediately after the injury. When shock continues long, and espe- cially when it gradually deepens, or when collapse only comes on at an interval after the injury, or when the patient has to some extent, if not entirely, recovered from the primary shock, the indication of a severe internal injury is v~6ry marked. Vomit- ing is another very frequent symptom. When a person receives a blow on the belly soon after a meal, vomiting simply to the extent of emptying the stomach is common, and has no serious significance ; but when the act is often repeated, and becomes "persistent," and particularly when the ejecta contain blood or bile, it is an important sign of visceral lesion. The significance of hcematuria, or of the passage of blood by the boivel, is too obvious to require comment ; but it may be pointed out, that if bright-red blood be passed per anum as the result of an abdominal injury, it points to a lesion of the colon, while an altered condition of the blood (tarry stools) would show that it comes from some part of the alimentary canal farther removed from the anus. Subcutaneous emphysema is not often observed in connection with abdominal injury ; when it is, care must be taken to determine whether it is thoracic or abdominal in origin. Of the former we have previously spoken (see page 127) ; the seat of the injury and the place where the swelling first appears are the signs by which this distinction is to be drawn. When abdominal in origin, it usually makes its appearance first in one or other loin or groin, and it indicates a rupture of the intestine ; and when, as is usually the case, it is not combined with pneumo-peritoneum, or gas in the general peritoneal cavity, it points unmistakably to a rupture of some Chap. XL] RUPTURE OF THE LIVER. 149 part of the gut where it is uncovered by peritoneum, such as the back of the second and third parts of the duodenum, of the caecum, or of the colon. ' The same symptom is occasionally observed in injuries of the rectum. In the absence of severe shock, or of increas- ing collapse, of severe pain, of vomiting, of em- physema, or of hsematuria, the probability is that there is no visceral lesion ; but such a conclusion is then conjectural, and it becomes absolute only when time has failed to elicit other signs, especially peri- tonitis and the formation of a tumour. When with pain which is neither very intense, nor increases spontaneously, but is exaggerated when the patient contracts the abdominal muscles in respiratory or general movements, there is swelling of the abdominal walls and the well-known dis- coloration of a bruise, it must be recognised as a bruise of the abdominal wall ; and when to this is superadded the presence of a gap or depression in the course of a muscle (and this especially happens in the case of the rectus abdominis muscle), it indicates a rupture of a muscle. It may happen that the gap in the muscle is not recognised until after the absorption of the effused blood. If a patient have received an injury upon the right hypochondrium, and complain of fixed and severe pain in that region, and if the shock be marked or, especially, collapse increase after the injury, with signs of internal haemorrhage (blanching, sweating, syncope, quick feeble pulse), rupture of the liver must be suspected. If now there be persistent vomiting, and the vomited matters contain bile, but not blood ; if there be an increase of the normal liver dulness, and especially if there be subsequent ascites, jaun- dice, and the passage of pale clayey stools, the sus- picion is converted into a certainty. In a large 150 SURGICAL DIAGNOSIS. [chap. xi. majority of the cases of this injury, as of others to the abdominal viscera, death quickly ensues. Cases of recovefy are by no means unknown, and the author quite recently had the opportunity of watching two in which the above-mentioned symptoms left no doubt as to the nature of the injury sustained. Sugar may be found in the urine after injuries to the liver. If an injury to the epigastrium or left hypochon- drium of a patient who has recently taken a meal be immediately followed by intense pain in the injured part, which quickly radiates over the whole belly, by extreme shock from which the patient does not rally, and by repeated painful vomiting with hsematemesis, the diagnosis of rupture of the stomach may be arrived at. This injury, fortunately, is rare ; it only occurs when the viscus is more or less distended, and it appears to be invariably fatal. The suffering it occasions during the short time the patient survives is intense, and is shown by the extreme anxiety de- picted on the countenance. When, following a blow upon the belly, especially about the umbilical and hypogastric regions, the patient is immediately seized with severe pain in the part struck, which then radiates over the belly, and on laying the hand on the belly wall the muscles are found rigidly contracted and immovable, and the patient complains of tenderness, and there is vomiting, con- stipation, and collapse, rupture of the intestine is to be diagnosed. The collapse is usually severe ; but it may be slight, and the general symptoms only become severe when the peritonitis excited by the fsecal extra- vasation sets in. Should there be subcutaneous em- physema, or the passage of blood per anum (the history of the case and examination alike excluding any injury to the rectum) the diagnosis of intestinal rupture be- comes still more positive. The signs of this injury may be quite absent when the patient is 6rst seen. Chap, xi.] RUPTURE OF ABDOMINAL VISCERA. 151 The author well remembers the case of a lad who was struck in the belly with a piece of wood, who, when seen shortly afterwards, was not suffering from collapse, severe pain, vomiting, or any symptom pointing to a grave visceral lesion ; but peritonitis quickly set in and proved fatal, and at the autopsy a complete rup- ture of the ileum was found. If a blow upon the left hypochondrium be followed by deepening collapse, blanching of the surface, syncope, and the other general signs of internal haemorrhage, and if pressure under the left margin .of the chest elicit tenderness, and especially if the splenic dulness to percussion be increased downwards and forwards, a rupture of the spleen is to be diagnosed. When the rupture is extensive the haemorrhage is profuse, and if not fatal, is followed by peritonitis ; the position of the blow and of the dulness caused by the accu- mulating blood are then the only signs to be relied upon for diagnosis. Should the position of the blow be unknown, or the injury more diffuse, and the local dulness masked, or not made out, it would be impos- sible to distinguish this injury from any other source of internal haemorrhage. When an injury to the loin is followed by hsema- ttiria, the blood being intimately mixed with the urine, sometimes forming long slender " casts" of the ureter, a rupture of the kidney of the same side is to be dia- gnosed. Should the loin be found bruised, painful and tender, and if there be pain in or retraction of the testicle, or pain or numbness down the front of the thigh, the diagnosis will be confirmed. - Where -the patient has received a very severe crushing injury of the loin, and there is much bruising of the part, deep swelling, pain, and tenderness on trying to feel the kidney, especially when, combined with these signs, there is marked collapse, even in the absence of haematuria. a rupture of the kidney may be 152 SURGICAL DIAGNOSIS. [Chap. xi. suspected to have been produced, the ureter being obstructed. For the diagnosis of rupture of the bladder, see page 166. If, after a blow on the belly, which may or may not be attended with more or less shock, the patient become increasingly collapsed, with a rapid, feeble, fluttering pulse, shallow and sighing respiration, blanching of the skin and of the muco\is surfaces, and restlessness, internal hemorrhage is going on. In some cases there is marked abdominal distension, due to the effused blood. In the absence of symptoms indicating the rupture of one of the large solid viscera, it is im- possible to determine the source of the bleeding ; it may be the mesenteric vessels, or the vena cava, or any other of the large vessels of the belly. The restless- ness of the patient may be a very marked symptom, and is in strong contrast to the dread of movement, especially of abdominal movement, in cases of rupture of the intestine. If vomiting occur at all, it is not the persistent emesis so distressing in rupture of the stomach, of the liver, or of the intestine. When, after a sudden strain or severe injury, the patient complains of a sharp pain in the left side of the chest, and of dyspnoea, and is found unable to take a full inspiration and to " fix " the diaphragm, a careful examination of the left chest should be made. If now the heart's apex be found displaced to the right, and the normal area of pulmonary resonance encroached upon from below either by the tympanitic note of the stomach or colon, or by dulness, and (he respiratory sounds are absent over the saaie area, but of normal charac- ter above, and if, further, the patient complains of sevoiv thirst, and is revtoatedK sick, rupture of the dia- phragm with hernia may be recognised. This acci- dent always occurs on the left side, and it may be but a part of a very severe and quickly fatal lesion, and Chap. XL] RUPTURE OF THE UTERUS. 153 escape recognition. When resulting from a sudden spasm of the muscle, the sharp pain followed by the inability to fix the diaphragm, the thirst and the special physical signs clearly point to the nature of the lesion. Diaphragmatic hernia may be a congenital affection, and, therefore, it is only when the symp- toms associated with it come on acutely after a strain or injury that the traumatic lesion must be diagnosed. If a pregnant woman receive a blow upon the belly, and complain of pain shooting down to the vulva, perineum, and thighs, and if the outline of the uterus be preserved unaltered, and there be neither hsemorrhage from its cavity, nor severe shock, it is a contusion of the uterus ; abortion will probably result. If, under similar circumstances, the woman be found collapsed, with signs of loss of blood, and blood be found flowing from the uterus into the vagina, rupture of the uterus has taken place ; and if the outline of the uterus be lost, and, in place of it, the head and limbs of the foetus can be plainly traced through the belly wall, the foetus has escaped through the rent into the peritoneal cavity. If a woman known to have an ovarian tumour fall on the belly, or receive a blow there, and then become faint, and complain of pain, and the outline of the tumour be altered or quite lost, and there be dulness in each flank, which disappears on turning the patient on to the opposite side, and a fluctuation wave can be felt across the belly, rupture of an ovarian cyst is to be diagnosed. Even without the knowledge of the prior existence of an ovarian tumour, the detection of free fluid in the peritoneal cavity immediately after an injury to the belly of a woman, the presence of shock, and the history of a " snap," or " bursting," being experienced at the time, especially in the absence of jaundice, or disease of the heart or Kings, would 154 SURGICAL DIAGNOSIS. [Chap. xi. render the diagnosis of rupture of an ovarian cyst very probable, B. Sequelae of contusions of the belly. Peritonitis. Abscess. Urinary cyst. The most frequent and the most fatal sequela of an abdominal contusion is peritonitis. It may follow upon the infliction of a very moderate amount of violence, and hence no contusion of the belly is to be regarded as of trivial importance. Severe internal lesions, unless fatal from shock or hse- morrhage, quickly induce peritoneal inflammation. Peritonitis very generally arises within a few hours of the accident ; it may come on later. Abscess is a less frequent, but by no means rare, sequel of an abdominal injury. It may form in the belly wall from a bruise in that part, or in the subperitoneal tissue, probably from a bruise or minute rupture of the bowel where un- covered by peritoneum, with a limited escape of fseces, or from a rupture of the peritoneal surface of the bowel if, happily, the effused lymph glue the adjacent coils of intestine together, and prevent general extra- vasation of fseces ; it is also met with between the liver and the diaphragm, probably as the result of a bruise or small laceration of the upper surface of the liver. The early diagnosis of these abscesses is im- portant ; for, while their treatment is successful, if neglected they may burst into the general peritoneal cavity and cause fatal peritonitis ; the subdiaphrag- matic abscess may burst into the pleura or the lung. When, a few hours or more after an accident, the patient complains of diffused pain over the abdomen, and is found lying upon his back with his knees drawn up, with pinched features clearly ex- pressing distress, and on examining the belly it is seen chap, xi.] PERITONITIS. t$5 to be immovable during respiration, which is wholly upper costal, and the least pressure with the hand upon the abdominal wall is resented on account of the pain it produces, and especially if there is increas- ing flatulent distension, vomiting, and constipation, acute peritonitis is to be diagnosed. The signs of this affection vary within wide limits. Severe pain in the back is sometimes complained of, rather than pain in the belly ; there may be little or no tender- ness ; the distension may be enormous, or, on the other hand, but slightly marked, the belly being retracted, and the muscular contraction making the wall firm and resistent. The pulse is quickened by the onset of the inflammation, and may be small and incompressible, or " wiry." The temperature may be considerably elevated, or but little above the normal. In the absence of all evidence of visceral lesion, the occurrence of peritonitis may be taken as pointing to laceration of the peritoneum, or of the mesentery; but no certain diagnosis of these lesions can be made. When a contusion of the abdomen is followed by the formation of a localised swelling and general febrile disturbance, an abscess must be suspected. Such swelling may follow an obvious bruise of the belly wall, in which case the onset and progress of inflammation are marked by increasing swelling, bright redness, greater pain, acute tenderness and fever. Or there may have been no external evidence of bruising, and febrile illness, local pain, and then the gradual occurrence of a more or less well-defined swelling may be the only symptoms. Examine care- fully for fluctuation and for surrounding oedema, and these signs, when obtained, or the occurrence of shivers, or of remittent temperature, will render the diagnosis of abscess more certain. Wherever doubt as to the nature of such a swelling is entertained, an exploring needle or syringe should at once be passed, 156 SURGICAL DIAGNOSIS. [chap. xi. as it is important that these abscesses should be evacuated as early as possible. The surgeon will endeavour to make out the seat of the abscess. When the redness and swelling appear early and fluctuation is quickly and readily perceived, and particularly if the swelling be found to be movable with the belly walls, it is to be diagnosed as a superficial abscess. In other cases the swelling and the area of fluctuation may be limited to one of the compartments of the sheath of the rectus muscle. But where the pus is deep it is always difficult, and it may be im- possible, to tell its exact position. In the lumbar region the abscesses occur in the fat on either side of the fascia transversalis ; in the iliac fossa suppuration is apt to arise in the pericrecal fat ; pus may form in the subperitoneal fat of the belly wall, and in the perito- neal cavity, being limited by adhesions of the omentum and coils of intestines to one another and to the belly- wall. When the abscess is opened exploration with the finger may be able to determine its exact situation. The character of the pus that is contained in the abscess must be noticed ; when comparatively superficial, it will be laudable pus, or a mixture of pus and blood ; where the abscess is around intestine,especially caecum and colon, it will be discoloured brown, and of a very foetid or feculent odour; and should faecal matter or flatus be mixed with it, or follow the escape of pus, it proves that the intestine is perforated, and & faecal fistula will result. Suppuration may occur between the liver and the diaphragm, and from its deep position its detection may be very difiicult. These abscesses are sometimes the result of the perforation of a gastric or duodenal ulcer, but they may arise from injury. As the pus accumu- lates it pushes up the diaphragm and depresses the liver, and it may point, and burst externally, or into the peritoneal cavity) not uncommonly it perforates Chap. XL] SUBPHRENIC ABSCESS. 157 the diaphragm and the base of the lung, and the pus is expectorated through the bronchi When, therefore, after an injury to the light hypochondrium the patient continues febrile, particularly if there are one or more rigors, the injured region should be carefully explored, and if the lower edge of the liver be found depressed below the normal, while its area of dulness reaches up to or is above the normal level, and if there be local pain, or any fulness of the intercostal spaces, sub- phrenic abscess is to be suspected. Should the abscess have pointed externally and give fluctuation the diagnosis becomes easier. But in all such cases an exploring syringe should be introduced to determine the presence of pus. But the question will even then arise whether the pus is above or below the diaphragm. To decide this, observe whether the onset of the disease was characterised by the signs of pleurisy or not; whether there was sharp pricking or stabbing pain on taking a deep breath, cough and dyspnrea; and whether at any time pleural friction was to be detected. The absence of these signs would indicate that the inflam- mation was below the diaphragm, but their presence would not prove the contrary. Further, examine the chest, to learn whether on taking a full inspiration the level of pulrnoiiaiy resonance descends, and if the respiratory sounds are normal ; the former of these two signs is a significant indication that the purulent collection is not in the pleural cavity. When a swelling forms slowly and gradually in one of the lumbar regions after an injury in that situation, unattended with fever, acute pain, or ten- derness, and this swelling be found to fluctuate, a rupture of the ureter, with the formation of an urinary cyst, is to be diagnosed ; and if, on tapping, the swell- ing watery fluid containing urea* be drawn off, this diagnosis is confirmed. Observation of a diminution, * Hee footnote, yoge 161, 158 SURGICAL DIAGNOSIS. [Chap. XL of the quantity of urine or of urea excreted daily since the injury would render the diagnosis more easy and certain. C. Wounds. In examining a wound of the belly the surgeon must endeavour to determine whether it is limited to the parietes, or whether it penetrates the peritoneal cavity ; if the former, whether it is su- perficial, or extends through one or more of the muscu- lar and deep aponeurotic layers ; if the latter, whether there is protrusion or wound of any of the viscera ; and, in all cases, whether any foreign body is lodged in the wound. Punctured wounds are those which generally present both the greatest difficulties in dia- gnosis, and the greatest dangers, for their small exter- nal size renders their exploration often unsatisfactory, and they are frequently penetrating and complicated with wounds of viscera ; bullet-wounds partake of the same characters. Enquiry should always be made as to the manner in which the wound was inflicted, and the instrument used should be examined, to discover, when possible, how deeply it has penetrated, and whether it is entire, or whether any part of it has been recently broken off. (1) Is the wound penetrating! In some cases a wound is obviously non-penetrating, and in others, especially when punctured, it may be impossible to decide. The edges of an incision may be gently drawn aside, and its surfaces explored ; when it ex- tends only through the skin and superficial fatty tissue it is to be called a superficial parietal ivound ; when, however, it severs a muscle, or the muscular aponeurosis, and opens up the intermuscular planes or the sheath of the rectus muscle, or even still deeper fascise, the danger of diffuse inflammation and suppu- ration renders it necessary to distinguish it from the former as a deep parietal wound. Should there be any visceral protrusion, or the escape of the contents Chap, xi.] WOUNDS OF ABDOMINAL VISCERA. 159 of any of the viscera (food, bile, faeces, urine) or a flow of clear serous fluid, or of dark blood from the depth of the wound, which flows faster and with more force when the patient coughs or makes any effort, or should there be severe shock or the signs of internal haemorrhage, hsematuria, or haematemesis, or the pas- sage of blood per anuin, it may be diagnosed as a penetrating wound. When a doubt is entertained, probing or any like exploration of the wound must not be made, but the treatment must be adapted for the severer injury. (2) Is there protrusion of viscera? This fact can be ascertained quite easily in the majority of cases; the omentum and small intestine are the viscera most commonly protruded; but the liver, stomach, spleen, and bladder may be. Where the protrusion is large there can be no difficulty whatever in recognising it, although the possibility of a loop of intestine lying behind a fold of omentum must not be forgotten, and pains must be taken not to overlook a small protrusion of omentum between the lips of a wound. All deep wounds must be carefully examined with this view, and if anything like a protrusion, anything lying between the lips of the wound, is observed, it must be noted whether it has the characteristic granular appearance of omentum, or whether it differs in colour from the fat on the surface of the wound, whether it is con- gested, whether any large vessels appear on it, then it should be seized and gently drawn upon, and if a dis- tinct pedicle on its deep surface be found, or, especially, if further prolapse takes place, the diagnosis is certain. With ordinary care, the smooth glistening surface of the intestine, stomach, and liver would be at once detected in a wound. It must be remembered that the urinary bladder when full may be protruded from a wound in the hypogastrium, even when the peri- toneal cavity is not opened ; when this lesion is 160 SURGICAL DIAGNOSIS. [Chap. xi. suspected, a catheter should be passed and all the urine drawn off, when the pi-otrusion will be> emptied, and will collapse ; should a silver catheter be used, its extremity may be made to enter, and be felt in, the protrusion. Any visceral protrusion must be caref ully examined for a wound in the protruded part, or the presence of dirt and foreign matters, and to note con- gestion. (3) Is there a wound of a visi-n* ! (a) Where there is protrusion of viscera. All protruded viscera should be carefully examined to see whether there is any rupture or wound, as well as to remove any foreign bodies that may be adherent to or entangled in them. In the case of omentum and mesentery note especially whether there is any haemor- rhage from a wounded artery or vein. The collapse of prolapsed intestine and stomach, and the escape of their contents, gaseous or semi-solid, may indicate at once a wound ; but the whole surface should be ex- plored to see whether the peritoneum is torn at any part, or whether there is at any spot a little projection of soft, red mucous membrane, indicating a puncture of the gut ; a larger wound of the intestine can hardly escape observation. (b) Where there is no protrusion the sur- geon may be left in doubt on this point. But if un- digested or partially digested food, unstained by bile, escape from the wound, or if the patient vomit blood, a wound of the stomach is to be diagnosed ; this lesion will be attended by severe shock, and be followed by acute peritonitis. When f secal matter escapes from the wound, or when blood is passed per anum, a wound of the intestine is also clearly evidenced. Where a wound is followed by the escape of urine, or by the occur- rence of htematuria, a wound of the urinary apparatus has been made, and the position of the wound, and the patient's power over his bladder, will determine chap, xi.] INTR A- ABDOMINAL HAEMORRHAGE. 161 whether it is a wound of t/te kidney or urinary bladder.* Similarly, where bile escapes from a wound in the region of the liver, a wound of the gall bladder or bile duct may be diagnosed. When a wound is fol- lowed by syncope and deepening collapse, and blanching of the mucous surfaces, and especially if dark blood escape from the wound, or if the belly be distended at any part, or there be dulness in the flanks, which may be noticed to increase, internal haemorrhage is occurring. The position and direction of the wound will enable the surgeon to surmise the source of the bleeding ; it may be the liver, the spleen, the vena cava, vena portse, or some other large abdominal vessel. Lastly, where, without such positive evidence, a penetrating or a punctured wound of the belly is quickly followed by acute peritonitis, a visceral wound is to be suspected as the cause of the intense in- flammation. D. Sequelae of wounds of the belly. Diffuse suppuration in belly walls. Peritonitis. Fistula. Artificial anus. Hernia. When a wound of the belly wall is followed by considerable diffuse swelling of the tissues, with red- ness and oedema of the skin, pain, and tenderness, and the body temperature is raised, with all the general symptoms of pyrexia, diffuse inflammation of the abdominal wall is proceeding, which, if not quickly subsiding, runs on to suppuration. Should the patient be attacked with pain spreading over the whole belly, and the part be found extremely tender, even the light pressure of the hand being * To determine whether a fluid is, or contains, urine, acidulate a portion of it with acetic acid, boil and filter it ; then take some of the filtrate, add a few drops of nitric acid, and evaporate it, when shining rhombic plates of nitrate of urea will separate, and may be recognised under the microscope. L 13 1 62 SURGICAL DIAGNOSIS. [Chap. XL resented, and the respiration be entirely thoracic, while abdominal distension increases, and may become ex- treme with vomiting and constipation, and the tem- perature is raised, acute peritonitis is to be diagnosed. Should the patient recover so far as the general results of the wound are concerned, but the wound through the belly wall remain open as a fistulous track, and through this the contents of any one of the abdominal viscera continue to escape, there is a fistula. If the discharge be unstained with bile, acid in reaction, and contain food unaltered, or but partly digested, it is a gastric fistula, or possibly a fistula in the upper part of the duodenum, above the entrance of the bile duct. Should the discharge con- sist of the contents of the intestine, it is a fcecal or intestinal fistula. When the matter escaping is soft, pultaceous, odourless, or nearly so, and of a light colour, the communication is with the small intestine; and when the discharge is distinctly fseculent, dark in colour, with a strong faecal odour, and mixed with much gas, the communication is with the large intes- tine. Should the discharge be bile unmixed with chyme, or a watery fluid containing urea, it would be respec- tively a biliary or urinary fistula. If, as the result of an operation, or of the natural separation of a slough of prolapsed intestine, the mucous membrane of the gut is immediately continuous with the skin, the intestine opening directly on the surface, it is an artificial anus. Should there be from such an aperture a soft, bright- red, corrugated projection, moistened with mucus, it is a prolapse of the mucous membrane of the artificial anus. But should there be from the aperture a smooth, rounded projection, covered by the same red mucous membrane, but emptying on gentle com- pression, leaving the mucous covering collapsed, it is a hernia of the artificial anus. If a cicatrix in the belly wall be found to yield Chap. XII.] BRUISES OF THE PELVIS. 763 before the pressure of the abdominal contents, and a projection be formed at the spot, smooth, rounded, soft, with an expansile impulse on coughing, and tym- panitic on percussion, it is a hernia. It may be re- ducible or irreducible; the coils of intestine ai - e often visible through the thinned cicatrix, or these and masses of omentum may be plainly felt through. There is no distinct neck to the sac of such a hernia. CHAPTER XII. THE DIAGNOSIS OF INJURIES OF THE PELVIS. CONTUSIONS of the pelvis are generally the result of heavy blows or kicks, falls from a height, or severe crushing violence. They naturally group themselves into three categories : injuries of the soft parts cover- ing the bones, injuries of the bones, and injuries of the contained viscera. The examination should be conducted with a view to determine under which of these categories the injury falls; the visceral injuries are, of course, very much the most fatal, and occasion the most severe symptoms. Bruising: of the soft parts will be at once re- cognised by the characteristic discoloration, the dull aching pain, and the swelling, which varies in amount within very wide limits. If the blood be effused from vessels at some depth, the staining of the skin may not appear for a day or two. Sometimes the ecchymotic discoloration extends over a very wide area, and then it is important to learn where it was first noted, as that fact will throw some light upon the seat of the lesion. Whenever the bruising implicates the perineum, scrotum, or penis, careful inquiry should 164 SURGICAL DIAGNOSIS. [Chap. xn. be made whether there has been, or is, any htemor- rhage from the urethra. If a more or less clearly- defined fluctuating swelling appear in the soft parts quickly after an injury, it is a hcematoma ; there may be no bruising of the skin around it ; the blood may long remain fluid, or be quickly absorbed. Such swellings are most frequently found on the buttock. Fracture. The surgeon, having examined the soft coverings of the pelvis, should then place one hand on each side of the symphysis pubis (the patient lying flat on his back) and run them along the bones from before back, and then down along the pubic arch, and observe if there be any irregularity in the outline of the bones. He next should seize the iliac crest, or the anterior iliac spine, and try to move it on the rest of the bone; then he should press the bone on each side of the sym- phisis pubis backwards (at first gently, and gradually more and more forcibly), and then placing a hand on each side of the pelvis, should press inwards. Lastly, he may try whether pressure on the pubic spine is painful, and also whether the great trochanter of the femur of the one side is flattened or raised above the other (see page 203); and whether movement of the hip joint is painful. If, by this examination, any marked irregularity in the outline of the pelvis, or mobility of any part of it, or crepitus, be detected, fracture oj 'the pelvis is at once to be diagnosed ; by noticing the position of the irre- gularity and of the crepitus, and the part that is movable, the seat of the fracture may be made out. No distinction need be drawn between these fractures and separations of the pelvic synchondroses. Inability to stand, pain on all movements of the hip joint, with great pain on pressing on the pubic spine, are said to indicate & fissure across the acetabuhim. But if, with great pain on moving the hip joint, there be distinct crepitus, there is fracture of tlw acetabulum with chap, xii.] RUPTURE OF THE URETHRA. 165 detachment of the fragments ; while if, with these signs, the trochanter be found approximated to the middle line, it points to displacement of the head of the femur into the pelvis. (See also page 216.) For the diagnosis of fracture of the sacrum and coccyx, see page 108. Injuries of the pelvic viscera. The condi- tion of the viscera must be next ascertained. Be careful to learn their condition before the injury, espe- cially whether the bladder was full and when it was last emptied ; if a female, whether she was menstruating at the time, or pregnant, or whether she had been the subject of an abdominal tumour. Then ask what the patient's sensations at the time of the accident were, and note particularly any feeling of something "bursting/' or "giving way;" inquire as to pain, its position, character, and time of onset, and whether there is desire to pass water or any tenesmus ; par- ticularly learn whether the patient has made any attempt to pass water, and if so, with what result, and whether any blood was passed, and notice whether any blood has flowed from the urethra independently of the act of micturition, from the rectum, or from the vagina. And then observe the patient's general condition, whether it indicates shock or not. The surgeon must not be misled by the entire absence of bruising of the skin to think that the viscera have escaped unhurt; extensive rupture of the bladder or of the uterus may occur without any 3xternal sign of so severe an injury. As the urinary organs are those that suffer most frequently, the surgeon should consider them first. If blood be found escaping, or be known to have escaped, from the urethra, and if there be bruising of the anterior part of perineum, perhaps entering into the scrotum, there is a rupture of the urethra. If the patient have tried to micturate, he may have been 166 SURGICAL DIAGNOSIS. [Chap. xn. unable to do so, or the attempt may have been attended with a sudden increase of the swelling in the perineum and scrotum (extravasation of urine), or the act of micturition may have caused pain as the urine flowed over the rent in the mucous membrane. A catheter should now be carefully passed, and if it reach the bladder clear urine will flow off; if this can be done, it shows that the urethra is not torn completely across ; but if the surgeon fail to pass the instru- ment, and especially if its end be found close under the skin, it is evidence that the urethra is torn quite through, and that it is not simply a superficial lacer- ation. This injury is usually the result of a fall across a beam, or some similar accident. If, as a result of a sudden strain, a patient experi- ence severe pain in one or other groin, and at the same time, or quickly after, bright blood flow from the urethra, but micturition be performed normally > and if the testicle on the same side become painful, tender, and somewhat swelled, and subsequently waste, the accident is rupture oft/te vas defer ens. The escape of the blood from the urethra will at first suggest an injury of the urethra ; but the nature of the accident (a strain, not a blow), the absence of bruising in the perineum and scrotum, as well as the normal per- formance of micturition, will exclude that lesion, while these signs, and the irritation and subsequent wasting of the testicle, will establish the diagnosis. If there be no evidence of rupture of the urethra, and the patient evince a great desire to pass water, and quite fail to do so, or pass but a few drops, a rupture of the bladder must be suspected. If, now, it be made out that the bladder was full at the time of the accident, and the patient felt something " burst," or "give way inside," and this was followed by acute pain in the hypogastrium and by shock, and that soon after a great desire to pass water was felt, with Chap, xii.] RUPTURE OF THE BLADDER. 167 inability to expel anything more than a few drops ; and if on examining the belly the bladder cannot be felt, although there may be dulness reaching up a variable distance above the pubes, and on passing the finger into the rectum no tense rounded fundus is to be made out, a catheter should be introduced, and if it be found to pass the usual distance without difficulty (the finger in the rectum will at once dispel any doubt as to its extremity having reached the bladder), but only a few drops of blood or urine escape along it; and further, if, by manipulation, it can be made to pass in its full length, and its end be very freely movable, or plainly felt under the belly wall, or a large quantity of urinous fluid then flow out, the diagnosis of rupture of the bladder is certain. In some cases the history is quite defective ; in others, again, the patient retains the power to pass just a small quantity of urine, and the catheter passed into the bladder draws off an ounce or two of bloody urine ; the diagnosis is then obscure. Reliance must be placed on the presence of shock, on the frequent desire to empty the bladder, the admixture of blood with the urine, the failure to detect, by any means of examina- tion, a full bladder, and, especially, upon the results of catheterism, particularly the passage of the end of the instrument through the rent into the belly cavity, where it can be moved about and felt, and whence it evacuates sometimes many pints of urine and serum. Should doubt exist, it may be justifiable to inject a warm weak solution of Condy's fluid or warm boracic acid lotion through the catheter, and if more than a pint can be injected without meeting with any resistance, or if a sense of warmth over the belly be produced by it, or dulness appear above the pubes, with or without fluctuation, the fact of a rupture in the viscus becomes certain. If now the symptoms of acute peritonitis come on (general abdominal pain 1 68 SURGICAL DIAGNOSIS. [Chap. xn. and tendeniess, distension, vomiting, constipation, cessation of abdominal respiration, quickened pulse, pyrexia, etc.), the rupture is intraperitoneal. If, however, these symptoms do not quickly ensue, and in place of them there be pain limited to the pelvis, with swelling in front of the rectum, or reaching up above the pubes or along the fold of the groin, with fever, quick pulse, and dry tongue, the rupture is extraperi- toneal, and has led on to pelvic cellulitis ; this, if unre- lieved, may lead to jjeritonitis. The bladder may be ruptured without fracture of the pelvis, by severe con- tusions of the hypogastrium, or with fracture of the pelvis (wound of the bladder), by muscular violence, during parturition, by over-distension, or as the result of disease. If there be an induration in any part of the penis immediately following an injury it is produced by extravasation of blood into the cor pits sponyiosum or corpus cavernosum ; if this be extensive, and in- volve the whole organ, it may cause "permanent chordee." The diagnosis of contusion and rupture of the pregnant uterus and rupture of an ovarian cyst is discussed on page 153. Wounds of the pelvic viscera. If from any wound of the penis or perinseum urine flow during the act of micturition, it shows that there is a wound of tlie urethra. Similarly the escape of urine from a wound over or above the pubes independently of micturition along with the signs of laceration of the bladder (vide antea) will indicate wound of the bladder. If there be an external wound of anus, or vulva, or vagina, or a history of a weapon of any kind having entered either of these canals, the finger must be passed gently into them, and their walls carefully explored ; a rent in either of them may in this way be found. The onset of acute peritonitis will point to a wound of the peritoneum ; if the bladder be found Chap, xiii.] INJURIES OF THE UPPER LIMB. 169 empty or containing only a little blood and urine, it will indicate wound of the bladder. (Vide antea.) The small intestines may be found prolapsed into the vagina. The escape of blood and liquor amnii from the wound, or protrusion of part of the foetus or of the placenta, and haemorrhage into the vagina, indi- cate wound of the pregnant uterus. Foreigrn bodies in the rectum or vagina will be detected on digital examination ; when recently introduced, the history of the case will lead to their detection ; when long impacted, the fact of a chronic muco-purulent discharge, with pain, and, in the case of the rectum, tenesmus will suggest the necessity of an examination. For foreign bodies in tlie bladder, see page 551. Foreign bodies in the urethra. If in the spongy portion,ithey may be felt by carefully passing the finger along the outside of the urethra, or they may be felt by a bougie, or seen by the endoscope. When deeper in, the finger in the rectum may detect them ; or if not, on passing a full-sized silver catheter or bougie obstruction will be met with near the neck of the bladder, and the foreign body may be pressed back into the bladder, and thus detected. CHAPTER XIII. THE DIAGNOSIS OF THE SPECIAL INJURIES OP THE UPPER LIMB. FULL directions for the diagnosis of wounds, sprains, and contusions are given in chapters ii. and iii. Here, therefore, we have to consider only the diagnosis of dislocations and fractures, and of any injuries liable to 170 SURGICAL DIAGNOSIS. [Chap. xin. be mistaken for them. In approaching this question we would urge upon students not to rely upon any individual "test" symptom, but upon the rational signs of these injuries, and to make a systematic ex- amination of the parts. Different teachers and sur- geons recommend various methods of examination, and it matters little which of several the student adopts, provided only that the method be systematic, and that he follow it faithfully. We shall here, of course, mention only one of these methods of procedure. In the large majority of cases the patient is able to point out the seat of injury; but this is not always the case, and the student must be particularly cautioned against omitting to examine all the parts of an injured limb, and all the limbs of a seriously injured person ; for it not uncommonly happens that when one fracture or dislocation has been detected other similar injuries or sprains and contusions are quite overlooked, and the results of such negligence may be very serious. Mode of examination. When possible, the patient should be seated in a chair, and the surgeon standing behind him should place the forefinger of each hand on the suprasternal notch of the sternum, and passing outwards he should feel on either side the large inner ends of the clavicles, noting whether they are symmetrical or not; he should then run the ends of his fingers along the upper surface of each clavicle, quite to the point of the shoulder, and along the acromion and spine of the scapula to the posterior border of that bone, all this arch of bone being subcutaneous. Comparing the two sides, he observes particularly any break in the line of the clavicle or scapula, and any tender spot in the bony arch. He should next proceed to examine the shoulder Chap. xiii.] EXAMINATION OF SHOULDER. 171 joint, to determine whether or not it is dislocated, or if there be a fracture near to it. Placing the hands flat upon the prominence of each shoulder, with the thumb resting on the point of the acromion, he must note whether the thumb or the hand is internal, whether he plainly feels the prominence of the upper end of the humerus beneath the hand, or whether he can press in the deltoid muscle, and feel through it the glenoid fossa of the scapula ; these signs prove a dislocation of the shoulder, and search must then be made for the head of the bone below the clavicle, in the axilla, or, failing to find it there, below the spine of the scapula ; then, with one hand grasping the head of the bone, let him rotate gently the elbow on the same side, and notice whether the head moves with the rest of the shaft, or not, and if there be crepitus. By this examination any lesser degree of flattening of the natural prominence of the shoulder will have been noted ; let the surgeon now place the points of his fingers in the groove between the pectoralis major and deltoid, and feel for the coracoid process, and press firmly upon that point of bone, and take special notice of acute pain, or crepitus, or mobility of the process so produced ; then pass the ends of the fingers out round the shoulder .to note any difference in the outline on the two sides. Gently raising the arm, place the fingers in the axilla, and feel the inner surface of the neck of the bone, first on the sound side, then on the injured, and note any projection, or if the head of the bone be too plainly felt. Then place the hand flat and rather firmly on the shoulder, and rotate the elbow, and feel for crepitus, noting as accurately as possible where the crepitus is produced. Finally, the hands should be passed over the back of the scapulae below the spine, and any irregularity or tender line noticed, and then the angle should be seized in one hand, and an attempt be made to move 172 SURGICAL DIAGNOSIS. [Chap.xm. it on the rest of the bone. Departures from the normal in these [various respects will indicate a fracture about the shoulder. The surgeon should then stand in front of his patient, and place the sound limb in exactly the same position as the injured one. There may be an obvious deformity, such as angular bend in the arm or fore-arm, or great projection of the point of the elbow, which shall at once declare a fracture or a dislocation ; but even in such a case it is best to follow out a systematic examination, for it occupies but a few seconds, and may save from seiious blunder. To examine the shaft of the humerus, place the thumbs on the inner side of the sur- gical neck of each humerus, and the fingers on the outer side, and run them down along the bone to the elbow, noting, of course, any want of symmetry, espe- cially any sharp projection or irregularity, and any local tenderness ; where either of these is detected, grasp the arm above it in one hand, and rotate the elbow with the other, and try to move the lower end of the bone laterally, or forwards and backwards, noting mobility in the length of the bone, crepitus, and whether the attempt produces sharp pain at the sus- pected spot. It may be well here to remark, that if on rotating the elbow distinct mobility or crepitus be obtained, and the place where they occur be detected, it is unnecessary and therefore wrong to repeat the act, or to tiy the effects of movement of the elbow in other directions. Coming now to the elbow, the two joints should be taken into the palms of the hands with the fore- finger resting on the tip of the olecranon, the thumb will then be placed on the outer epicondyle of the hume- rus and the middle digit on the inner epicondyle. The relative distance between and level of the olecranon and these two points of bone is to be noted, also whether Chap. xiii.] EXAMINATION OF THE ELBOW, 173 the outline of the sigrnoid notch of the ulna can be felt, or a gap in the line of the olecranon, whether the olecranon is more or less prominent on the in- jured side than the other, and whether flexion and extension of the joint are painless and free. The thumb of the left hand should then be placed on the outer condyle of the humerus, and the hand seized with the surgeon's right hand and gently rotated, when the rounded head of the radius should be felt rotating immediately below the condyle. If this movement be painful, and produces crepitus at the elbow, of course special note is to be made of it. Then each epicondyle is to be separately grasped, and an attempt made to move it on the rest of the humerus, the surgeon observing, so far as he can, the size of the fragment that he is able to move. Lastly, he should run the finger care- fully along the olecranon to note any slighter irregu- larity in it that may have escaped notice before, or any tender spot, and, grasping the tip of the pro- minence, he should attempt to move it laterally, and should then notice how much of the bone, if any, is detached, and whether there is crepitus between the two fragments or not; the tendon of the triceps muscle should be followed down to its insertion into the ulna, and it will not then be possible to overlook a fracture of the olecranon, with drawing up of the upper detached fragment. It may happen that when the surgeon first sees his patient the part is so swelled that an exact diagnosis is impossible, he should endea- vour to assure himself that there is no dislocation ; extensive ecchymosis should be taken as strongly in- dicating a fracture. Fracture of the shaft of both bones of the fore-arm is usually a very obvious accident, on account of the angular deformity of the limb at the site of the frac- ture. The whole length of the ulna can be plainly felt through the skin, and the finger should be run along 174 SURGICAL DIAGNOSIS. [Chap. xm. its posterior border from the olecranon to the styioid process, and the radius should be similarly examined ; as already mentioned, the head of the radius should be felt immediately below the outer epicondyle of the humerus at the bottom of a slight dimple in that situa- tion ; the shaft of the bone is covered by muscle, but the finger can plainly feel its outer surface the whole way down ; its lower end and styioid process are easily felt, and compared with the same parts on the sound side. The hand should then be pronated and supinated, to determine whether the head of the radius moves with the lower end of that bone ; by attempts at angular movements in the fore-arm, the solidity of the bones or the reverse may be shown. The bones of the wrist being so subcutaneous any displacement at the joints or fracture with displace- ment of the fragments is easily detected by the eye and by the hand. The same is true of the fingers and thumb, the bones are all practically subcutaneous on the dorsirjQ ; the surgeon should, therefore, run his fingers along the dorsum of the metacarpal and pha- langeal bones, and note any irregularity, and then grasping the extremities of each bone, one in either hand, should see if there be any mobility with crepitus. Measurement of the limb is sometimes useful in diagnosis, and before going further it will be well to notice the best measurements to take, and the injuries that modify them. First, measure from the inner end of the clavicle to the tip of the acromion ; this is not increased by any injury ; it may be shortened by frac- ture of the clavicle with over-riding of the fragments, bending of the bone (greenstick fracture), or by dislocation of its outer end. Next, measure from the tip of the acromion to the outer epicondijle of the hume- rus, or from tlie tip of the coracoid process to tlie inner epicondyle. If lengthened, there is a dislocation chap, xiii.] MEASUREMENTS OF UPPER LIMB. 175 of the shoulder: Shortening of the arm, as shown by this measurement, may be caused by dislocation of the shoulder, by fracture of the humerus, or by fracture with displacement downwards of either the acromion or the coracoidjbt?' process. Then measure from each epi- condyle of the humerus to the styloid process of the same side ; shortening of the outer line may be caused by dislocation of the radius at the elbow, or by fracture of the same bone ; shortening of the inner line is similarly due either to fracture or dislocation of the ulna. In the wrist and hand measurements may be taken from the tip of either styloid process to the base of the first and fifth metacarpal bone respectively, shortening of this measurement indicating a dislocation of the wrist. A useful measurement is the circumference of the shoulder, taken by passing the tape under the axilla, and bringing its ends vertically up over the shoulder ; dislocation of this joint increases this measurement by from one to two inches. The distance between the tip of the olecranon and either epicondyle of the humerus indicates the relative position of the ulna to these bony points. Among many other " pathognomonic signs" may lie mentioned this : when a flat rule or some similar body is placed with one end resting on the outer epicondyle of the humerus, and the other extremity on the prominence of the shoulder, its point should not touch the acromion, but should be separated from it about an inch ; if, however, its upper end rest against the acromion, it shows that the upper end of the humerus is not occupying the socket of the scapula, in other words, that it is dislocated. By this examination, which, when the surgeon is expert in his movements, can be very quickly conducted, we are able to decide whether there is any serious in- jury to the bones or joints, any fracture or dislocation ; 176 SURGICAL DIAGNOSIS. tchap. xm. and ai-e also able to tell where the injury is, and to put it in one or other of these categories : Fracture and dislocation of clavicle, acromion, or spine of scapula. Dislocation of the shoulder. Fracture of the shoulder. Fracture of shaft of humerus. Fracture of fore-arm. Fracture or dislocation of elbow. Fracture or dislocation of vmst. Fracture or dislocation of fingers and thumb. We will now discuss the diagnosis of the various lesions in each of these groups. A. Fractures and dislocations of the clavicle, acromioii, and spine of the scapula. (1) If, in commencing the examination, the siipra- sternal notch be found narrowed, and the sternal end of the clavicle be felt to be on the top of the sternum, projecting strongly under the skin, and allowing its whole articular surface to be felt, it is a dislocation of tlie clavicle iipwards. If, however, on passing the finger out from the suprasternal notch the end of the clavicle be not felt in its proper place, feel for it behind the sternum or in front, and, according to its position, it will be recognised as dislocated backwards or for- wards. In all these cases there is no shortening of the measurement from the inner end of the clavicle to the point of the shoulder, and owing to the large size of the inner end of the bone, and its superficial posi- tion, the diagnosis is not difficult. When the bone is dislocated backwards there may be veiy great dis- tress, owing to the displaced bone pressing upon the trachaea, the oesophagus, or the great vessels and nerves of the neck.' (2) On running the finger along the clavicle a dis- tinct break in the line of the bone may be detected, one part of the bone being obviously separated from the other ; this is most often met with a little to the outer side of the middle of the bone, the end of the Chap, xiii.] FRACTURE OF THE CLAVICLE. '177 inner fragment projecting under the skin, the outer fragment being on a lower level ; it may occur close to the inner end of the bone, when the outer fi-agment will, in most cases, be prominent, riding downwards and forwards over the inner. This sign will of itself suffice to indicate a, fracture of tJie clavicle, and to localise it precisely. When the fracture is near the inner end of the bone, the facts that the inner extremity is felt in its right position on the sternum, that movement of the clavicle is attended with crepitus, and that the point of the shoulder is ap- proximated to the inner end of the bone, will at once distinguish the injury from a dislocation of the bone, for which it might possibly be mistaken. If on running the fingers over the outer flattened end of the bone, it be found that there is an angular projection backwards, that the shoulder has rolled forwards, and is approximated to the inner end of the clavicle, that over the bony projection there is pain and great tenderness, and especially when on rotating the elbow freely crepitus at this spot is detected, a fracture of the acromial end of tJie clavicle is to be diagnosed. Sometimes the angular deformity is up- wards instead of backwards. There may, however, be no displacement of the fragments, and no deformity ; but if, as the finger passes along the bone, at one spot the patient winces and complains of great tenderness, and when the shoulder joint is freely moved it causes pain at the same point, & fracture of tlie clavicle without dis- placement, or, as some prefer to call it, & fracture oppo- site the coraco-clavicular ligaments, is to be suspected ; if crepitus can be obtained, the diagnosis becomes cer- tain ; but without that, or some slight irregularity in the bone, the diagnosis cannot be certain, unless in the course of a week or ten days slight thickening from callus at the spot clears it up. Where there is no displacement there is no shortening. When in an M 13 178 SUKCICAL DIAGNOSIS. [Chap. XIII. infant or young child, who has fallen on its shoulder, the middle of the clavicle is found projecting forwards or upwards, but the bone quite continuous, it being simply bent, and the bone is found shorter than the one on the other side, a greenstick fracture of the clavicle may be diagnosed. This can only be mistaken for the curve in the bone often seen in rickets. If, however, the bone can be straightened out again with more or less distinct crepitus, or if it become swelled along the curvature in a few days, there can be no difficulty whatever in the diagnosis. In rickets the deformity of the bone is the same on the two sides, and there will be other signs of the disease in the bones, teeth, etc. This fracture may, however, occur in a rickety child, and the surgeon must then be guided by asymmetry (the rickety curve being exaggerated by the fracture), by the marked local tenderness, by the crepitus if present, and by the swelling coming on or increasing for a day or two after the injury. (3) The articulation of the clavicle with the scapula can always be felt as a slight projecting ridge. If, however, in place of this slight ridge there be, just in- ternal to the point of the shoulder, a marked bony projection, it is a dislocation of the scapula. If the projection be continuous with the clavicle, and that bone be found lying upon the acromion, it is a disloca- tion dowmvards. As a very rare occurrence the acromion may be found lying on the clavicle, and pro- jecting under the skin, dislocated upwards. In the latter case try to feel the coracoid process, as that has been described as lying above the clavicle. These in- juries are sometimes called dislocations of the acromial end of the clavicle. (4) When there is bruising, swelling, and pain over the top of the shoulder, examine carefully the line of the acromion to detect an irregularity, or the de- tachment and displacement downwards of a fragment Chap, xni.] FRACTURE OF THE SCAPULA. 179 in front of the outer end of the clavicle, or crepitus on forcibly raising the elbow ; inability to abduct the shoulder owing to a sharp pain referred to the end of the acromion, as well as slight flattening of the shoulder, should make the surgeon strongly suspect a fracture of the tip of acromion, but it is only when he detects the fragment displaced and movable that the diagnosis is certain. If, on running the finger still farther back along the acromion, a gap be found in it behind the point of the shoulder, if the shoulder be flattened and dropped, and if on raising the elbow this latter deformity be corrected, and the acromion be then found to be raised to the level of the spine of the scapula, crepitus thus being obtained, a fracture of root of acromion has occurred. Where there is no crepitus, or only soft friction to be obtained, it is to be regarded as diastasis of the acromion, or separation of the epiphysis. Care must be taken to ascertain that the mobility of the acromion is not a natural condition, and present on the uninjured side also. If on running the finger along the spine of the sca- pula, a depression or sharp projection in it be detected, grasp the bony prominence, and attempt to move it while holding the rest of the scapula firm in the other hand; if this be possible, and especially if crepitus be at the same time noticed, a fracture of spine of scapula is to be diagnosed. This injury is a very rare one. B. Dislocations of the shoulder. The sur- geon having found that there is a dislocation of the head of the humerus, the diagnosis will be made com- plete by his determining where the head of the bone is now lying. While comparing the two shoulders, the possibility of a bilateral dislocation of the shoulder must be borne in mind. The globular head of the humerus should first be felt for in front, i8o SURGICAL DIAGNOSIS. tchap. xin. tilling out the groove between the deltoid and pectoi'al muscles, obscuring the coracoid process, and forming a rounded prominence, moving when the arm is rotated ; if it be found there, the dislocation is sitbcoracoid. Some would draw a distinction be- tween subcoracoid and intracoracoid ; in the former the arm is rotated out, in the latter the arm is rotated in. This fonn of dislocation is much the most fre- quent, and the surgeon must remember that in it, when the arm is raised, the head of the bone can be plainly felt in the axilla. The length of the arm may be unaltered, a little shortened, or a little lengthened. If, on examining the front of the shoulder, the tip of the coracoid process can be plainly felt, but a rounded prominence is seen and felt under the pec- toral muscle, one or two fingers' breadth below it (the prominence being shown to be the head of the humerus by its outline, and especially by its rotating with the shaft of the bone), and if the head of the bone be plainly felt in the axilla, bulging down its floor, even without raising the arm, the elbow being directed far away from the side, the dislocation is subglenoid. Subcora- coid dislocations ai - e often spoken of as dislocations into the axilla, and are mistaken for subglenoid, owing to the ease with which the misplaced bone can be felt in the axilla, especially when the arm is raised. A sub- glenoid dislocation is rare, and is only to be diagnosed when there is a distinct interval between the coracoid process and the head of the humerus, and when the whole globe of the head can be readily felt in the axilla. The arm is usually lengthened in this dis- placement ; it has, however, been described as short- ened. Mr. Hulke has described two cases of this dislocation, in. which the arm was placed vertically up by the ear of the same side, the head of the bone filling out and projecting from the axilla ; he has called this particular variety luxatio erecta* Chap, xiii.] DISLOCATIONS OF THE SHOULDER. 181 If the head of the bone be found lying below the clavicle internal to the coracoid process, and out of reach of the fingers passed into the axilla, the disloca- tion is subclavicular. If the head of the humerus cannot be found in front, feel for it behind, below the acromion and spine of the scapula ; if detected there, and it will be easily known by its rounded shape and its moving with the shaft of the bone, it is a subspinous dislocation. Mr. Holmes has drawn attention to cases where the head of the humerus is found forced up under the skin between the deltoid and pectoral muscles, forming a very marked and unmistakable projection, at the top of the shoulder ; this form is called the supra- coracoid dislocation, and is always associated with fractm-e of the acromion or of the coracoid process. It is occasioned by severe violence applied to the elbow forcing the humerus upwards against the scapula. If, in reduction of the dislocation, crepitus is ob- tained, and the head of the bone easily slip out of place again, and the surgeon be able to assure himself that there is no fracture of the humerus or of the coracoid or the acromion process, he should diagnose a fracture of the glenoid cavity, an injury never met with apart from dislocation of the joint. C. Fractures of the shoulder. The surgeon having decided that there is no fracture or dislocation of the claviculo-acromial arch, and that the upper end of the humerus still occupies the glenoid cavity of the scapula, finds that there is deformity about the shoulder or crepitus on rotating the arm or on manipulating the scapula ; he therefore decides that there is a frac- ture of the bones entering into the shoulder, either of the upper end of the humerus or of the scapula. Let him first grasp the rounded head of the humerus immediately below the acromion, and with the other hand 1 8z SURGICAL DIAGNOSIS. [Chap. xm. rotate the elbow ; if now rough crepitus be obtained, and the shaft move independently of the head, it demonstrates a fracture of the upper end of the hume- rus. If with the fingers pushed up into the axilla a projection inwards of the upper end of the lower fragment be detected, or on rotating the elbow again the line of the fracture is made out running below the tuberosities, it is a fracture of the surgical neck of the humerus. These cases usually occur in elderly people ; the shoulder preserves its round- ness, and the rotation of the upper fragment may even increase its normal prominence, and the lower fragment may be displaced inwards considerably, or in other cases not at all. Where there is marked dis- placement the limb is shortened, and the axis of the arm is directed down and out. If, however, the finger in the axilla find the sur- gical neck of the bone entii-e, and still there be crepitus in the upper end of the bone, with slight flattening of the shoulder, and especially if, when the arm is abducted and rotated, the head be felt not to move with the shaft, or the breadth of the upper end of the bone be found increased, fracture of tlw ana- tomical neck of the humerus is to l>e diagnosed. This injury also occurs in old people, and its diagnosis is often attended with difficulty. If the patient be under the age of twenty years, and the shaft of the bone be found to move independently of the upper end, with distinct, or in- distinct and soft crepitus, and especially if the upper end of the shaft of the humerus make a pointed pro- minence on the front of the shoulder below the cora- coid process, it is a separation of the upper epiphysis of the humerus. This injuiy may be met with in in- fants at birth, or at any age up to twenty. The dis- placement when present is very characteristic. If, however, the upper end of the bone be found Chap, xiii.] FRACTURES OF THE SHOULDER 183 to rotate with the shaft, and yet the movement occa- sion crepitus, the surgeon should next examine care- fully the great tuberosity of the humerus, and try to grasp it between the finger and thumb and to move it on the rest of the bone, or notice whether the shoulder is broadened by the fragment being drawn out and back. By these signs, when obtained, a fracture of the tuberosity of the humerus will be recognised. Tliis injury may complicate a dislocation of the head of the bone, and is said to be produced by muscular action as well as by direct violence. When, however, on attempting to grasp the upper end of the bone and to rotate the elbow, the surgeon finds that this upper end moves with the shaft, but is not the rounded head of the bone, and that the deltoid is flattened and theacromion rather prominent, he should at once feel for the head below the coracoid process and in the axilla, and if he find that it does not move when the shaft is rotated (the manipulation perhaps eliciting crepitus), he will readily recognise a fracture of the neck of the humerus with dislocation of the head. The head of the bone has been found on the dorsum of the scapula. In this injury the arm is notably shortened, and the deformity of the shoulder is striking, and often at first suggests a simple dislocation of the bone, until the surgeon discovers that he cannot force his hand down to the glenoid cavity, that the arm is less rigid than in dislocation, and that the head of the bone does not move with the shaft. If, however, rotation of the elbow cause crepitus at the shoulder, but the head and neck of the hume- rus are found to be entire and to move with the shaft of the bone, the surgeon should notice whether the limb is lengthened and the acromion a little prominent ; if so, and if on simply raising the elbow this lengthen- ing and prominence of the acromion are corrected and at the same time crepitus is elicited ; and further, if 184 SURGICAL DIAGNOSIS. [Chap. xin. on pushing the fingei's into the axilla the axillary border of the scapula be found irregular, with a pro- minence close to the joint which is corrected by push- ing up the arm, and if the crepitus be then felt just under the finger, a, fracture of the tieck of the scapula is to be diagnosed. The surgeon should notice whether the coracoid process move up and down with the arm, and whether the measurement from the tip of this process to the inner epicondyle of the humerus is increased or not; if the former, it shows that the fracture does not separate this process, and vice versa. But if there be some slight flattening of the shoul- der, and a little shortening of the arm, with pain, and some deformity about the upper end of the humerus, while the head of the bone is found to be in the glenoid cavity and to move with the shaft of the bone, an impacted fracture of the neck of the humerus is to be diagnosed. This injury is sometimes succeeded by a slow and gradual downward displacement of the head of the bone, so that months afterwards the upper end of the humerus may be found in the glenoid cavity, and the head of the bone projecting in the axilla below its socket. Having assured himself as to the condition of the hurnerus, the surgeon should next feel the coracoid process, and notice whether the distance between its tip and the clavicle is increased ; he should grasp it, and try to move it on the rest of the scapula, noticing if crepitus, or acute pain be caused by the attempt, and also if, when the patient attempts to bend the elbow, it cause pain at the site of this process. If the process be movable, it demonstrates the existence of a. fracture of tlie coracoid process. If met with in a child, and the crepitus be absent or soft, these signs would indicate separation of the epiphysis. To examine the body of the scapula, the arm should be drawn as far forwards as possible, when the Chap, xiii.] FRACTURE OF THE SCAPULA. 185 siirgeon is able to trace with his fingers the outline of the bone ; he should specially notice any irregularity of the vertebral border of the bone, or depression of the infraspinous fossa, or displacement forwards and up- wards of the lower angle. If the shoulder be now placed as far back as possible, the vertebral border projects behind, and the surgeon can grasp it and obtain crepitus, or examine its outline still more accu- rately. By these means a, fracture of the body of the scapula may be recognised. This injury most com- monly extends across the bone below the spine, but it may be limited to the thin central part of the bone, and not implicate either border, being a fissured de- pression ; or the fracture may detach either the upper, or more often the lower, angle of the bone ; in the latter case the teres major draws the fragment up and forwards towards the axilla. Mention may be made here of cases in which the arm is found to be fixed in the abducted position ; but the head of the humerus occupies the glenoid cavity, and there is no fracture to be made out ; but when the surgeon flexes the elbow and rotates the arm, he feels something slip, and then finds the de- formity cured and all the rigidity gone, the accident is supposed to be dislocation of the tendon of the biceps from the bicipital groove. D. Fracture of the shaft of the humerus. This injury is readily recognised by the deformity in the arm (often an angular bend forwards or to one side), by mobility in the length of the bone, and by crepitus. Care must be taken to ascertain not only the exact position of the fracture, but particularly the direction in which displacement occurs, and whether the radial pulse is the same on the two sides, and whether there is any anaesthesia or paralysis of the fore-arm or hand ; as the vessels and nerves of the arm lie so close to the bone, they are liable to be injured 1 86 SURGICAL DIAGNOSIS. [Chap. xin. both by the fracturing force and by projecting angles of the bone, and it is important to recognise the fact at the time. E. Fractures and dislocations of the elbow. The fractures and dislocations about the elbow joint are very numerous, and their diagnosis is extremely important, as unless all displacement is corrected, the function of the joint may be per- manently interfered with. The surgeon should stand in front of his seated patient, and grasping the two elbows in his palms, place his thumbs on tht*. external epicondyles, his middle fingers on the in- ternal epicondyles, and his forefinger tips 011 the points of the olecranon processes. The relative posi- tion of these three bony prominences is first to be ascertained. When the joint is bent the olecranon sinks below the epicondyles, when the elbow is straight it lies in a line with them. Having observed whether the relation of these three bony points is altered or unaltered on the injured side, the surgeon should next feel whether the head of the radius is lying imme- diately below the external epicondyle. By this means this large group of injuries will be divided into four classes. (1) The relation between the olecranon and both epicondyles is altered. The surgeon must particularly notice what the alteration is, whether the olecranon is simply raised, or displaced backwards, to either side, or forwards ; and if the head of the radius follo\r the ulna in its displacement. (a) The tip of the olecrauon is displaced upwards, and at the same time is found to be movable laterally ; when the elbow is extended the fragment may be rubbed against the upper end of the ulna, producing crepitus. These signs, of course, indicate a fracture of the olecranon with displacement. The patient will complain of pain and inability to Chap, xin.] DISLOCATIONS OF THE ELBOW. 187 extend the elbow, and there will be swelling and ecchymosis. (b) The olecranon is displaced directly backwards, the distance between it and each epicondyle is much increased, and the point of the elbow projects strongly behind, while the head of the radius is felt at the back of the outer condyle of the humerus. These signs unmistakably indicate a dis- location of the radius and ulna backwards. The outline of the greater sigmoid notch of the ulna will probably be plainly felt at the back of the joint, and the tendon of the triceps muscle will stand out at the back of the arm above the olecranon. The distance between either epicondyle and the corresponding styloid process will be diminished, the joint will be rigid in the flexed position, and there will be a rounded pro- minence across the front of the bend of the elbow formed by the lower end of the humerus covered by the brachialis anticus muscle. If the deformity be easily reduced, but at once recur on removing the traction upon the fore-arm, and if when re- duced flexion of the joint elicit crepitus, there is a fracture of the coronoid process ; possibly the de- tached piece of bone may be felt at the front of the joint, and may be found movable from side to side. If the head of the radius be found occupying its normal position, and the length of the fore-arm on the outer side be unaltered, it shows the injury is a dislocation of the ulna backwards ; while if the head of the radius be found lying on the front of the epicondyle, the injury is a dislocation of the ulna backwards and of the radius forwards. These last two dislocations are very rarely met with. (c) The olecranon is displaced forwards, its prominence at the back of the joint being lost, and the head of the radius is felt separated from the external condyle and below it, while the distance i88 SURGICAL DIAGNOSIS. [Chap. xin. from the epicondyle to the styloid process is increased on each side of the fore-arm ; the injury is a disloca- tion forwards of the radius and ulna. If the olecranon be felt resting against the lower end of 'the trochlea, the dislocation is partial ; if, however, the olecranon fossa and the lower end of the trochlea can be plainly felt at the back of the joint, the dislocation is complete ; either form of injury is very rare. (d) The olecranon is displaced inwards, filling up the hollow behind the internal epicondyle, and so masking the latter, while the external epicon- dyle is very prominent, and the head of the radius is not immediately below it, but also displaced inwards, with the length of the fore-arm little or not at all altered ; these signs point to dislocation of radius and ulna inwards. If, however, at the same time that the olecranon is displaced inwai-ds, it also projects back, being more than normally prominent behind, and the head of the radius is felt resting against the back of the trochlea, while the length of the fore-arm is a half to one inch shorter than on the uninjured side, the injury is dislocation of the radius and ulna bachvards and inwards. (e) The olecranoii is displaced outwards, covering the external epicondyle, the head of the radius projects strongly under the skin, and on the inner side of the joint the internal epicondyle is very prominent, so that the lateral width of the joint is greatly increased, there is a dislocation outwards of radius and ulna. If the olecranon be prominent be- hind, and the radius project on a level posterior to the external epicondyle, and the fore-arm be shortened, the injury is a dislocation of radius and ulna back- wards and outwards. (/') The width between the epicondyles is increased; each of these processes is movable inde- pendently of the other with crepitus. These signs Chap, xiii.] FRACTURES OF THE ELBOW. 189 indicate an intercondyloid fracture of the humerus, in which with a transverse or oblique fracture across the lower end of the shaft there is combined a vertical fissure of the lower end of the bone separating it into two fragments. This fracture is the result of severe direct injury, is usually attended with very marked deformity of the joint, and is not unfrequently com- pound. The olecranon may be raised above its normal position and sunk in between the displaced lateral fragments of the humerus. (2) Relation of internal epicondyle and olecranon normal, olecranon above external epicomlyle, and the lateral distance between the two increased. When this defoi'mity occurs, and is corrected by simple traction upon the fore-arm, and with the occurrence of crepitus ; and, if a sharp projection is felt in the internal supracondyloid ridge, it shows that there is a fracture through internal condyle of humerus, with riding of the fragment up and in carrying the ulna with it ; generally in these cases the head of the radius is dislocated backwards, and is felt on the back of the humerus, and then the outer side of the fore-ann is shortened, but not the inner. (3) Relation ot external epicondyle and olecranon normal, distance between in- ternal epicondyle and olecranon increased. This deformity may be due to displacement of either the olecranon or the internal epicondyle. If the epicondyle be movable on the shaft of the humerus, and the movement give crepitus, while the point of the elbow is not unduly prominent, the injury is a frac- ture of internal epicondyle. If the internal epicondyle, on the other hand, be immovable, but the point of the elbow be too prominent behind, and the movements of the joints are pi'eserved, while drawing forwards the fore-arm corrects the deformity altogether, at the same time eliciting soft crepitus, and when the traction force 190 SURGICAL DiAGtro$r& [Chap. xin. is removed the deformity recur, there is a separation of the lower epiphysis of the humerus, the internal epicondyle remaining attached to the diaphysis. This accident only occui's before the age of sixteen years. (4) The relation between the olecranoii and the epicondylcs is unaltered. (a) Feel whether the head of the radius is in its normal situation below the external epicondyle, if not, feel for it in front of that condyle under the swell of the supinator longus, or resting on the back of the bone, or it may be felt and seen very promi- nently under the skin, lying on the outer side of the epicondyle. In either of these cases the length of the inner side of the fore-arm is normal, while on the outer or radial side it is shortened ; the movements of the joint are restricted, and in the forward displacement of the bone the elbow can only be flexed to a right angle. These signs will clearly indicate a dislocation of the head of the radius forwards, backwards, or out- wards. If, however, the head of the radius occupy its normal position below the external epicondyle, there is no dislocation present, and the surgeon must then examine carefully for fracture of the various bones. He should first notice whether the line of the humerus is normal, or whether there is any displace- ment of the elbow backwards, and then grasping either condyle try to move it separately. Having satisfied himself as to the condition of the humerus, the finger should be run very carefully along the olecranon process, and any irregularity or very tender spot noticed, and then seizing the tip of the process an attempt to move it should be made, and crepitus felt for. Next, placing the thumb of one hand on the head of the radius, with the other hand rotate the fore-arm, and notice whether the head moves with the rest of the bone, or whether the movement causes crepitus at the neck, Chap, xiii.] FRACTURES OF THE ELBOW. 191 the head being immovable Lastly, pressing upon the head see if any point of it be movable, or whether the pressure cause crepitus. (6) The elbow is too prominent behind, and there is a rounded projection of the front of the arm a little above the fold of the elbow; the joint is not locked ; the relation of the bony parts of the elbow is normal, and the length of the fore-arm is the same on each side of the two limbs ; the deformity is corrected by simply drawing the fore-arm forwards, and this movement gives crepitus ; when the traction ceases the deformity at once recurs. On running the finger down the supracondyloid ridges, a sharp projecting point of bone, or a " break " in its line, may be detected. These signs clearly indicate a transverse fracture of humerus above the epicondyles. When occurring in children under sixteen years of age, the deformity is generally less marked, and the crepitus is soft ; the signs then indicate a separation of the lower epiphysis of the humerus. (e) If either epicondyle be found movable, the movement giving rise to crepitus, it of course proves the existence of a fracture ; this injury may or may not be accompanied with displacement of the fragment. The surgeon must notice, as far as he can, the size of the fragment, and whether the fracture simply detaches the epicondyle or runs up higher into the supracondy- loid ridge, and into the joint ; in this way fracture of. a condyle or epicondyle may be diagnosed. Fracture of the internal condyle, with displacement of the frag- ment up and in, with dislocation of the radius back- wards, has already been mentioned. The corresponding fracture of the outer condyle may be attended with displacement of the fragment outwards, upwards, or backwards, with or without dislocation of the bones of the fore-arm outwards. (d) If a part or the whole of the olecranon be 192 SURGICAL DIAGNOSIS. [Chap. xin. found movable on the rest of the ulna, with crepitus, the surgeon will diagnose a fracture of the olecranon witlwut separation. This injury may be attended with some slight irregularity of the bone, and cer- tainly with morbid tenderness over the line of frac- ture ; this variety is more common than the fracture with separation. (e) If, on rotating the fore-arm, the head of the radius be found not to move, and crepitus be felt just below it, & fracture of the neck of the radius may be diagnosed. (f) If, on rotating the fore-arm, crepitus be felt just below the outer epicondyle, and be also elicited by pressure on the head of the radius, and especially if any part of this bony process be felt to be movable, this will be evidence of fracture of the Jiead of the radius. (g) If the presence of crepitus on moving the elbow show that there is a fracture, but all the bony points of the joint are in their normal relation and not detached, and further if there be a deviation in the line of the limb at the elbow joint, or a lateral movement there with crepitus, a fracture of tJie articular process may be diagnosed. This injury is very rare. F. Fracture of fore-arm. Either of the bones may be broken singly, but the fracture of the two bones together is more common; "greenstick fracture" is said to be more frequent in this situation than in any other. The signs of fracture are the common ones of pain, swelling, usually very marked deformity, mobility, and crepitus. The posterior edge of the ulna is subcutaneous in its whole length and may therefore be easily examined ; the continuity of the radius may be shown by observing whether the head of the bone follows the movement of the wrist in pronation and supmation. Chap, xiii.] FRACTURES OF THE FORE- ARM. 193 (1) If there be marked deformity in the limb, a bend to either side, forwards or backwards, occurring as the result of a fall on the hand or a twist of the fore-arm in a child or young person, and there be no mobility in the length of either bone, and no crepitus be obtained, the injury is a greenstick fracture ; this diagnosis will be confirmed if the surgeon be able to straighten out the bones again. (2) An angular deformity of the fore-arm with mobility in its length and crepitus, will indicate fracture of the radius and ulna. (3) If there be pain and swelling over the ulna, and on running the finger along the subcutaneous edge of the bone a very tender spot is found, and here mobility and crepitus, with or without irregu- larity of the bone, are detected, while the length and general outline of the fore-arm are unaltered, and the radius is fouiid to be entire, the signs will point to a fracture of the ulna. (4) Similarly, if the ulna be felt to be entire, but on rotating the wrist crepitus is obtained, and the head of the radius is found not moving with the lower end, a fracture of the radius is to be diagnosed. A depression in the line of the bone as felt from the outer side, or the position of greatest pain and tenderness, will mark the seat of the fracture. This fracture is usually attended with displacement of the lower fragment inwards, and abduction of the hand ; it is most common in the lower third of the bone. G. Fractures and dislocations of the wrist. In this region the commonest accident is fracture of the lower end of the radius, known as Colles' fracture; in addition, and rarely, are observed separation of the lower epiphysis of the radius, fracture of the styloid process of the radius, dislocation of the wrist, of the lower end of the radius from the ulna, N 13 194 SURGICAL DIAGNOSIS. [Chap. xin. and of some of the carpal bones. Deformity is the sign by which these injuries are diagnosed, and the position and shape of projections and depressions, together with alterations in local measurements and in the axes and planes of the hand and fore-arm, are the signs by which a diagnosis has to be made. (1) If there be a prominence on the back of the wrist above the styloid process of the radius, which is itself on a horizontal level with or above that of the ulna, while corresponding to the dorsal projection there be a slight hollow on the palmar aspect, and above that a rounded prominence over the radius, and the styloid process of the ulna appear too promi- nent, and with a marked groove or depression below it, the injury is a Colles' fracture. The distance from the styloid process of the radius to the base of the first metacarpal bone is the same on the two sides, but that from the styloid process to the external epi- condyle of the hurnerus is shortened on the injured side. If this deformity be met with in a young person under eighteen or twenty years of age, and it be reduced with a soft grating sensation on extension of the hand, it is a separation of the lower epiphysis of the radius. In elderly adults the fracture is usually impacted and mobility and crepitus are not obtained. (2) If there be a prominence just above the dorsum of the wrist, and the whole hand be carried back, but is in a straight line with the fore-arm (not abducted), and each styloid process is approximated to the epicondyle of its own side, and situated at a normal distance from the metacarpus, the injury is & fracture of the lower end of radius and ulna ; in this fracture there is generally mobility and crepitus, and the break in the line of the ulna is obvious. (3) If, however, the prominence on the back of the wrist have a distinct convex upper margin, and the styloid processes keep their normal relation to Chap, xiii.] DISLOCATIONS AT THE WRIST. 195 each other, that of the radius being below that of the ulna, with the measurement of the length of the fore-arm unaltered, while the distance between either styloid process and the base of the metacarpus is considerably shortened, the injury is a dislocation backwards of the carpus ; this diagnosis will be con- firmed if the deformity be corrected by extension, the bone slipping in with a snap, but without any crepi- tus being felt. (4) If, however, the prominence on the dorsum of the wrist be formed by the two styloid processes and concave extremities of the radius and ulna, while immediately below this is a marked depression, the hand being on a lower level than the fore-arm when held out palm down, and a projection be found on the palmar side opposite the fold of the wrist, and the measurements are the same as in the last case, it is a dislocation forwards of the carpus. Dislocation of the wrist is a very rare accident, especially the displace- ment of the carpus forwards. 5. If the lower ends of the radius and the ulna project on the back of the wrist, the hand being on a plane anterior to that of the fore-arm, with a palmar prominence opposite the fold of the wrist, and the styloid process of the radius be above its usual position, approximated, that is, to the external epicondyle, but not separated from the first metacarpal bone by a longer distance than on the opposite side, the injury is a fracture of lower end of radius, with displace- ment forwards. This is a very rare injury. (6) If the lower end of the radius be found very prominent on the back of the wrist lying over the end of the ulna, and pronation and supination be impossible or very limited, the diagnosis should be dislocation of lower end of radius backwards. Should the prominence on the back of the wrist be formed by the lower rounded end or head of the ulna, which is 196 SURGICAL DIAGNOSIS. [Chap. xin. very prominent under the skin resting on the radius, it is a dislocation forwards of the lower end of the radius. These dislocations are both of them quite uncommon ; they are sometimes spoken of as dislocations of the ulna in the opposite direction. In either case the length of the fore-arm, and the distance between the styloid processes and the bones of the metacai-pus, are un- altered. Pronation and supination of the hand are very limited and painful. (7) If a rounded projection be felt on the back of the cai-pus about its centre, firm and unyielding, and the movements of the wrist-joint are found to be free, a dislocation backwards of the head of the os magnum may be recognised. Occasionally the whole bone is displaced backwards, or one of the other bones, as the semilunar or pisiform bone, may be felt displaced. The position and the shape of the bony prominence will determine the diagnosis. (8) If there be no obvious deformity, such as the above fractures and dislocations produce, the surgeon should seize the styloid process of the radius, and try to move it on the rest of the bone. If he find it movable, and the movement occasion crepitus, he will have no difficulty in diagnosing a fracture of the styloid process of radius. Similarly, mobility with crepitus are the signs of & fracture of the styloid pro- cess of the ulna. (9) If free movement of the wristrjoint be painful and attended with crepitus, and yet neither of the styloid processes be movable, the injury is probably a fracture of the carpus. (10) Pain in moving the wrist persisting for some days, and attended with marked tenderness along a vertical line over the end of the radius, and subsequently some slight thickening along this line, have been held to warrant the diagnosis of a fissure of the lower end of the radius. Chap, xiii.] INJURIES OF THE HAND. -197 H. Fractures ami dislocations of the metacarpus and phalanges. These bones are so subcutaneous that any irregularity in their con- tour is easily detected. The examination is to be made first by running the fingers along the bones of each digit to note irregularity, then by grasping the two extremities of each bone to attempt to obtain mobility in its length and crepitus, and lastly by pressing the end of each, finger up towards the wrist, to observe whether it produces acute pain or crepitus. A convenient way of ascertaining whether there is any shortening is to place the two hands together palm to palm, when any shortening of a finger or the thumb is at once rendered obvious. (1) Dislocation of metacarpal bone of thumb may occur backwards, or, more rarely, forwards. It is recognised by approximation of the base of the bone to the styloid process of the radius, and by the marked prominence the base of the bone forms on the dorsurn or palm of the hand. It is distinguished from fracture with displacement by the position and shape of the prominence, and by the absence of crepitus. Either of the other metacarpal bones may be partially dislocated backwards, and form a prominence on the back of the hand ; the bone can be pressed into place when the corresponding finger is extended. (2) If a metacarpal bone is found to be deformed, and movement in its length is obtained, or crepitus, or the finger is found shortened, and pressure upon it up towards the wrist causes acute pain at one spot in the metacarpus, or is attended with crepitus, a fracture of the metacarpus may be diagnosed. (3) Irregularity, mobility, or crepitus, or all these three signs together enable the surgeon to recog- nise easily fracture of a phalanx. (4) Stiffness and pain at a phalangeal joint with shortening of the digit, and great increase of the 198 SURGICAL DIAGNOSIS. tchap. xiv. antero-posterior diameter of the joint, point to dislo- cation of a phalanx. The outline of the bones can be so plainly felt that there is no difficulty in deciding upon the direction of the displacement. All phalanges are most frequently dislocated backwards ; those of the thumb may be dislocated forwards. CHAPTER XIV. THE DIAGNOSIS OP THE SPECIAL INJURIES OF THE LOWER LIMB. A LARGE proportion of the fractures and dislocations of the lower limb are at once rendered apparent by the obvious deformity they occasion ; in others the seat of pain marks the position of the injury, and the ready detection of crepitus enables the surgeon at once to diagnose a fracture ; only in a small minority of cases is there grave difficulty in arriving at a conclusion as to whether a patient has sustained a fracture or a dislocation, and these are mainly met with in in- juries of the hip-joint where the difficulty arises from the thickness of the soft parts overlying the articula- tion. In examining an injured limb, the surgeon should first of all expose the two limbs thoroughly, and look carefully to see if there be any deformity, an alteration in the axis or position of the limb or of any of its parts, an unusual prominence or depression or obvious alteration in its length, the existence of which will indicate both the fact of a lesion of the skeleton of the part, its situation, and in many cases its nature. Next, the limb should be examined by the hand, and here again it should be compared with the sound member. One hand should chap. xiv.] EXAMINATION OF HIP AND THIGH. 199 be placed on the outer side of each hip just below the crest of the ilium, and the top of the great trochanter of the femur felt for. In this way any marked alteration in the position and shape of this process will be detected. The fingers should be passed round behind it towards the buttock to explore that region, and to note any difference between the two sides, and particularly whether the head of the femur can be felt there. Next, the fingers should be gently pressed into the hollow of the groin, and any difference in the resistance encountered on the two sides, or any marked pain produced, noticed. The hands run down along the thighs will detect any great deformity in the shafts of the femurs, but in muscular persons these bones are so thickly covered that a slight alteration in the contour of the bone may readily escape notice. The marked local tenderness, which has been often before referred to in connection with fractures, will in this case, too, be of considerable value in this manipula- tion in arresting the surgeon's attention in cases where there is no obvious deformity. The bones of the knee, being more subcutaneous, can be more thoroughly examined. The joint should first be grasped laterally to determine whether there is any increase in its width, and then the hand may be passed down from the femur to the tibia, and the relative position of these two bones carefully compared on the two sides for the purpose of deciding whether the tibia is displaced forwards, backwards, or laterally upon the femur, or rotated upon its own axis. Then the patella should be felt for, and as this bone is wholly subcutaneous, its surface is easily felt and its posi- tion noticed. It may then be grasped above and below, and an attempt made to move one part independently of the other. Failing this, a similar attempt may be made upon the lateral halves of the bone. The head of the fibula resting against the outer tuberosity of 200 SURGICAL DIAGNOSIS. [Chap. xiv. the tibia should then be examined. And now the surgeon will pass his fingers down along the crest and subcutaneous inner surface of the tibia, and notice carefully any irregularity in the bone, or marked tenderness. By somewhat firmer pressure the outline of the fibula can be similarly explored. At the ankle joint the bones again become wholly sub- cutaneous, and the breadth of the malleoli and their outline can be easily compared on the two sides. The skeleton of the foot is readily felt from the dorsum, and any displacement of the bones either at the joints or elsewhere can be determined. The bony points to be specially felt for are the prominence of the heel, the tubercle of the scaphoid, and the projection of the base of the fifth metatarsal bone. The examination of the general conformation and relations of the bones by the hand will add much to the knowledge obtained by the eye alone. Where such examination has led the surgeon to suspect the existence of a fracture, he will seek to determine this point at once by trying to obtain mobility or crepitus in the length of the bone. As in all other cases, so here, the utmost gentleness should be observed in making the necessary manipulations. The limb should be firmly grasped close above and below the suspected spot, and at first an attempt should be made to obtain movement or crepitus with quite slight force ; this may be gradually increased when it is found that the bone resists, or at once discontinued as soon as any crepitus is felt. In some places the manipulation is a little different. At the upper part of the thigh it is impossible to grasp the limb in this way, and the plan adopted is for the surgeon to place his hand flat over the trochanter, and for an assistant to seize the foot and gently rotate the whole limb, the sur- geon observing whether there is any crepitus, and also whether the trochanter moves with the shaft Chap. xiv.] EXAMINATION FOR CRRPTTUS. 201 of the femur, simply rolls around its own axis, or moves in a circle as large as that on the sound side. This manipulation, too, must be carefully and gently executed, lest an impacted fracture should be un- impacted. At the knee, when the bone is broken, the parts of the patella may be separately taken hold of, and moved one upon the other, or either condyle of the femur may be movable in an antero-posterior direction upon the rest of the bone. At the ankle either malleolus may be moved in a similar manner. And I may here pause to point out that fractures of the malleoli are often overlooked from want of care in this manipulation, the injury being attributed to a sprain. Whenever there is marked local pain over either malleolus, and especially when to this is added acute tenderness to pressure at the same spot, the part of the bone below this spot should be seized, and a careful attempt made to move it upon the rest of the bone ; failing that, the limb should be grasped with the thumb or fingers firmly pressed upon the painful spot, and with the other hand the foot should be flexed and extended and rocked laterally ; by one or other of these manipulations crepitus will be ob- tained if there is a fracture. The examination by the hand also gives other valuable information. Thus, in the thigh, it will determine the tension of the strong outer band of the fascia lata (ilio-tibial band). At the knee, the position, tension, or continuity of the ligameii- tum patellae, and the state and position of the hamstring tendons will be noticed^; while at th(5 ankle the tendons behind each malleohi&^wiill be felt for, as these are liable to be displaced forwards. Having done this, or before -attempting 1 to elicit crepitus where fracture is not suspected, the surgeon will pro- ceed to compare the two limbs by measurement. This is a most important part of the examination, and 262 SURGICAL DIAGNOSIS. tch ap . xiv. should never be omitted, unless the diagnosis is absolutely certain without it, as in transverse fracture of the patella, for example ; and at the same time great care must be taken that the measurements are really between the same points on the two sides, or the surgeon may be seriously misled instead of being helped by his results. It is necessary also to place the two limbs in the same position when measuring them, and for this purpose the sound limb, which can be moved without occasioning pain, must be brought into the position assumed by the injured member. The best position for taking these measure- ments is the patient lying flat on his back, with the limbs extended straight and parallel, and the pelvis so placed that a line drawn from one anterior superior iliac spine to the other cuts a median vertical line at right angles. This latter line can be easily obtained by having one end of a piece of string held between the patient's central incisors and drawing the other end down so that the thread lies over the umbilicus and the symphisis pubis. The following measurements will be found of use : 1. The length of the limb from the anterior superior iliac spinous process to the tip of either malleolus. This gives the length of the entire limb, and alterations in it afford no guide as to the site of the deforming lesion, which may be in the hip, thigh, knee, or leg ; it, of course, affords no information as regards the foot. When the measurement differs on the two sides, the surgeon must then proceed, by other sec- tional measurements of the limb, to determine where the deformity actually exists. It has of late years been shown as a normal occurrence that a good many people have the lower extremities unequal in length, and generally without any knowledge of the fact on Chap, xiv.] THE LOWER LIMB. 203 their part, and this inequality may amount to as much as an inch, or even more. But sectional measurements always show that this want of sym- metry is not limited to any one section of the limb, but is shared by both the thigh and the leg. Therefore it is not enough to find simply that one lower extremity is longer or shorter than the sound one ; it is necessary further to show that this inequality exists in one particular section of the limb. It must also be borne in mind that if one limb is an inch longer than the other, and it receives an injury (a fracture, for instance), it may be shortened by just so much, and the tape would then show the two limbs to be of the same length. This would be a circumstance of very exceptional character, but its mere possibility must arm the surgeon against being misled by it. It must also be remembered that previous injuries, diseases, or operations may have altered the length of a segment of the limb. In conclusion, then, although this measurement is of great general value, by itself it is not conclusive, and must always be corrected by vertical measurements of the thigh and of the leg separately, and by enquiry into the history. It is necessary to remind the surgeon to be very careful to take the measurement from exactly the same point of the spine of the ilium on the two sides. Mistakes in this may easily be made in fat persons, and the best safeguard is for an assistant to mark the spot from which the measurement is to be taken with the fore- finger of each hand ; in this way it is easier to fix upon exactly the same point on each side. 2. Determine the position of the great trochanter of the femur, both as to its vertical and horizontal situation. This is to be done by the following methods : (a) Nelaton's line. Draw a line from the anterior superior iliac spine over the outer side of the 264 SURGICAL DIAGNOSIS. tchap. xiv. hip to the prominence of the ischial tuberosity. The top of the great trochanter should just touch this line in every position of the joint. This line is of use to determine whether the trochanter is above or below its normal position. The length of the line in front of the trochanter gives roughly the horizontal position of the bone. It is a measurement easily taken ; but possesses the drawback of requiring the patient to be rolled over towards the sound side, a movement which may be painful and injurious. (6) Bryant's line. With the patient lying flat on his back, draw a line vertically down to the bed from the anterior superior iliac spine, and then draw a second line from the top of the great trochanter up to join the first line at right angles ; the length of the second line marks the vertical distance of the top of the great trochanter below the front of the iliac crest. This measurement, therefore, gives us the same information as Nelaton's line, but is greatly to be preferred to it, as it is obtained without any move- ment of the patient, and therefore without inflicting any pain or damage. If a third line be drawn from the front of the iliac crest to the trochanter, it forms a triangle, and this third line gives roughly the horizontal position of the trochanter. (c) The horizontal position of the trochanter may be measured by a tape passing from its tip to the middle line ; but Mr. Henry Morris employs a more exact and trustworthy method. He places a straight rod on the pelvis, resting on the two anterior superior iliac spines, with the centre of the rod exactly over the middle line of the body. On each end of the rod he has a sliding vertical pointer, which is to be placed with its tip just resting on the outer side of the tro- chanter, the distance between the pointer and the centre of the rod, which is marked off in inches, can Chap. xiv.] THE GREAT TROCHANTER. 205 then be read off and at once compared on the two sides. These measurements are of great value, as they are modified in all cases of dislocation of the hip joint, fracture of the acetabulum with displacement of the head of the femur into the pelvis, impacted fracture of the neck of the femur, many cases of unimpacted fracture of that part of the bone, and in cases of fracture and detachment of the great trochanter itself. Disease also modifies the position of the trochanter, for it may lead to dislocation of the bone or to shorten- ing of the head and neck in morbus coxarius, or to shortening of the neck of the bone with depression of the head in chronic rheumatic arthritis ; and it is here noteworthy that both these morbid states may be excited by injuries to the hip. It is doubtful if the great trochanter be ever depressed below its normal position, though it has been stated to occupy such a position in thyroid dislocation of the hip. With this doubtful exception, all injui'ies and diseases which affect its position in the vertical direction cause it to be raised, or, in other words, they make it pass above Nelaton's line, or shorten Bryant's line. A result of this displacement, which has been stated to be diag- nostic of fracture of the neck of the femur, is lessened tension of the fascia lataof the outer side of the thigh, which can be detected by pressing the fingers horizon- tally inwards just above the great trochanter, or above the outer condyle of the femur. This relaxation of the ilio-tibial band of the fascia lata may be produced by any injury causing shortening of the thigh and approximation of its two attachments, and may be of use as a measure of this shortening, but must not be regarded as pathognomonic of fracture of the neck of the femur. 3. The length of the thigh is ascertained by taking the distance from the anterior superior spine of 206 SURGICAL DIAGNOSIS. [Chap. xiv. the ilium to the upper border of the patella ; or from the pubic spine to the adductor tubercle of the femur. Some prefer to take the lower border of the patella as the lowest point. If the patella be taken, great care must be used to ensure that the knee joint is in the same position in the two limbs, and the bone should be pushed up to its full extent. This measurement is affected by all those conditions modifying the vertical position of the trochanter, and, in addition, by fracture of the shaft of the femur with over-riding of the frag- ments, and by dislocation upwards of the patella, or, when the top of the patella is taken as the lower point, by transverse fracture of the patella, with separation of the fragments. The result may therefore be the same as that obtained by taking Nelaton's or Bryant's line ; but when these lines show the head and neck of the femur to be uninjured and in their normal position, and yet the whole length of the thigh dimi- nished, it indicates that the shaft of the femur is broken and shortened or the patella displaced. 4. The length of the leg is to be measured from the upper edge of either tibial condyle to the tip of the malleolus on the same side ; these are the best points to take, but the lower edge of the patella or the tubercle of the tibia are also used as the upper points. 5. The distance between the front of the head of the fibula and the tubercle of the tibia will show whether the head of the fibula is occupying its right position on the outer tuberosity of the tibia. 6. The relation of the malleoli to the tarsus is a point of great importance in the diagnosis of many injuries of the foot. It may be ascertained by measuring in three directions : (a) From the tip of either malleolus to the point of tlie heel. If this measurement be shortened on each chap, xiv.] MEASUREMENTS OF THE FOOT. 207 side of the foot it shows that the os calcis, with or with- out the astragalus, is displaced forwards upon the leg; similarly, if lengthened on each side it shows dis- placement of that bone backwards. A lateral dis- placement of the os calcis will increase the distance between the point of the heel and the malleolus from which it is removed, while the similar measurement on the side of the foot towards which the foot is dis- placed" may be shortened or lengthened, but in the latter case will not be affected to the same extent as on the other side. These lateral displacements of the foot are so obvious that the surgeon is not likely to be led into any error by the fact that they modify the measurements in question, and so confound the lateral with the antero-posterior displacements of the foot, in the detection and correction of which these measurements are of great importance. (b) From the tip of the internal malleolus to the tubercle of scaphoid or point of great toe, and from the tip of the external malleolus to the tubercle of fifth metatar- sal bone, or point of little toe. These measurements are lengthened when the foot is displaced forwards, and shortened when it is displaced backwards, and in all pure antero-posterior displacements of the foot corre- spond to the measurements from the malleoli to the heel. Where, however, the anterior measurements are different only in the two feet it shows that the injury is in the front part of the foot, and then it is of value to have taken the length not only to the point of the toe, but also to the scaphoid or fifth metatarsal bone, as it enables the surgeon to decide whether the deformity is in front of or behind these two bony points ; displacement of a single bone, as e.g. the cuboid or the cuneiform, will affect the measurement on one side of the foot only. (c) From the tip of either malleolus to the sole. This is obtained by placing a book or flat board against the 2o8 SURGICAL DIAGNOSIS. [Chap. xiv. sole of the foot and then measuring the distance from it to each malleolus. This measurement may be short- ened on the inner side by Dupuytren's fracture, and on both sides by dislocation of the astragalus, and may be lengthened by subastragaloid dislocation of the foot. The seat and character of the pain the patient suffers, the functional disturbance in the limb, the re- sistance to passive motion at the various joints, and the history of the accident, with the age of the patient, are all of them points which may give important aid in diagnosis. In reference to the last two points, it may be mentioned that children are very liable to fracture of the shaft of the femur, which is fre- quently transverse in direction, as well as to separa- tion of epiphyses and to greenstick fracture, which is, however, much rarer in the lower limb than the upper. Elderly women are predisposed to inti'acapsular fracture of the neck of the femur from slight indirect violence. Twists of the foot, as in slipping off the edge of the kerb, are the common cause of Pott's and Dupuy- tren's fractures. In missing a step, or in other attempts to prevent a fall, the patella may be broken; the neck of the femur is snapped by slight indirect violence, as in catching the foot against a mat, while from severe direct violence to the hip (falling on it, heavy blows upon it) impacted fracture of the neck is produced. Dislocations of the foot or of its individual bones are caused by falls from a height on to the foot, especially when the toes are pointed. The knee is dislocated by severe and sudden wrenches ; and Mr. Morris has shown that the hip joint is only dislocated when in a position of abduction either by the limb being drawn away from its fellow, or, what comes to 'the same thing, by the trunk being forced over to the same side, and that the form of dislocation depends upon the amount of flexion of the joint and the direction in which rotation Chap, xiv.i INJURIES OF THE HIP. 09 occurs. The severest fractures and injuries are those produced by direct crushing force. By this examination the surgeon will have no difficulty in deciding what part of the skeleton of the limb, if any, is injured. We will now pass on to consider the diagnosis of the various injuries of the different regions, which we will group as follows : A. Injuries about the hip joint. B. Injuries of the thigh. D. Injuries of the leg. E. Injuries about the ankle. F. Injuries of the foot. C. Injuries about the knee. A. Injuries about the hip join!. When the history of the case, the seat of pain and possibly also of bruising and swelling, the loss of function, as well as obvious deformity and exact measurement, show that there is an injury to the bones of the hip, it is necessary to distinguish, as far as possible, between the numerous and important fractures and dislocations of this region. Deformity is the great symptom of all dislocations, and combined with it is marked fixedness of the joint ; in fractures the deformity is, as a rule, less marked, and the simple helplessness of the patient, the loss of power, with pain, are the two most striking phenomena. The first grouping of these cases may be made according to the position of the limb, whether it is inverted or everted, and in any case in which the surgeon is in doubt as to which of these groups a case rightly belongs, the fact that the patient is unable to invert his limb may be taken as indicating that the limb is everted. (1) The limb is inverted, or rotated in. The injuries that are attended with this deformity are : Dislocation backwards. Impacted fracture of the neck of the femur. Press the fingers into the hollow of Scarpa's triangle and try to feel the head of the femur in its socket ; if, o13 2io SURGICAL DIAGNOSIS. [Chap. xiv. however, this space be found deeper than usual, and the fingers meet with no bony resistance just below the brim of the pelvis, there is a dislocation ; while if the space be normal, and the same bony resistance is felt as on the uninjured side, the joint is not dislo- cated. If the joint be much flexed it clearly indicates a dislocation, while if quite extended, dislocation is ex- cluded. Lastly, an attempt must be made to find the head of the femur in its new position on the buttock by firmly pressing the fingers into the mass of muscle of this region and at the same time gently rotating the limb inwards. (a) If the limb be found inverted, flexed upon the pelvis, and adducted, shortened to the extent of one to two inches, the great trochanter being raised to this amount and anterior to its normal position, while the groin is found hollow and the rounded head of the femur is to be made out under the gluteal muscles on the buttock, it is a dislocation on to tJie dorsum ilii. There will be considerable rigidity of the part, and while passive flexion, adduction, and further rotation in will be possible, the attempt to extend, abduct, or rotate out the limb will cause great pain and meet with great resistance. If in manipulating the bone into its place crepitus be met with, and especially if the head of the bone at once or quickly slip out of its socket again, the case is one of dislocation with frac- ture of t/ie rim of t/ie acetabulum. (b) If the limb be much inverted and flexed, ad- ducted, slightly shortened, the trochanter being raised half an inch, or, at the most, an inch above its normal height, and the groin be hollow, the joint very rigid, flexion being the only movement possible, and the fingers fail to feel the head of the femur on the buttock, or feel it but indistinctly on the lower and back part of that region, there is a dislocation on to t/ie ischium, or what is called "into tfte sciatic notch." chap, xiv.] DISLOCATIONS OF THE If IP. 211 The head of the bone is farther back, but lower down than in the former variety, and hence the actual shortening of the limb is less, although in some cases the apparent shortening may be greater, and the knee be found some inches above the sound knee ; it is further noteworthy that the flexion of the joint be- comes much more marked when the patient lies down than when he stands up. If the thigh be a little shortened and strongly inverted, and also adducted and behind its fellow, it indicates that the head of the bone is " strapped down by the great sciatic nerve." (c) If the limb be greatly flexed, adducted, and in- verted, the thigh even being in contact with the belly, the groin very hollow, and the head of the bone felt above the prominence of the ischial tuberosity, there is a dislocation on to the tuber ischii. This is a very rare form of the dislocation backwards ; the trochanter may be found a little below or a little above its normal situation, according to the distance the head of the femur has passed back. (d) If, in the absence of the signs of dislocation just enumerated, the limb be found extended and inverted, Bryant's line shortened from half an inch to an inch, the great trochanter approximated to the middle line, and there be pain and tenderness over the trochanter, while the joint can be moved passively in all directions, it is an impacted fracture of the neck of the femur. It is unusual for such a fracture to give rise to inversion of the limb, and the surgeon will therefore be careful to assure himself that the head of the bone is in its socket, by observing the usual fulness and resistance in the groin, its absence from the buttock, and the ability to obtain passive motion in all directions ; but these movements must be made with all gentle- ness, lest the fracture be unimpacted ; it is the direc- tions and not the extent of the passive movements that are characteristic. 212 SURGICAL DIAGNOSIS. (Chap. xiv. (2) The limb is everted, or rotated out. The injury may be either of the following : Contusion of the hip. Dislocation of the hip. Fracture of the neck of the femur. Fracture of the acetabulum. Place the patient flat on his back, and notice whether the injured limb is flexed or extended upon the pelvis ; as a flexed hip may, by spinal lordosis, appear extended, bend up the opposite thigh to its full extent, until it lie against the belly and chest ; if there be flexion of the injured hip, the thigh will be raised from the bed by this movement ; if the joint be extended it will lie flat along the bed. In this way this large group of injuries may be subdivided. The hip is flexed. (a) If the prominence of hip be greatly flattened, the trochanter being considerably adducted towards the middle line and slightly raised towards the iliac crest, and the thigh abducted from its fellow, while the adductor muscles are found to be tense, and the rounded head of the femur is felt deep down under these muscles, it is a dislocation of the head of t/ie femur into the thyroid foramen. If the patient be examined from behind, the fold of the buttock is found to be lowered on the injured side. The limb has been described as lengthened in this injury ; but probably this is an error, arising from the tilting of the pelvis downwards to relax the psoas and iliacus muscles ; should it occur, however, Bryant's line will, of course, be found lengthened, not shortened. (6) If the thigh be strongly abducted from its fellow, and flexed, and the trochanter greatly adducted to the middle line, and the head of the femur bo plainly felt in the perinseum much more superficial than in the previous case, it is a dislocation of tJw Jwad of tlie femur into the perinceum ; this is a much chap, xiv.] DISLOCATIONS OF THE HIP. 213 rarer variety of the injury, but the signs are very characteristic. (c) If the great trochanter be raised by an inch or more from its normal position, and adducted, the hip being flexed, and the hollow of the groin lost, being filled out by the rounded head of the femur resting on the pelvis beneath Poupart's ligament, it is an ilio-pubic dislocation or dislocation on to the pubes. The femoral vessels should be felt for, and they will usually be found internal to the head of the bone. (d) If the hip be greatly flattened, the trochan- ter being adducted, and Bryant's line considerably shortened (two inches), and the eversion of the limb be extreme, while the abduction and flexion are but slight, the head of the femur will be found resting on the pelvis below the outer part of Poupart's ligament close to the anterior inferior spine of the ilium ; the injury is a subspinous dislocation. (e) If the limb be shortened to the extent of two or three inches (the trochanter being raised to that extent) a little abducted as well as everted, and the head of the femur be plainly felt just below the an- terior superior spine of the ilium, it is a supraspinous dislocation. The great trochanter is behind and out- side the head of the bone, and is to be felt with difficulty, owing to the mass of muscle covering it. (f) If the thigh be adducted, shortened, and everted, and the groin be hollow, and wanting in its normal re- sistance, and the head of the femur be felt on the dorsum of the ilium under the glutsei muscles, with the trochanter behind it, the injury is an everted dorsal dislocation. In this dislocation the limb may be extended. These last three are among the rarest forms of dislocation of the hip. It is useful to remember, as Bigelow has pointed out, that when the femur is unbroken, the direction of the internal condyle and of the head is always the same, and, therefore, in 214 SURGICAL DIAGNOSIS. [Chap. xiv. dislocations the direction of the head of the bone can with certainty be determined by noticing that of the internal condyle. (g) If the limb be everted, shortened to a slight extent (half an inch or so), and the head of the femur be felt under the iliacus muscle below the anterior inferior spine of the ilium, and rotation of the thigh elicit crepitus, there is a dislocation with fracture of the acetabulum. (3) The limb is extended. (a) If the limb be extended, everted, powerless, but admitting of pas- sive movement in all directions, shortened, the great trochanter being raised and adducted, and if gentle rotation elicit crepitus, and the trochanter which is not deformed be found to rotate around a very small circle, there is an unimpacted fracture of the neck of the femur. This accident is usually met with in old people, particularly in women, and as the result of indirect violence ; there may be little or no bruis- ing of the hip, or, what is still more characteristic, the bruising may only appear after some days, when the effused blood has had time to reach the surface. The limb is powerless, but admits of passive move- ment in all directions. The amount of shortening is generally slight (about half an inch, it may be more), and it is not uncommon for it to increase to an inch or more, either siiddenly under manipulation, or gradually. (6) If the limb be powerless, everted, extended, shortened, and the trochanter is adducted, and rolls around a circle only little smaller than the normal, and without crepitus, it is on impacted fracture of the neck of the femur. This injury results from direct injury to the hip, and is attended with greater bruising of the part. The shortening may be much greater than in the unimpacted variety, even two inches, or more ; when the line of fracture implicates the trochanter or Chap, xiv.] FRACTURES AT THE HIP. 215 the extracapsular part of the neck of the bone, the surgeon may be able to detect some deformity about the bone. Great care must be taken in these manipula- tions not to unimpact the fracture. (c) If there be eversion of the limb, loss of power, bruising, pain, and tenderness over the great tro- chanter, which may be found raised and drawn back, while the length of the thigh is unaltered, and on seizing the trochanter it is found to be movable, with or without crepitus, there is a fracture of the great trochanter ; if these signs are found in a child under sixteen years of age, they indicate a diastasis of the great troclianter. This injury is very rare. (d) If there be eversion of the limb, with shorten- ing, and the tip of the trochanter is found raised, and perhaps displaced backwards as well, while rotation of the limb occasions crepitus, but the tip of the tro- chanter is found not to move with the shaft of the femur, the accident may be diagnosed to be & fracture through t/te neck and great trochanter of t/te femur. The patient will be unable to sit, and any attempt to rise or to flex the hip will cause great pain. It is a veiy rare injury. (e) If after a fall upon the hip the patient be unable to stand, and complain of great pain in the joint, but the various measurements of the limb are unaltered, and movement do not occasion crepitus, but pressure upon the pubic spine elicit sharp pain, the signs were said by B. Travers to indicate a fissure of tJie aceta- buhim ; but this diagnosis is always open to grave doubt. (f) If, however, after a direct injury to the hip, the limb be found of its normal length, the trochanter neither raised nor lowered, abducted nor adducted, and the trochanter is found to rotate normally, and yet on moving the hip joint pain and crepitus are pixxluced, ^fracture of the acetabulum may be diagnosed. When 216 SURGICAL DIAGNOSIS. [Chap. xiv. the head of the bone is displaced towards the pelvis, being forced through the acetabulum, the diagnosis becomes more difficult, as the limb is shortened, the trochanter adducted and raised, there may be either eversion or inversion, and fracture or dislocation may be simulated. Failure to find the displaced head of the bone would eliminate dislocation. Examination of the interior of the pelvis per rectum and per vaginam, as well as the pain elicited by pressure upon the pubes and ilium, would probably enable the surgeon to dis- tinguish this injury from a fracture of the neck of the femur. (See page 165.) (ff) If after a direct injury to the hip the limb be found everted, and (possibly) bruised, and the patient complain of pain in it, and is unable to move it, but the surgeon finds no alteration in its length, no dis- placement of the trochanter, no limitation of move- ment, no crepitus, no want of proper resistance in the groin, no obliteration of the depression behind the trochanter, he may diagnose a contusion of the hip. This injury may be followed by slow gradual shortening of the limb and raising of the tro- chanter from absoi-ption of the neck of the bone. The great pain, the loss of power, and the ever- sion of the limb make this injury simulate a fracture, and the subsequent shortening makes the resemblance still closer. When the patient is already the subject of rheumatoid arthritis, which has led to shortening of the limb and some deformity of the trochanter, it is impossible to diagnose a contusion of the soft parts from an impacted fracture of the neck of the bone, unless the surgeon is aware of the previous condition of the joint. B. Injuries of the thigh. The diagnosis of a fracture of the femur is usually to be easily made from the obvious deformity, marked shortening, loss of power in the limb, mobility in the length of the bone, chap, xiv.] FRACTURE OF THE FEMUR. 217 and crepitus. But several of these signs may be absent. Where, then, as the result of an accident, or, rarely, of sudden muscular effort, a patient complain of pain in the thigh, and inability to stand upon it, or to move it at all, inspect the limb, and if there be eversion of the foot and knee, with obvious angular deformity of the thigh below the great trochanter, with shortening of the thigh (the position of the trochanter being normal), there is a fracture of the femur. The deformity is usually a curve of the bone outwards and forwards. To detect the abnormal mobility and crepitus, it may be sufficient to place the hand beneath the deformed part of the thigh, and to raise it gently, or the limb may be extended, and gently rotated, when the surgeon will notice crepitus, a lessening of the deformity and of the shortening, and want of rotation of the trochanter with the foot. Where there is this angular deformity of the thigh, if crepitus be obtained without extension of the limb, it shows that the fracture is oblique, with overriding of the fragments. When, however, crepi- tus is only obtained after extension and correction of the deformity, it shows that the fracture is transverse, with complete displacement of the fragments. Where, however, on examining the limb there is found eversion of the knee and foot, but no shortening ".nd no obvious deformity, the surgeon should pass his fingers down along the thigh, pressing in upon the bone until he comes upon a very tender spot, where he will probably find some swelling ; while he grasps the thigh above this spot, his assistant should gently ro- tate the leg and knee, and if the surgeon feel crepitus, or notice that the upper part of the thigh does not move with the knee, he diagnoses a fracture of the femur without displacement of the fragments. This injury is most common in children ; in such cases the periosteum is usually incompletely ruptured. In 2i8 SURGICAL DIAGNOSIS. [Chap. xiv. children the surgeon can make the necessary mani- pulation himself without any aid. Where in a young child, after a fall, the thigh is found bent forwards and shortened, and the child does not use it or move it, and the bent part is tender and swelled, but there is no crepitus, while the upper end of the bone moves with the lower end, there is an incomplete fracture of the femur. The surgeon should remember that it is common to find the signs of effusion into the knee joint a few days after fracture of the femur, especially when the injury is in the lower third of the bone, and is the result of direct violence. C. Injuries about the knee. The special in- juries that may be met with in this region are : Fracture of the lower end of the femur, of the upper end of the tibia, and of the patella. Dislocation of the tibia, of the fibula, of the patella, or of a semilunar cartilage. Sprain, rupture of lateral ligaments, or of ligamentum patellae. As the bones are so superficial, and their fracture and dislocation are attended with marked deformity, there is usually not much difficulty in distinguishing these various injuries. In cases where there is an alteration in the plane or in the axis of the limb about the knee joint, the surgeon must determine whether the displacement is at or near the articulation. For this purpose the head of the tibia must be carefully felt to ascertain whether the displacement is between the femur and tibia, or at a higher or a lower level. Being satisfied on this point, the surgeon should grasp each condyle of the femur and each tuberosity of the tibia separately, and attempt to move it on the rest of the bone ; the same may be done with the head of the fibula on the outer side of the tibia. The patella may then be examined, its outline defined, and compared Chap, xiv.] INJURIES OF THE KNEE. 219 with that on the other side ; an attempt may also be made to obtain movement transversely and longitudi- nally ; while failing that, firm pressure should be made all around its edge, and across its surface, any crepitus elicited being carefully noticed. The relations of the patella to the femoral condyles should be compared on the two sides, and the continuity of the patellar liga- ment traced from the patella to the tubercle of the tibia. Until the surgeon has satisfied himself that the patella and its ligament are entire he should not bend the knee joint, as fracture of the bone and rupture of the ligament may be seriously exaggerated in their effects by such a movement. Having in this way examined the bones and the patellar ligament, the surgeon should examine closely the interval between the tibia and the femur, to notice any differ- ence between the two limbs, and then, grasping the leg, he should test the amount of lateral motion in the joint ; of course he will observe the outline of any swelling of the soft parts. The leg is displaced laterally. This may be due either to dislocation of the tibia, or to separa- tion of the lower epiphysis of the femur. (1) If the femoral condyles be found continuous with the shaft of the bone, and immovable upon it, and the head of the tibia project to either side of the femur, the patella lying on the corresponding condyle instead of between the two, and the joint being nearly if not quite immovable, the injury is a lateral dislocation of the tibia. This form of disloca- tion is incomplete ; it may occur to either side, and when the tibia is displaced outwards it is usually also rotated out, the foot being everted. Correction of the deformity is not attended with crepitus. (2) If, however, both the femoral condyles be found i-estiiig upon the head of the tibia in their normal relation, but the lower end of the femur 22O SURGICAL DIAGNOSIS. [Chap. xiv. be displaced to either side, movable, with soft crepitus, and if there be some amount of flexion and extension movement in the joint, there is a separation of the lower epiphysis of the femur with lateral displacement. This accident may occur at any time up to sixteen years of age. The leg is displaced aiitero-posteriorly. (a) If the femoral condyles with the patella lying between them project at the front of the knee, and the leg is lying at a posterior level, projecting backwards into the ham, the whole limb being shortened, and the measurement from the adductor tubercle to the tip of the internal malleolus is also shortened, there is a dislocation of the tibia backwards. (6) If, however, the anterior projection be found above the condyles of the femur, higher up than or tilting forward the patella, and the condyles of the femur are situated immediately above and in contact with the head of the tibia, but a firm mass or bony pro- jection is felt in the ham, and the measui'ement from the adductor tubercle to the internal malleolus is not shortened, although that from the iliac crest to the malleolus is shortened ; and, further, if movement of the part elicit crepitus, there is a supracondyloid fracture of the femur. If the patient be under seven- teen years of age, and the crepitus soft, it is a diastasis. In this injury the sharp lower end of the upper fragment may transfix the triceps muscle, or even the skin. If with these signs either condyle be found movable apart from the other, it would show that the injury was an intvrcondyloid fracture ; there would then certainly be effusion of blood into the knee joint, distending the sy no vial cavity. (c) If the anterior prominence be formed by the head of the tibia, and the back of the femoral condyles be felt projecting strongly in the ham, the joint being rigid, the entire limb, and the leg as measured from the Chap. XIV.) UlSLOCATIONS OF THE PATELLA. 221 lower end of the femur, being shortened, and there being no crepitus, the injury is a dislocation of the tibia, forwards. In these injuries the circulation in the popliteal vessels is very apt to be interfered with, and therefore in every case the surgeon must care- fully observe the pulse in the tibial arteries, the state of the superficial veins, and whether a swelling rapidly forms in the ham. The leg is not displaced. The surgeon must first assure himself of the condition of the bones, and he should examine them in the following order : patella, femur, tibia, fibula. (a) The patella should be found lying flat upon the femur between the two condyles, with its liga- ment passing straight down from it to the tubercle of the tibia, and when the knee joint is extended, and the quadriceps is relaxed, the bone can be moved laterally. It may be found lying on the side of either condyle of the femur, more frequently the outer, with its anterior surface directed outwards or inwards, and its articular surface resting on the femur, fixed in position, and having its ligament passing obliquely down to its insertion, and leaving the trochlea of the femur empty, and easily felt through the skin ; in such a case the surgeon has no difficulty in diagnosing a lateral dislocation of the po.tella. (b) The patella may be seen and felt very prominent in front of the knee, with one edge directed forwards and the other edge resting on the trochlea of the femur ; what should be the anterior surface of the bone, that continuous with the front of the patella ligament, will be found directed outwards, while the articular surface will be directed inwards. This is a dislocation of the patella on to its outer edge. (c) If, on feeling for the patella, the trochlea of the femur be felt, and the bone be found higher up the 222 SURGICAL DIAGNOSIS. tchap. xiv. thigh, movable both laterally and vertically, and if below the bone a gap in the firm patellar ligament be felt, the case is one of rupture of the ligamentum patellce with dislocation of the patella upwards. (d) If the bone be felt occupying too low a position, and its ligament be relaxed, while above the bone a depression in the quadriceps muscle be felt, there is a rupture of the extensor muscle with dislo- cation of the patella, downwards. If some time have elapsed since the accident, there may be a swelling over the rupture in the muscle, preventing the surgeon feeling the gap in it. In either of the latter two cases the patient will have lost the power of extending the knee joint. The displacement of the patella can be verified by measurements between it and the iliac crest and the tibial tubercle. (e) If on examining the bone a gap be seen or felt across it, a part of the bone being attached to the extensor muscle and a part to the patellar ligament, with mobility between the two parts ; or if, without any such gap, on seizing the upper and lower parts of the patella in the two hands, one can be moved on the other with crepitus, there is a transverse fracture of the patella. The amount of separation between the fragments varies from nil to two inches or more ; it should never be increased or made apparent by flexing the knee if the injury is recent, as this may lacerate the fibrous structures on the side of the bone, which are of great importance in preventing the dis- placement of the upper fragment. The amount of separation of the fragments is a measure of the laceration of the fibrous tissue over and on the sides of the bone. Quickly after the accident the joint will be swelled from effusion of blood into it. The patient will have lost the power of extending the knee. (f) If on grasping the bone laterally a portion of chap, xiv.] FRACTURES AT THE KNEE. 22$ it be found to move on the rest with crepitus, or if, on pressing over the front of the bone, an irregularity of the bone be felt, and crepitus be elicited, or on pressing on the edge of the bone in some one spot crepitus be detected, a vertical or oblique fracture of t/ie patella has occurred. In these cases, too, the joint becomes distended with blood, but the loss of power is not so great as in the former case, nor is there the obvious deformity sometimes met with in transverse fracture of the bone. When the surgeon has satisfied himself that there is no fracture of the patella, he may in his subsequent manipulations bend the knee joint. Grasp each condyle of the femur separately, and try to move it from before back, or obliquely up and down on the shaft of the bone, and run the fingers over the bone to detect any projecting angle. Repeat this manipulation on the tuberosities of the tibia ; notice any increase in width of the head of the tibia, and measure it with compasses, measuring also the length of the leg from the patella to either malleolus. Then feel for the head of the fibula, and, comparing it with the one on the un- injured side, notice if it be displaced forwards or backwards, be more movable than normal, or whether the tendon of the biceps attached to it is lost under the ilio-tibial band of fascia lata, or is too prominent at the back of the joint. (g) If either condyle be movable on the rest of the bone, or the attempt to obtain movement elicit crepitus, there is a fracture of a condyle of t/te femur. The direc- tion of the mobility as well as the detection of a project- ing ridge or angle of the bone will enable the surgeon to determine the position and direction of the fracture, which may be transverse or oblique. The symptoms of the injury will be pain, bruising over the knee, loss of power to move the joint, and effusion into it. (h) If either tuberosity of the tibia be movable 224 SURGICAL DIAGNOSIS. [chap. xiv. with crepitus, or the head of the bone be increased in width with slight shortening of the leg, and the part be painful, tender and swelled, a fracture of the liead of the tibia is to be diagnosed. This is a rare and a severe accident. The upper epiphysis of the bone may separate in a child or adolescent. If there be much shortening of the leg from impaction of the shaft in the head, there will be found either a fracture or a dislocation upwards of the fibula. This injury is quickly followed by effusion into the knee joint. (i) If the head of the fibula be found in front of its normal position, and the usual prominence of the biceps tendon be lost beneath the ilio-tibial band or fascia, there is a dislocation of the head of tJie fibula forwards. The signs may be reversed, and the head of the bone be found projecting at the back of the knee with the outer hamstring abnormally prominent in the ham ; then a dislocation of the head of the fibula backwards is to be diagnosed. When the surgeon has in this way examined all the bones of this region, and found them unbroken and not displaced, he must proceed to investigate the softer parts, and he must be especially careful to assure himself that there is no displacement of a semilunar cartilage or rupture of either lateral liga- ment of the joint, in cases which might be assumed to be simple sprains. To do this he should feel carefully on each side of the patellar ligament for any projection as of a displaced cartilage, also over the line of the joint between the femur and the tibia ; and he should then estimate the amount of lateral movement possible in the joint. (j) If, after some jerk, strain, or sudden move- ment of the joint, the patient complain of a sudden severe pain in the joint, and if he be unable to extend it or bend it completely, although passive movement short of extreme limits is free, and does not occasion Chap. XIV.] SEMILUNAR CARTILAGE. 22$ much paiii, there is probably a dislocation of a semi- lunar cartilage. If, now, there be a swelling felt on either side of the joint just over the line between the femur and tibia, corresponding to the cartilage in outline and feel, especially if there be a clear history of this swelling having appeared at the time of the accident, and if on manipulation it can be pressed into place with relief of pain and of the stiffness of the joint, this diagnosis is certain, and the displacement is to be described as marginal or extra-articular. If, how- ever, there be no such swelling, but an interval be felt between the femur and tibia, and especially if to this be added the detection of a projection on the same side of the patellar ligament, and slight re- laxation of the ligament, the diagnosis is con- firmed, and the displacement is to be described as central or intra-articular. This injury is liable to be mistaken for the impaction of a loose body in the joint and vice versd. But attention to the following points will enable a diagnosis to be made. A semi- lunar cartilage is always first displaced by some sudden wrench of the joint, although subsequently it may slip out of place during any sudden or extreme movement of the joint. The impaction of a loose body between the articular surfaces is not dependent upon a wrench or sudden twist of the joint, but occurs during the customaiy movements. When dislocated, the semilunar cartilage may be felt pro- jecting ; the loose body, on the other hand, cannot be felt when impacted, but may be felt between the attacks of pain freely floating in the sy no vial cavity. In impaction of a loose body the joint is locked ; in dislocation of a semilunar cartilage, the joint is capable of free passive motion. A cartilage may remain dislocated and cause lameness for a long period, or even permanently ; the impaction of a loose body p 13 226 SURGICAL DIAGNOSIS. [Chap. xiv. between the bones is always an acute affection, and is corrected by some sudden active or passive movement ; it may often recur, but is not a chronic or permanent condition. (k) If, after a sudden wrench of the knee, there be found increased lateral movement of the tibia to one side, the surgeon may diagnose rupture of tJie lateral ligament on the opposite side of the joint ; this diagnosis will be confirmed by finding the pain chiefly situated on that side, or by swelling and ecchymosis. (I) If, after a wrench or strain of the joint, there be great pain, inability to move the joint, swelling assuming the form of the synovial cavity, and passive movement be found free but painful, and there be an absence of the signs of any of the injuries above mentioned, the case is to be diagnosed as a sprain of the knee. D. Injuries of the leg. The tibia for its whole length, and the fibula for some distance, are so sub- cutaneous that any deformity of the shafts of these bones is readily recognised, either by the eye or by the hand. Deformity is not marked unless both bones be fractured, but it may be so striking as to render the diagnosis certain. Where that is not the case, the surgeon should run his fingers carefully down the inner surface of the tibia, comparing the two bones, noticing any little unevenness, the position of chief pain, and particularly of marked tenderness; then grasp- ing the leg above and below the most tender or painful part, he should attempt to obtain mobility and crepitus. A similar examination of the fibula should be made, and in addition it should be pressed in towards the tibia just below its head and above its malleolus, to observe whether this gives crepitus, or causes acute pain at a distance from the point compressed. The deformity, or the direction of mobility, will usually at Chap xiv.] FRACTURES OF THE LEG. 227 once make it clear in what direction the bones are broken. (1) If there be marked deformity of the leg, with pain, swelling, loss of function, shortening of the dis- tance between the tubercle of the tibia, and either malleolus, free mobility in the length of the leg, and crepitus, these signs clearly indicate a fracture of the shafts of the tibia and fibula. The most frequent de- formity is the projection forwards of the lower end of the upper fragment of the tibia, with eversion of the foot and the lower part of the leg. Where this de- formity exists a very careful examination of the ankle joint should be made, with a view of deter- mining whether the lower fragment is fissured into the joint (the V-shaped fracture of Gosselin), in which case both the surgeon and the patient should be pre- pared for more or less ankylosis of the ankle. When it is certain the tibia is fractured, there is no justification for a prolonged or painful examination into the state of the fibula ; that bone is certainly broken when the injury is the result of indirect violence, or when there is marked shortening, deformity, and ready mobility. When the surgeon is in doubt upon the point, the bone should be assumed to be broken ; the fact will not alter the treatment, and the attempt to discover the full truth may seiiously increase the laceration of the soft parts. (2) Where there is no obvious deformity of the leg, with no shortening of the limb, and yet there are marked pain and tenderness over one part of the tibia, with swelling, and loss of power in the limb, and on manipulation crepitus is elicited, slight mobility being detected, but the line of the fibula un- broken, and this bone is not the seat of severe pain or tenderness, the surgeon should diagnose a, fracture of the shaft oftlie tibia. (3) If there be a severe fixed pain at a particular 228 SURGICAL DIAGNOSIS. [Chap. xiv. spot on the outer side of the leg, increased by stand- ing or attempting to walk, the surgeon should examine the fibula carefully. If he find that the painful part is very tender, and that when the fibula is com- pressed against the tibia by grasping the leg just below the knee or above the ankle, smart pain is caused at the same tender spot (not at the point pressed upon) the diagnosis (A fracture of the shaft /' the fibula may be made. This diagnosis will, of course, be confirmed if the finger detect any irregu- larity in the outline of the bone, or any crepitus on compressing the two bones, or if the surgeon notice a failure of the natural rebound of the fibula after its compression against the tibia. (4) If there be no evidence of a complete fracture of the tibia, such as we have just mentioned, but the patient complain of a severe and fixed pain in the bone, and 011 careful examination the part where the tenderness is greatest is found not to be a spot, but a line running obliquely across or vertically down the bone, and if along this same line of tenderness a linear induration or swelling on the bone be subsequently detected, the surgeon may diagnose a fissure of the tibia. This injury is often very difficult to diagnose, and to distinguish from a bruise of the part. (5) If, during some sudden exertion, the patient experience a severe pain in the calf, or behind the ankle, and lose power in his leg, and on examination the bones and joints are found uninjured, but above the heel there be ecchyniosis and swelling, and a depression be felt where the prominent tendo Achillis should be, the surgeon will have no difficulty in dia- gnosing a rupture of t/te tendo Achillis. When with these symptoms this tendon is found entire, but all voluntary attempts to extend the ankle give great pain, while passive movement of the joint is free, and especially if the patient felt or heard any "snap" at Chap. XIV.] fNyURIES OF THE ANKLE. 221) the time of the accident, a rupture of the planhiri-s tendon is to be recognised. Rupture of the tendo Achillis may be attended with a loud snap. E. Injuries about the ankle. Under this head are included a large group of injuries : fractures of the lower ends of the bones of the leg and of the astragalus ; dislocations of the fibula, the ankle, the astragalus, and of the foot from the astragalus, to- gether with displacement of the peronei or posterior tibial tendons and sprains of the ankle joint. The difficulty of diagnosis is increased by reason of the fact that a characteristic deformity (as of Pott's fracture) may be corrected before the surgeon sees the case, and by the great swelling which quickly ensues upon many of these injuries. The nature of the accident, the charac- ter and seat of the pain, and the degree to which the function of the part is lost, are facts valuable as suggestive of the nature of the injmy. The cases group themselves naturally into those in which there is no obvious deformity, and those in which there is a striking deformity. (1) There is no obvious deformity of the ankle. Careful measurement should be taken of the length of the leg, and of the distance between the malleoli and the heel, and between the malleoli and the tubercles of the scaphoid, and of the fifth meta- tarsal bones respectively to show that there is no bony displacement, as a slight slipping of the part laterally or antero-posteriorly might otherwise escape detection. The seat of pain and tenderness should be carefully observed, and then each malleolus should be grasped, and an attempt made to move it independently. The part should then be seized and moved laterally, and be pressed up into the arch of the tibia, and moved freely. (a) If in this examination either malleolus be found movable with crepitus, it will demonstrate the 230 SURGICAL DIAGNOSIS. [chap. xiv. presence of a fracture of a, malleolus ; the line of fracture may separate the whole of the lower end of the tibia. (6) If, with signs of fracture of the lower end of the fibula, there be found increased lateral mobility in the ankle joint, it shows that the internal malleolus or the internal lateral ligament has been broken, and that the injury is a Pott's fracture, with reduction of the displacement. (c) If there be no evidence of fracture of the bones of the leg, but the attempt to stand causes great pain, and movement of the foot causes crepitus deep in under the arch of the ankle, the surgeon may diagnose fracture of the astragalus. (d) If there be acute pain over or behind either malleolus, with swelling and ecchymosis, feel carefully for the tendons which should be behind the bones, and if there be an unnatural depression behind, or an elongated prominence over either malleolus, or if, when the patient extends the foot, the tendon can be felt to slip forward on to the bone, with severe pain, the diagnosis of dislocation of peroneus longm or tibialis posticus tendon should be made. There may be some unnatural mobility of the foot in this injury. (2) There is obvious deformity about the ankle, (a) The foot is displaced outwards. This may be due to (a) Pott's fracture ; (0) Dupuytren's fracture , (7) Subastragaloid dislocation of the foot. (o) If the foot be displaced out, if its outer border be raised, with the sole looking down and out, and the inner ankle be very prominent, while there is a marked depression on the outer side of the leg above the ankle joint, the injury is a Pott's fracture, with persistence of the original displacement. The shape Chap, xiv.] FRACTURES AT THE ANKLE. 231 of the inner nialleolus, or the detection of a small movable fragment of bone below it, may show that this process of bone is broken ; where this bone does not give way the internal lateral ligament is torn. When the deformity is reduced there may be found increased lateral mobility in the ankle. (0) If the foot be displaced outwards to a consider- able extent, and not at all, or only to a slight degree, everted, the inner ankle being very prominent, and nearer the sole than normal, while the breadth between the two malleoli is greatly increased, and the length of the leg, measured to the tip of the outer malleolus, is shortened, the injury is a Dupuytren's fracture. There is a depression over the fracture of the fibula, above the malleolus, as in the former case. (7) If there be no increased lateral movement in the ankle, no depression over the lower part of the fibula, but both it and the tibia be entire, and the length of the leg as measured to the tip of either of them be unaltered ; and with this there be great prominence of bone in front of and below the inner ankle, while the foot is displaced out and everted, and the outer ankle is sunk in a depression, the injury is a subastra- galoid dislocation of the foot outwards. This is usually combined with backward displacement of the foot, undue pointing of the heel, and shortening of the part in front of the ankle. (6) The foot is displaced inwards. This may be due to (a) Dislocation of the ankle inwards ; (8) Subastragaloid dislocation of the foot inwards ; (y) Dislocation inwards at the medio-tarsal joint. (a) If the lower end of the fibula be very prominent on the outer side, and the astragalus and internal malleolus project on the inner side of the ankle, while the width between the malleoli is increased with the 232 SURGICAL DIAGNOSIS. tchap. xiv. ankle joint allowing of lateral movement, the injury is a dislocation inwards of the ankle. This is a very rare accident, and is always accompanied with fracture of one or both of the bones of the leg. (/B) If the foot be displaced inwards and the inner malleolus be sunk in a hollow caused by the inward projection of the foot, and on the outer side of the dorsum is a rounded prominence of the head of the astragalus in front of the outer malleolus, there is a subastroi/aloid dislocation of tJtefoot inwards. This is generally combined with some amount of backward displacement of the foot, increasing the distance be- " tween the malleoli and the heel, and lessening the distance between the inner malleolus and the scaphoid, or the outer malleolus and the base of the fifth meta- tarsal bone. (7) If the relation of the malleoli to the heel be un- altered, but the anterior part of the foot be displaced inwards, the tubercle of the scaphoid bone being very prominent on the inner side of the foot, while the front of the os calcis projects on the outer side in front of the outer malleolus, and the cuboid and fifth metatarsal bone are displaced inwards, the surgeon will recognise a dislocation inwards at the medio-tarsal joint. (c) The heel is flattened, i.e. has lost its natural prominence. This may be due to (a) Dislocation of the foot forwards , (/3) Subastragaloid dislocation forwards ; (y) Transverse fracture or the os calcis. (a) If the projection of the heel be lessened or lost, and the length of the foot in front of the tibia and fibula, as measured from either malleolus to the ex- tremity of the toe of the same side, or to the tubercle of the scaphoid or to the base of the fifth metatarsal bone be increased, there is a dislocation of tlw foot chap, xiv.] DISLOCATIONS OF THE FOOT. . 233 forwards. The dislocation may be partial or com- plete ; when complete the malleoli are approximated to the sole, the tibia projects behind, and the upper sur- face of the astragalus can be felt in front of it. This is a very rare injtiry. v'/8) If the projection of the heel be lost, and the length of the foot in front of the leg be increased, but the malleoli not approximated to the sole, the ankle still allowing some amount of passive movement, while in front of the lower end of the tibia the rounded head of the astragalus can be felt, and in front of that a depression, the surgeon may diagnose a subas- tragaloid dislocation of the foot forwards. This is an exceedingly rare accident. (7) If the heel be flattened, but the length of the foot in front of the malleoli is not increased, feel care- fully along the tendo Achillis, and if at its extremity, which is above the heel, the portion of bone to which it is attached be felt movable, there is & fracture of the os calcis. There may be great, little, or no separa- tion of the fragments, depending' upon the extent to which the fibrous structures are torn. (d) The heel is elongated, i.e. its prominence is increased ; this may be due to (a) Fracture or diastasis of lower end of tibia , (fl) Dislocation of the ankle backwards ; (7) Subastragaloid dislocation of the foot backwards. () If the heel project behind, and its relations to the two malleoli are unaltered, Avhilst above the ankle- joint there is a projection forwards of the tibia, and by drawing the foot forwards the deformity is corrected, and crepitus is elicited, there is a fracture of the lower end of the tibia, and fibula. If the accident occur in an individual under eighteen years of age, and the anterior projection be rounded, and the crepitus not easily obtained, and soft in character, it is to be 234 . SURGICAL DIAGNOSIS. [chap. xiv. recognised as a diastasis of the lower epiphysis of the tibia. (0) If the heel be lengthened, and the front of the foot shortened, as measured from the malleoli, while the malleoli are approximated to the sole, all move- ments at the ankle joint being abolished, and if the lower ends of the tibia and fibula can be felt resting upon the scaphoid and cuboid bones, while the astra- galus, if felt at all, is felt behind the tibia, between it and the tendo Achillis, the injury is a dislocation of the foot backwards. (y) If the heel be lengthened, and the front of the foot shortened, but the tibia and fibula are not resting on the scaphoid and cuboid, but are separated from those bones by the rounded and prominent head of the astragalus, which projects on the dorsum of the foot, in front of the tibia, the injury is a snbastragaloid dis- location of the foot backivards. There may be some amount of passive flexion and extension still possible at the ankle joint. (e) The heel is raised. This deformity may be caused by o) Dislocation of the foot upwards ; Fracture of posterior part of tibia and fibula ; Fracture of os calcis. (a) If the malleoli are widely separated, with the skin tightly stretched 'over them, and their extremi- ties approximated to, or actually reaching, the sole, while the length of the tibia is unaltered, and that of the leg, measured to the sole, is decreased, the injury is a dislocation of the foot upwards between the tibia and the fibula. (0) If the heel be raised, the toes pointed down, and the breadth of the outer malleolus increased, while a vertical depression or groove along it shows that it is pplit into an anterior part continuous with the shaft Chap, xtv.] FRACTURE OF THE Os CALCIS. 235 of the bone, and a posterior one adherent to the dis- placed foot ; and, further, if there be a depression im- mediately in front of the lower end of the tibia, with crepitus on attempting to reduce the deformity, the surgeon is to recognise a, fracture of tlie posterior part of tJie lower end of the tibia and of the fibula, with dis- placement of the foot and of the separated fragment up and back. (7) If the prominence of the heel be raised, and be movable apart from the rest of the foot, the surgeon will, of course, recognise a fracture of tJie os calcis, which in a young person under sixteen years of age may be a separation of the epiphysis of the bone. This injury is also referred to on page 233. (/) The beel is displaced outwards. This is a very rare deformity ; but if the heel, with- out the anterior part of the foot, be displaced outwards, and be very prominent under the skin, and the arch of the foot be flattened, the injury is a dislocation out- wards of tlie os calcis. Passive flexion and extension of the ankle joint is possible, but abduction and ad- duction of the foot are impossible. In this deformity measurements show that the relation of the internal malleolus and the scaphoid are unaltered, and the astragalus can be felt occupying its normal position under the tibia. If the heel be found to be painful, tender, not dis- placed, but increased in width, and if on manipulation crepitus be detected in it, there is evidence of & fracture of tJie os calcis. The signs will vary somewhat with the amount of crushing of the bone. If the accident was strong inversion of the foot, which was immediately succeeded by eversion, and the arch of the foot be found flattened, and the malleoli approximated to the tendo Achillis, and there is pain in standing, with crepitus and mobility of a fragment of a bone on the inner side of the os calcis, the signs are believed to 236 SURGICAL DIAGNOSIS. iChap. xiv. indicate a fracture of the sustentacn luni tali In some cases a scale of bone on the outer side in connection with the middle slip of the external lateral ligament may be felt detached, movable, and giving crepitus when nibbed against the body of the bone. If the malleoli be found approximated to the sole, not separated from one another more than the normal distance, and there be no, or but very slight, alteration in the length of the heel or of the anterior part of the foot, there is a dislocation of t/te astragalus. If the bone be displaced forwards, it will be seen and felt pro- jecting under the skin of the dorsum of the foot, and not only its head, but its saddle-shaped upper surface, will be felt ; the bone passes forwards and obliquely outwards or inwards. This dislocation may be confounded "with the subastragaloid dislocation of the foot backwards and laterally ; but it is to be dis- tinguished from the latter by the absence of prominence of the heel, by the depression of the malleoli, by the loss of all flexion movement in the ankle, and by the detection of the upper articular surface of the astra- galus, as well as the displaced head of the bone riding on the tarsus. When the astragalus is dis- placed backwards it will be found lying between the tibia and the tendo Achillis, and rotated. The de- tection of the displaced astragalus, of course, is neces- sary to establish the correctness of the diagnosis of this very rare dislocation. Where the most careful examination fails to show any deformity of the ankle, any alteration in the mea- surements between the various bony points, or any mobility of any portions of bone, or crepitus, or dis- placement of any tendons, and yet, as a resiilt of a twist or strain, the part is hot and swelled, movement in it is painful, and pressure in certain parts causes pain, the surgeon is to diagnose a sprain. By moving individual joints separately, the injured joint will be detected ; chap, xiv.] FRACTURES OF TAE FOOT. 237 and by noting the points of tenderness and the move- ments which excite most pain, an estimate may be formed of the parts of the articulation which are most injured. F. Injuries of the foot. Under this head are included all those injuries of the foot which are not attended with deformity about the ankle, and which are therefore not liable to be confounded with fractures and dislocations of that joint. The diagnosis will mainly rest upon the history of the accident, and the existence of pain, loss of power, deformity, abnormal mobility, and crepitus. CEdematous swelling may mask deformity and obscure the other signs of these injuries, and in such cases the formation of the dis- coloured blebs, so characteristic of fractures of bones, may enable the surgeon to determine upon the exis- tence of a fracture. (1) When the pain and swelling are located in the instep, and on grasping the front of the foot and rotating or flexing it upon the heel firmly held in the other hand, crepitus is elicited ; or when the swelling is great, preventing this manipulation and the observ- ation of the outline of the metatarsus, and dark dis- coloured blebs arise, the surgeon should diagnose a fracture of the metatarsus. The position where the crepitus is felt will determine which bone is broken. (2) The toes are to be separately examined, and on detecting any deformity, pain or swelling in any one of them, the surgeon should attempt to obtain movement in the length of each phalanx separately ; and if he find abnormal mobility and crepitus he of course diagnoses a fracture of a plialanx. The last two injuries are produced by direct violence. (3) If the relations of the heel and the malleoli are normal, but the distance between the malleoli and the bases of the first and fifth metatarsal bones is short- ened, and these latter bones are very prominent on the 238 SURGICAL DIAGNOSIS. [Chap. xiv. dorsum of the foot, the sole being preternaturally hollow, there is a dislocation of the metatarsus up- wards. The internal cuneiform bone may be displaced with the metatarsus forming a marked prominence on the dorsum behind the base of the first metatarsal bone, and extending nearer the ankle than the outer part of the dorsal prominence. If, however, the dorsal prominence be formed by the anterior bones of the tarsus, being abrupt in front instead of behind, as in the former case, and the bases of the metatarsal bones be found lying beneath the tarsus and projecting into the sole, there is a dislocation of the metatarsus dmvn- wards. (4) If the middle line of the front of the foot be not in a line with the axis of the leg, ankle, and instep, but be displaced to one or other side, and if the base of the metatarsal bone, towards which it is dis- placed, be unusually prominent, while the bone on the opposite side of the metatarsus is sunk in and cannot be felt so readily as usual, and if the front of the bone of the tarsus with which it articulates (cuboid or cuneiform) project, there is a dislocation of the meta- tarsus laterally. (5) If a firm evidently bony projection be found on the dorsura of the foot, corresponding in position and shape to the scaphoid or one of the cuneiform bones, and the corresponding toes or toe be found shortened, the diagnosis of dislocation of tlie scaphoid or cuneiform bone must be made. Similarly, if the little toe be found shortened, the base of its metatarsal bone un- duly prominent, and approximated to the outer malle- olus, with a depression immediately behind it, and below this depression a bony mass be felt in the sole making the middle of the outer border of the sole project, a dislocation of the cuboid bone would be diagnosed. (6) If at either of the phalangeal joints there be chap, xv/] CONGENITAL TUMOURS. 239 a deformity (a projection upwards of the base of the phalanx) with fixity of the articulation, there is a dislocation of a phalanx. This displacement may be partial or complete, purely dorsal or partly lateral also. CHAPTER XV. THE GENERAL DIAGNOSIS OP SWELLINGS AND TUMOURS. WHEN examining a swelling or tumour for the purpose of arriving at a knowledge of its nature, there are certain general facts to be ascertained and investigated in every case ; it is from a knowledge of its exact physical characters that, in most cases, we are able to arrive at a recognition of its vital character. In this chapter it is proposed to examine the bearing of the various features of swellings upon the diagnosis of their nature, and to state the general rules by which the surgeon may be guided in the diagnosis of tumours. I. The history of its first appearance is the first fact to be ascertained in respect of any swelling. This may present several varieties. (A) Congenital tumours. These include mal- formations, such as meningocele, encephalocele, spina bifida, attached foetus, included foetus, congenital dis- locations, hydrocele, and hernia ; cystic tumours, such as dernioid cyst, serous cyst of neck, axilla, perineum, etc., blood cyst, cystic hygroma; solid tumours, such as lipoma, fibrous tumour of gum, scalp, skin, sacral and coccygeal tumours ; ' hypertrophies, seen particu- larly in the limbs ; vascular growths, or the different varieties of nsevus ; and thickenings around bones in cases of intra-uterine fracture. 240 SURGICAL DIAGNOSIS. [Chap. xv. (BS\velliiigs arising: suddenly. Such a swelling can only be caused by (1) the displacement of parts, as in dislocations, herniae, and pneumatocele ; (2) t/ie rapid effusion of blood, as in traumatic an- eurism, hsematocele, haematoma ; or (3) the escape of t/ie contents of the hollow viscera, as in extravasation of urine. (1) The displacement of parts will be recog- nised by three signs (a) the absence of the part from its normal situation, as e.g. the head of the humerus immediately below the acromion, or of the head of the radius below the external condyle of the humerus ; (b) by the continuity of the swelling with the part sup- posed to be displaced, as e.g. when the swelling produced by a displaced bone moves when the other end of the bone is rotated, or its connection is traced by the finger passed along it, or by certain special signs, as the reducibility and impulse in a hernia, and the respiratory modifications of a pneumatocele (see page 145) ; and (c) by the outline and general char- acters of the swelling resembling those of the dis- placed organ, as e.g. the rounded head of the humerus, the smooth tympanitic gurgling intestine, or the granular omentum. (2) The rapid effusion of blood will be dis- tinguished (a) by the absence of the above signs, and also of those associated with the escape of the contents of the hollow viscera ; (b) by the evidence of the fluid nature of the swelling, shown either by fluctuation or by its infiltrating character, for a rapid infiltration can only be by fluid ; (r) by signs of bruising or blood staining ; (d) by the general signs of loss of blood (in some cases) ; (e) in some few cases by evidence of the disturbance of the circulation in the part ; and (/) by increase in size of the swelling going on for a time at least ; this is one of the most important signs of all. Where the effused blood is more or less limited and chap, xv.] RUPTURED ARTERY. 241 circumscribed, but yet forms a distinct tumour, it is called a haeniatoma ; in such cases the blood is usually poured out from smaller vessels. When, however, it is poured out from a single large vessel, and is not circumscribed but infiltrates the cellular planes of the part, it is spoken of as a ruptured artery or ruptured aneurism. These may be thus distinguished : If the swelling be more or less well defined and circumscribed, at first, and perhaps subsequently, fluctuating, without pulsation, bruit, or thrill, and there be no interruption of the pulse in the arteries beyond, and especially if it have resulted from direct violence, it may be diagnosed as a hcematoma. If the swelling be ill-defined, very tense, of great size, not fluctuating, but more or less boggy at the edges, and the limb beyond be found cold, cedematous, livid, and numb, and the arteries pulseless, and if there be severe pain in the part, with fainting and the other general signs of a severe loss of blood, it is a diffused aneurism. A bruit may be heard in such a swelling, at times a thrill may be felt, and if the parts around the fluid blood are much compressed and condensed into a spurious sac, pulsation may be detected, while if the artery be but partially ruptured there may be a faint pulse in the arteries beyond. Often the patient experiences a sensation as of something snapping or giving way, followed by a hot rushing feeling. If such a swelling have formed as the result of a severe twist, and there be no previous history of any affection of the vessel, it must be diagnosed as a ruptured artery. But if the swelling have occurred spontaneously, or from some slight violence, and there be a history of aneurism, or of a swelling or sense of beat- ing in the part, or of pain supposed to be " neuralgic," or of venous engorgement below, then it must be dia- gnosed to be a ruptured aneurism. If unrelieved, this condition speedily runs on to moist gangrene. Q 13 242 SURGICAL DIAGNOSIS. [Chap. xv. (3) Extravasation of urine is characterised by the position and limits of the swelling ; by its occur- rence in connection with the act of micturition, and by the osdematous nature of the swelling. (See page 502.) (c) Swellings arising acutely or rapidly. - In all cases these are due to an accumulation of excess of the animal fluids or of air in the swelling part, for only these can thus rapidly collect. Acute inflammation, as it occurs in the cellular tissue, glands, periosteum, tonsil, tongue, larynx, tunica vaginalis, bursse, synovial membranes, etc., is the most frequent cause of such rapid swelling. It also occurs when a sudden or rapidly-formed obstruction to the venous circulation leads to passive oedema of a part, as in thrombosis and compression of veins, and it may occur when some profound change in the charac- ter of the blood leads to increased transudation of serum, as in acute nephritis. A swelling is rapidly formed, too, when small blood-vessels are injured and blood is poured out, as in some bruises ; and in cases of obstruction of the ducts of actively secretix;/ (jliiody allow of a certain amount of movement one upon the other ; muscles move over each otter and over belies ; the skin is movable over muscles, deep fascia, and, bone. The exceptions are in the case of the struc- tures forming the scalp, the mucous covering of the hard palate, the gums, the teeth, the skin of the 252 SURGICAL DIAGNOSIS. [Chap. xv. palm and sole, the sheaths of muscles, and the perio- steum, which are not movable over the subjacent parts. Adhesion of a swelling to a tissue may be reed, as in the case of an exostosis, a gumma in muscle, or a wart on the skin ; or it may be only ap- parent, as in the case of parosteal tumours, hydrocele, and fatty tumour, the swelling being so firmly bound down that it has no independent movement. The adhesion may be primary, the tumour actually springing from the tissue, as in the case of aneurism, sebaceous cyst, gumma, exostosis ; or it may be secondary, occasioned only by the growth of the tumour, as in abscesses gradually reaching the sur- face, and in malignant tumours of all kinds, which, by their infiltrating mode of growth, become adherent to surrounding tissues as they enlarge. The adhesion or connection of a swelling with more than one tissue is an especial feature of inflammatory and malignant tumours. Adhesion to the skin is sometimes obvious at a glance, as in the case of cutaneous warts. In the case of deeper swellings, it is to be tested by attempt- ing to glide the skin over the swelling which is held fixed, and by pinching the skin up in a fold over every part of the surface. It must be borne in mind that a tumour of large size by mere tension considerably lessens the natural mobility of skin. Connection with the subcutaneous tissue is shown by the mobility of the tumour under the skin and over the muscles, or other deeper tissues. The best example of such a tumour is the common tipoma, or fatty tumour. As the skin is normally connected with the subcutaneous fat by fine fibrous processes continuous with the dissepiments of the fat, such tumours show a slight dimpling of the skin over the tumour when it is pinched up. Adhesion to the deep fascia of a part may be Chap, xv.i ADHESION OF TUMOURS. 253 determined by the mobility of a tumour over the subjacent muscle and under the skin, by its being less movable than a tumour in the loose subcutaneous tissue, and by its being fixed when the deep fascia is made tense, and more movable when it is re- laxed. Adhesion to muscle is detected by putting the suspected muscle in action, when the tumour will move with the muscle ; and, further, by noticing that while the tumour is movable over bone, it is deeper than the skin and subcutaneous fat, and perhaps not adherent to them. The mobility of the tumour is much greater when the muscle is relaxed than when it is firmly contracted. Adhesion to a vessel is diagnosed by noticing that the tumour, while movable over skin, muscle, and "bone, is yet not freely movable along the line of a vessel, although it may be movable transversely. The mobility of nerve-swellings, or neuromata, is characteristic ; for while it is free in the direction transverse to the long axis of the swelling or of the nerve, there is no mobility in the length of the nerve. This is similar to what is observed in connection with vessels, but is more striking, as the mobility of neuromata in the transverse direction is greater than is that of aneurisms, thrombi, or phleboliths. Adhesion to bone is determined by the immobi- lity of the tumour apart from the bone. Apparent mobility of a fixed tumour may be caused by its elasticity, or by the mobility of structures over it, as, for example, in the case of an exostosis of the femur with a large movable bursa developed upon it. Care in examination will, of course, preclude error from either of these sources. The adhesion of a tumour to a gland, e.g. the breast, is determined by seizing the gland in one hand and the tumour in the other, and attempting to move 254 SURGICAL DIAGNOSIS. [chap. xv. one without the other. This sign is of great im- portance in the diagnosis of mammary tumours, particularly in the separation of simple and malignant growths. The range of mobility of a swelling or lump may determine its position ; as, for instance, in the case of a loose body in a joint, bursa, or the tunica vaginalis. Mobility during certain acts may determine the connection of a tumour with some tissue or organ only moving them. A good illustration of this is the rise and fall of a goitre during deglutition. V. The consistence of a tumour may be uni- form or varied ; it is important to distinguish between gaseous, liquid, and solid swellings. Gas may be present in a tumour (a) being contained in one of the gas-con- taining viscera (lungs, stomach, intestines), as in pneu- matocele and hernia ; or (6) having escaped from one of these viscera, as in cutaneous emphysema ; or (c) having arisen from decomposition, as in some cases of moist gangrene. In gangrene the bubbles of gas may be seen in the superficial bullte and veins. Where the gas is contained in the connective tissue spaces it gives a fine dry crackling sensation, and the swelling yields when compressed ; this is best observed in subcuta- neous emphysema, and is less well shown in some cases of moist gangrene. Where the gas is mixed with liquid, its manipulation gives a gurgling sound, which is often perceived in the reduction of a hernia. But the most important physical sign of the presence of gas is a tympanitic percussion note ; this is only obtained when the gas is present in sufficient pro- portion, as in pneumatocele, subcutaneous emphy- sema, tympanites, and enterocele. The presence of fluid in a tumour is deter- mined' by one of three signs, fluctuation, fluctuation wave, and pitting on pressure. As these are signs Chap, xv.] FLUCTUATION. 255 of much importance, special attention must be de- voted to them. Fluctuation is the name sometimes given to two distinct impressions, which should be distinguished as "fluctuation" and "fluctuation wave." To observe "fluctuation" place the balls of the fingers gently but firmly on one side of the swelling, and then with the fingers of the other hand gently press into the tumour ; if the tumour be felt to rise under the fingers of the first hand it is due to the presence of fluid, and this sensation is fluctuation. The pre- cautions to observe in reference to this sign are : (a) always to use two hands ; the manipulation should never be conducted with the fingers of one hand only, as it is then very liable to mislead ; (6) to be careful to fix the tumour with one hand, so that the pressure of the other does not move it en masse, but, if liquid, merely displaces a part of its contents ; the unprac- tised observer may easily mistake mobility of a tumour for fluctuation, unless this error be guarded against ; (c) one hand only should be xised to com- press the tumour, the other being placed immovably on the swelling ; if the two hands are both moved, errors are very easily made; there is, of course, no objection to alternate the hands, but there is no pos- sible advantage in so doing ; (d) fluctuation should always be obtained in at least two different directions across a swelling ; in collections of fluid the dis- placement occurs equally in all directions ; in some solid tumours a sense of fluctuation may be obtained in one direction only, but not in more than one, as across muscle, for example ; in narrow elongated collections of fluid, as in tenosynovitis, it may be difficult or even impossible to obtain this sign across the swelling, owing to its narrowness ; (e) care must be taken not to mistake mere elasticity or compressi- bility for a sense of fluctuation ; this is best avoided 256 SURGICAL DIAGNOSIS. [cnap. xv. by noticing that the sign is detected by the stationary hand, not by the compressing hand, and it is not the fact that the tumour yields to pressure, but that its contents are displaced and press up the other hand, that constitutes fluctuation. It requires practice and skill to detect fluid in small quantity or at a considerable depth, and where doubt is entertained it should always be removed by puncturing the swelling with a grooved needle, or, better, a syringe. It may be well to enumerate the errors that may be made in connection with this very important sign. The surgeon may fail to obtain the sense of fluctu- ation (1) Because of the great depth of the fluid ; (2) Because of the small size of the swelling rendering the manipulation very difficult ; (3) Because of the extreme tension of the fluid ; (4) Because of the extreme lack of tension of the fluid. He may wrongly suppose that he obtains the sense of fluctuation (l\ If the tumour be very elastic ; (2) If the tumour be very soft ; (3) If the tumour be very movabla For the diagnosis of fluctuating swellings see pages 290 et seq. If the fluid of a tumour contain numerous small solid bodies, the displacement of these in obtaining fluctuation may give rise to a very characteristic kind of fremitus. This sign enables the surgeon to detect the presence of " melon-seed bodies " in " gan- glion." In some cases of hydatid tumour, if the left hand be placed on the swelling and percussed with the right, a fine thrill or fremitus is perceived (called the hydatid fremitus), which is attributed to vibrations set up by the impact of the daughter cysts in the mother sac. On listening over a hydatid tumour Chap. xv.] FLUCTUATION WAVE. 257 when thus percussed a musical sound may sometimes be perceived. A fluctuation wave is obtained in cases of large collections of fluid, with more or less tense walls, as in unilocular ovarian cyst and ascites. It is ob- tained by placing the palm of the hand smoothly over one side of the swelling, and then sharply tapping the opposite side of it with a linger or fingers of the other hand, when a distinct wave may be felt, as it were, to strike the palm. This sign should be obtained across more than one diameter of the tumour, and care should be taken not to mistake a mere impulse or wave conveyed along the covering of the tumour for a wave transmitted through it ; the former is never such a sharp abrupt impulse as the true fluctuation wave, but it may be entirely eliminated by gently pressing upon the coverings somewhere between the two hands. In the case of the belly this is usually done by getting an assistant to press the edge of his hand on the walls between the hands of the surgeon, and so interrupt any wave passing that way. The character of the fluctuation wave differs somewhat with the consistence of the fluid transmitting it, and so affords some criterion of its nature. Pitting on pressure. If, on pressing a finger into a swelling, it yields under it and leave a pit which is gradually filled up again when the pressure is removed, the phenomenon is known as " pitting on pressure." This is due to fluid or gas infiltrating the cellular tissue ; when fluid, the swelling is dull on per- cussion and the pitting is unattended with any other sensation ; when clue to gas it may be tympanitic on percussion, and it gives a fine crackling sensation to the finger, as already mentioned (page 254) ; a gaseous swelling is also more elastic than fluid. This condi- tion of fluid infiltration of cellular tissue is known as oedema. It may also be recognised, but not so surely, R 13 258 SURGICAL DIAGNOSIS. [Chap. xv. by a lessening or total obliteration of the natural wrinkles of the part. (Edema is caused by (a) acute inflammation, (b) venous obstruction, (c) hydrcemia, (d) urinary infiltration. If inflammatory, it is local- ised, and accompanied by the usual signs of inflamma- tion, i.e. pain, tenderness, heat, and fever, and usually redness; much surrounding O3dema is sometimes an useful indication that the inflammation has run on to suppuration. When due to venous obstruction it is generally localised, and attended with some lividity of the surface or venous distension, and the obstruction may be obvious, as a tight bandage, an aneurism or other tumour, or pulmonary or cardiac disease. If due to hydrcemia it is always associated with mai-ked anaemia, is painless, and when severe is more or less general The peculiar limits of urinary infiltration sufficiently characterise that form of redema. The limits and extent of O3dema should always be carefully ascertained j where local it owns a local cause, and vice versa. Swellings caused by fluid yield, of course, a dull percussion note. Swellings which are dull on percussion, and neither fluctuate nor pit on pressure, are solid. Solid tumour* may be soft, easily yielding to pressure, sometimes requiring care to distinguish from fluid tumours. Examples of such are seen in lipoma and myxoma. Or they may be of any consistence firmer than this, up to the incompressible hardness of bone. Of the firm tumours may be mentioned fibroma, adenoma, and many sarcomata ; of the very firm, but still slightly elastic and compressible tu- mours are enchondroma and scirrhus ; cartilaginous tumours only yield very slightly to pressure, and the recoil is very rapid; of the absolutely hard unyield- ing swellings we have osteoma, calcified tumours Buch as phleboliths, and swellings due to calculi. In examining the consistence of a solid tumour, a chap, xv.] EGG-SHELL CRACKLING. 259 peculiar crackling may be met with ; where this is very dry and high-pitched, like the sensation pro- duced by compressing a cracked egg, it is known as "egg-shell crackling," and is caused by the yielding of a very thin plate or shell of bone over a softer tumour. A similar sensation, but less dry, and of a lower pitch, is produced by the like yielding of a thin plate of cartilage. This sign is a useful indication of the expansion of the bone by a tumour growing in its in- terior (sarcoma or enchondroma), and if it affect the articular end of a bone, while at the same time it expands the cartilage-covered surface of the bone, the softer sensation may be felt. The author has recently noticed this in a case of soft sarcoma growing from the outer condyle of the femur. A very similar sensation may be felt in cases of subperiosteal cephal- haematoma, where the pericranium becomes thickened by soft callus, and bends like stiff parchment under the finger. As already stated, swellings may vary in consis- tence in different parts or at different times, and a knowledge of this fact may aid in the diagnosis. The association of firmer and softer solid material in one swelling indicates sometimes that a soft tumour, growing within a hard substance, has at one or more places burst through the enveloping tissue ; this is sometimes observed in the growth of central sarcoma of bone. At other times it shows that the soft tissue has undei'gone some indurating change, as when a sar- coma chondrifies or ossifies : while in other swellings it indicates that the tumour is composed of quite different constituents, as intestine and omentum in a single hernial sac. Still more common is the associa- tion of solid and fluid parts in one swelling. Where, with signs of inflammation, part or parts of a solid swelling become fluctuating, suppuration may be re- cognised. Where, on the other hand, such a change 260 SURGICAL DIAGNOSIS. [Chap. xv. takes place without any indication of inflammation, a degenerative softening of the tumour, or a growth of a cyst or cysts, is the cause; and the distinction between these may be difficult, but the more te'nse and the more globular the collection of fluid the more likely is it to be a true cyst, and not a collection of soft detritus. The causes of the changes in the consistence of tumours have already been mentioned. The association of cystic and solid matter in a tumour is characteristic of cystic hygroma, cystic sarcocele, and many other tumours ; variation in their consistence, while a frequent feature of malignant tumours, especially sar- comata, is rarely seen in benign growths. (For the diagnosis of solid tumours, see pages 279 et seq.) VI. Tlie form of a tumour must be carefully observed, as it not unfrequently aids very materially in the diagnosis. (1) A tumour or sivelling may have tlie form of one of the normal structures of the bod;/, and so prove its relation with such structure ; many examples of this might be cited, but the fact is of practical diagnostic value in the following instances : enlargement of lym- phatic glands, enlargement of the salivary glands, varix, thrombosis, phleboliths, arteritis, fusiform aneu- rism, synovitis, bursitis, hydrocele, sarcocele, misplaced testicle or ovary, movable kidney, enlarged liver or spleen, distended bladder or uterus, and various dislocations. (2) A ylobular shape of a neoplasm indicates the uniform yielding of the implicated tissues to the pressure of the growth, or the general implication of all tissues equally in a rapidly-growing tumour. Thus we find that cysts of all kinds tend to assume a globular outline, so also do sacculated aneurisms ; diseased joints when the fibrous structures are softened and are no longer able to maintain the normal out- line of the uart, while soft sarcoma and carcinoma chap, xv.] TRANSPARENCY OF TUMOURS. 261 frequently assume a globular shape. The globular form of dermoid or sebaceous cysts generally distin- guishes these swellings from ovoid fatty tumours and hemispherical abscesses. (3) A tumour may be lobulated, and this may be chai-acteristic. Thus the fine lobulation caused by the distension of the acini of the mamma in milk con- gestion, or of the lobules of the submaxillary gland in obstruction of the duct by a calculus, are quite charac- teristic of glandular distension. The flattened ovoid lobulation of a fatty tumour is also distinctive ; and the presence of omentum in a hernial sac is usually easily determined by its granular and loosely lobulated feel. Coarser lobulation of tumours may be due to yielding of the surrounding tissue in certain directions only, as in some ganglia; to cystic formation, as in cystic sarcoma of the mamma and testicle; or to an in- herent mode of growth of the tumour, as in enchon- droma, which has a special tendency to form botryoidal masses. Lobulation may also be explained by the anatomical relation of the swelling, as in psoas abscess. (4) The retraction of a tumour is an important feature, indicating a contraction of the tissue ; it is a special feature of scirrhous carcinoma. (5) Other characteristic forms are the warty or villous, the pedunculated or polypoid. VII. Trauslucency of a swelling shows that it consists of a collection of transparent fluid, serous or synovial; and it is, therefore, a diagnostic sign of great importance. To test for translucency, the tumour should be grasped so that it is made tense and the skin is stretched tightly over it ; a good light is then to be held close to it on one side, while the ob- server's eye is on the opposite side, the rays of light which pass over the surface of the swelling being shut off by the hand or some suitable screen ; if translucent, 262 SURGICAL DIAGNOSIS. [Chap. xv. the light is seen through the swelling more or less in- tensely. Some prefer to look through a stethoscope, a roll of paper, or some similar tube. Translucency may be missed by carelessness in carrying out this manoeuvre ; thus, a scrotal swelling may be so held that the patient's penis, or the sound testicle, or the surgeon's hand is placed between the light and it, and the rays of light effectually interrupted ; or one part only of a swelling, which is partly solid and partly fluid, such as an hydrosarcocele, may be examined. On the other hand, it may be wrongly detected, if the observer be not careful to shut off from his eye all the rays of light except those passing into the swelling , thus, if a stethoscope or other tube be used and the end be not placed quite firmly and uniformly on the swel- ling, light passing into the tube under its tilted end may be mistaken for that passing through the swel- ling. Tumours usually translucent may be opaque through great thickening of their coverings, as in some old cases of hydrocele ; or through a change in their fluid, as when haemorrhage occurs into a hydrocele, or a spina bifida becomes filled with organisable lymph, or a serous cyst becomes inflamed and suppurates. When testing for translucency, it is well always to examine the whole swelling, both because a translucent part may otherwise be overlooked, and also to localise exactly any opaque portions. In this way the posi- tion and approximate size of the testicle in a hydro- cele, or the presence and position of the spinal cord or nerves in a spina bifida, may be determined. While translucency is positive evidence of the presence of a clear fluid in the swelling, serous or synovial, the surgeon must remember that opacity is not by itself evidence of the absence of such fluid. Transparency of the coverings of a tumour, the result of thinning, is sometimes of use in diagnosis when the colour and appearance of the swelling seen Chap. xv. REDNESS OF SKIN. 263 through are characteristic, as e.g. in the pointing of an abscess, many cases of spina bifida with very thin sacs, nsevi, sebaceous cysts, and dilated veins. VIII. The colour and vascular condition of the skin covering a swelling are often note- worthy. (1) The skin may be white and blanched, as in oedema from Bright's disease, or ansemia. (2) The skin may be reddened, and if so, care must be taken to distinguish between certain varieties of this discoloration. If the colour be neither banished nor altered by pressure, it is due to escape of blood from the vessels, the result being spoken of as pete- chise if in small isolated spots, or as a bruise or an ecchymosis if more diffused ; such a condition aids in the diagnosis of purpura, scurvy, haematoma, bruise, or the rupture of an artery or a vein. If, however, the colour disappear on pressure, it shows that this is due to blood circulating in the vessels, and the rapidity with which it returns corresponds with the activity of the circulation in the part. When the red colour is uniform and the individual dilated vessels cannot be detected, this condition is due to capillary dilatation, is very often inflammatory in nature, and hence may aid in the diagnosis of the tumour, as in the case of an acute abscess; such inflammatory redness of the skin, however, may be of secondary origin, e.g. the intertrigo over a large scrotal or umbilical hernia, or large pendulous fatty tumour. If the colour be not thus uniform, but the individual vessels can be seen with clear spaces between them, the hypersemia is limited to vessels larger than capillaries, and is cer- tainly not inflammatory ; if of a purple tint it is pro- bably due to obstruction to the venous circulation. Where, however, this dilatation of vessels larger than capillaries containing blood of a bright red colour is seen over malignant tumours it indicates the 264 SURGICAL DIAGNOSIS. [Chap. xv. involvement of the skin in the morbid growth ; this is seen very characteristically in some cases of cancer of the breast. When the bright capillary inflammatory redness is associated with oedema it is a useful sign of suppuration ; the redness of inflammation is always accompanied by increased local heat. (See page 20.) To be carefully distinguished from the above forms of redness is the ncevoid condition, the appearance of which is quite characteristic ; the colour varies from bright to dark red, the affected skin is slightly raised, always sharply defined, and often presents an un- even appearance from the looped and pouched arrange- ment of the vessels ; further, this condition of skin is congenital, or appears soon after birth. Such a state of the skin indicates that any subjacent swelling is either a nsevus or some other form of congenital tumour. (3) The skin may be piymented. This is met with as a congenital deformity in hairy moles, or results from the degeneration of nsevi ; in each case there are a long history, dating back to birth or infancy, a deep colour, sharp outline, and often an abnormal growth of hair or of the papillae of the part, while in each case it would point to a nsevoid or congenital nature of any subjacent tumour. Pigmentation also results from prolonged congestion, and is then less defined and shades away at the edge, unlike a hairy mole. Pos- sibly the characteristic discoloration of the skin in Addison's disease might be met with over a tumour ; it would have no diagnostic significance quoad tumour. The hairy or pigmented moles frequently become the seat of epithelioma, and this fact might aid in the dia- gnosis of commencing epithelioma. (4) The skin may be so thinned as to allow the colour and form of the parts within to be seen. (5) The skin may be quite unaffected. IX. Pulsation is sometimes present in tumours, Chap, xv.] PULSATION: BRUIT. 265 and is of the utmost importance as a symptom, for in all cases the special connection with the arterial sys- tem that it indicates requires careful investigation. It must be noted at the outset that only when the pas- sage of blood into a part meets with a certain amount of resistance is pulsation to be observed ; thus, when an aneurism or an artery ruptures subcutaneously and the blood is diffused in the loose tissue of the part there may be no pulsation in the swelling. Pulsation in a swelling may be due to (a) the direct communi- cation of an artery with the swelling, as in aneurism, aneurismal varix, pulsating proptosis ; (b) to the pre- sence of numerous pulsating arteries in the tumour, as in aneurism by anastomosis, and in very vascular sarcoma, hence called " pulsating tumour ; " (c) to the presence of an artery in close contact with the swelling, to which it transmits its pulsation, as in some cases of enlarge- ment of popliteal glands, and of tumours of the thyroid gland and some abdominal tumours. The fact of chief importance in connection with any tumour that pulsates is to determine whether an artery directly communi- cates with it, whether it is an aneurism. (For the diagnosis of pulsating tumours, see pages 296 et seq.) X. We will here speak of the other phenomena connected with the vascular system that may be met with in tumours. Of these, the first is (1) A bruit, or murmur, a sound audible when the ear is applied directly to or with a stethoscope over a swelling. It may be caused either by the rush of blood into an aneurism, and in some cases also out of the sac, or by the partial compression of an artery by a swelling placed over it, and this particularly in certain blood states. It is heard simultaneously with the pulse, but may be also diastolic in cases of aneurism. It varies much in character, being described by such terms as soft, loud, blowing, rough, musical, etc. In aneurisms it is generally of a blowing character ; in 266 SURGICAL DIAGNOSIS tchap. xv. partial compression of an artery it is usually a dull toneless sound, or "thud," or it may be rough in character. The points to notice in regard to a bruit are (a) the time of its occurrence ; (6) if it be intensi- fied by pressure ; (c) if it be heard of equal intensity all over the swelling, and with the pressure of the stethoscope in any direction ; (d) if heard at a distance. Only in aneurismal tumours do we hear both a systolic and a diastolic bruit. An aneurismal bruit is not in- tensified by pressure ; one due to compression of the artery is intensified by moderate pressure in the direc- tion of the artery ; an aneurismal bruit is heard equally well all over the tumour ; an arterial bruit is heard loudest, and perhaps only, just along the line of the artery ; an aneurismal bruit is often conducted along the diseased artery, or is heard at a distance, as over the back in aortic aneurism; a "compression murmur'' is not thus conducted. (2) A tin-ill is a vibrating sensation, detected by the fingers lightly placed over the part ; it is caused by the forcible passage of blood through a small orifice. It is felt in many cases of aneu- rism and in cases of direct communication between an artery and a vein. In aneurism it is limited to the tumour, and its presence depends upon the relative size and conformation of the mouth of the sac, and possibly, too, upon the condition of the interior of the sac. In aneurismal varix the thrill is often very intense, and is particularly characterised by its wide extent, being conducted and felt in some cases along the veins of a whole extremity. In cer- tain conditions of the arterial wall and possibly also of the circulating blood, a tin-ill can be produced by com- pression of an artery against a firm tumour or a bone ; this thrill is increased by gentle pressure. (3) Tlie arterial pulse on the distal side of a tumour should always be noticed. In the case chap, xv.] THE PULSE. 267 of an aneurism, the pulse in the vessel beyond is delayed and rendered smaller and of less tension than in the corresponding artery of the other side. These differences are usually quite perceptible to the finger, but the alteration of tension can be best demon- strated by a carefully taken sphygmographic tracing. Sometimes, bey9nd an aneurism, the usual arterial pulse is entirely lost from embolism or thrombosis, or from the tumour obliterating the mouth of an artery. The complete subcutaneous rupture of an artery is always attended with the abolition of the arterial pulse below. An examination of the superficial arteries is of use to throw light upon the general condition of these vessels ; the superficial temporal, brachial, radial, and common femoral arteries are those most easily seen and felt, and if they be tortuous, with a visible pulsa- tion causing their locomotion, and the tubes be hard and incompressible, and especially if, when the finger is gently passed along them, it detect slight uneven- ness in them, it may be taken as evidence that the arteries of the body generally have undergone the dege- nerative changes known as atheroma and calcification. (4) The heart. Associated with arterial degene- ration and the consequent increased difficulty in the cir- culation, and especially when to this an aneurismal dilatation of an artery is added, we have hypertrophy (rarely dilatation) of the heart. In cases, therefore, in which the diagnosis of aneurism is obscure the existence of cardiac hypertrophy, especially when no other cause for it, such as valvular disease, can be detected, the fact is in favour of the tumour being aneurismal. (5) Venous pulsation, or pulsation in a vein, is observed in the rare cases of a direct communication between an artery and a vein, and is a very charac- teristic symptom. In the jugular veins it is also seen in cases of tricuspid regurgitation. 268 SURGICAL DIAGNOSIS. [Chap, xv ( 6) Venous engorgement, as indicated by tho dilated veins coursing over the part, or by its general lividity, is an important indication of an intimate con- nection of a swelling with the vascular system. It is well, however, to remember that the association may be entirely accidental, as in the case of a fatty tumour on the thigh and varicose veins of the leg ; enquiry as to the time of appearance of the swelling and of the venous distension will generally be sufficient to eliminate this error. The direct connection of venous distension and swellings is fourfold, (a) Venous distension may be t/ie entire swelling. In this case the swelling will have the outline of dilated, convoluted, and sacculated tubes, and will especially be characterised by being entirely compressible, unless the contained blood has at some spot or spots coagulated. (b) The venous dis- tension and the swelling may be produced by one com- mon cause, as e.g. obstructive or regurgitant heart disease ; in this case the swelling is cedematous. (c) The venous distension may be produced by the swelling obstructing the return of blood, either by compression or obliteration of a vein or veins by the growth, or by a communication between an artery and a vein, the flow of the arterial blood into the vein im- peding the venous return ; examples of the former are seen in popliteal and other aneurisms, mediastinal and other growths, etc. In these cases the venous disten- sion is on the distal side of the swelling, and may be accompanied by more or less oedema, (d) In other cases it is due to increased blood supply necessitating enlargement of the efferent veins. This is observed in very vascular growths, where the original calibre of the veins is not sufficient to carry off the great amount of blood conveyed to the part. In such cases the venous distension is noticed over and on the cardiac side of the swelling. As these growths may also obstruct the deep veins, some part of the venous chap xv.] REDUCIBILITY OF TUMOURS. 269 engorgement may be explained by this fact. These very vascular new growths are nearly always malig- nant, either sarcoma or carcinoma, and the blue veins coursing over a swelling are therefore of positive dia- gnostic value. Such veins are seen in some cases of chronic abscess, from destruction or compression of deeper veins. XI. Some tumours are reducible, either wholly or in part, really or apparently. A tumour is really reduced when its contents 'are more or less com- pletely emptied out of its capsule into one of the normal cavities of the bodies or into the vessels of the part. Examples of this are seen in hernia, some forms of hydrocele, varix, aneurism, and meningocele. A tumour is only apparently reduced when it disappears from its original position, but is not emptied out, and still remains of its original size. Examples of this we see in the reduction of hernia en bloc, in some cases of tumour of the spermatic cord, and of crypt- orchismus, in psoas abscess, where the femoral pouch can be emptied into the abdominal, and in effusion into the bursa beneath the semimembra- nosus tendon, when this does not communicate with the knee joint. In the limbs the reducible contents of tumours are always fluid (blood, pus, synovia) ; in swellings in connection with the trunk the contents may be solid or fluid, as in hernia and varicocele. Reducible tumours are also subject to temporary increase of their usual bulk, and the conditions under which they become over full or emptied often aid materially in diagnosis. Position, pressure, and effort or strain, are the means usually employed to cause these variations in tumours. (1) Position. It is only the most easily reducible swellings, and particularly varices, that are affected by position. In the dependent position dilated veins, whether in the limbs or scrotum, fill out, and when 270 SURGICAL DIAGNOSIS. [Chap. xv. the part is raised, they at once empty themselves, either wholly or in part. This is, in a measure, due to the action of gravity, and also to the fact that the arterial blood supply to a part is increased by depres- sing it, and vice versd. For this latter reason, aneurisms of the limbs become tenser and fuller when depressed. Some hernia? slip up and down, with alterations in the position of the patient. It must be observed that oedema may be greatly modified by or only appear in the dependent position. When this is the case, the oedema is certainly passive. It is a well-ascertained fact that vaginal hydrocele may be fuller in the evening than in the morning, although entirely irreducible, the effect being due, it is supposed, to increased exudation during the day. In both these cases, however, the changes take place slowly. Position has a still further influence upon tumours, due to the altered tension of muscles and fasciae accom- panying changes in position of the limbs. A typical illustration of this is seen in the case of effusion into the bursa between the tendon of the semimembranosus and the inner head of the gastrocnemius. When the knee is flexed, these muscles are lax, and the swelling partially or wholly disappears, the fluid bulging the sac towai'ds the space of the ham ; but when the knee is extended, these two muscles are tightly stretched and compressed one over the other ; the fluid is driven from between them and dis- tends the superficial part of the bursal sac, causing a prominent swelling behind the inner part of the knee. (2) Pressure. When exerting pressure we are enabled to judge of the amount of resistance to re- duetion, to note the manner of reduction, whether sudden or gradual, and any special accompaniments of the process. Venous tumours are always very rapidly reduced by pressure ; other fluid tumours, such as chap, xv.] REDUCIBILITY OF TUMOURS. 271 hydrocele and abscess, are steadily reducible, and whether rapidly or slowly depends upon the size of the aperture for reduction and the amount of resistance in the cavity into which they are reduced. . If the con- tents of the tumour be fluid containing numerous small solid particles in suspension, a fine thrill, or sense of friction, is detected by the finger during reduction. Solid tumours go back with an appreciably sudden motion recognised as a "slip ;" while the reduction of intestine is often accompanied by a gurgle. By the use of pressure, too, we are able to judge of the com- pleteness or incompleteness of the reduction, as in the case of partially reducible hernia, or reducible hernia conjoined with an irreducible hydrocele. By following up the reduced swelling, we may generally ascertain with the finger the aperture through which reduction has taken place. Pressure is employed in yet another way, by making it circularly round a limb, or pre- ferably to individual blood-vessels above or below a swelling, and noting its effect. Pressure on the cardiac side of a varix, unless so applied as to cut off the arterial supply to a part, causes the swelling to become fuller ; whereas, if a varix be emptied and then pressure be applied to the vein below, it does not refill. Pressure on an artery feeding an aneurism causes a partial shrinking of the swelling, and if applied to the artery below the sac may lead to its increased tension; and further, when the artery lead- ing to an aneurism is compressed, pressure upon the sac causes its reduction. (See pages 299 et seq.) (3) Effort or strain causes distension of tumours which consist of the contents of the abdomen or thorax, and of those which are influenced by obstruc- tion to the venous circulation. The production of, and especially the filling out, or impulse, in a hernia during effort, strain, or coughing, is one of its most characteristic symptoms ; a similar impulse is observed 272 SURGICAL DIAGNOSIS. [Chap, xv in congenital hydrocele, in some tumours of the cord, iu psoas ami iliac abscess, and in pneutnocele. The increased tension of tumours produced by the venous obstruction attendant upon straining efforts is par- ticularly seen in venous nsevi, varicocele, and in spinal or cranial meningocele and hernia cerebri, where the venous congestion in the spinal or cranial cavity presses out into the tumour more of the cerebro- spiual fluid. It is important to distinguish a true imjwlse, or filling out of a swelling, from a mere thrust forwards of a tumour or displacement. (See page 297.) XII. The pressure effects of a tumour are always noteworthy, and they sometimes aid in the diagnosis. Reference has already been made to venous engorgement below aneurisms and other tumours com- pressing main veins. Neuralgic pains may be produced by similar compression of the popliteal or other sensory nerves, an interesting example of which is pain along the obturator nerve, felt in the knee, from the compression of the trunk of the nerve by an obturator hernia ; here this symptom is of consi- derable diagnostic importance. Among other pres- sure effects of tumours must be mentioned muscu- lar spasm and paralysis, of great importance when occurring in the larynx, and the gradual absorption of surrounding structures, even bone. They are of diagnostic value in indicating the position and relation of the swelling, as in the case of a popliteal aneurism, and also as showing the aggressive nature of a neo- plasm, as in cases of tumours of bone. XIII. Concomitant affections are frequently of special value in the diagnosis of tumours. This association may be twofold. Tumours may accompany other lesions produced by the same disease, both re- sulting from some common cause ; the best examples of this are found in svphilis, where the existence of chap, xv.j PUNCTURE OF TUMOURS. 273 the characteristic ulcerations of the skin or mucous membranes, or of the tongue, nodes, necrosis of the bones of the nose or of the skull-cap, etc., greatly simplifies the diagnosis of a gumma. The association of exophthalmos with goitre, and the coincident enlarge- ment of many groups of glands, aids in the diagnosis of Graves' disease or of ade"nie ; and the presence of tubercular disease of the lungs may simplify the dia- gnosis of a strumous testicle. In other cases, the tumours are secondary to the local affections ; this association is still more common, and still more useful for purposes of diagnosis. As examples of this may be mentioned particularly glandular swellings, such as those in the groin from an abrasion on the foot, soft chancre, urethritis, soot -wart, epithelioma of penis; those in the axilla from inflammation or carcinoma of the mamma ; those in the neck from pediculi capitis, otorrhcea, tonsillitis, facial chancre, epithelioma of lip, tongue, or larynx. Another example is furnished by the association of chronic epididymitis, or of perinaeal abscess with stricture of the urethra. XIV. Puncture of the tumour, with a view of removing some of the contents for examination, often determines its nature in cases which otherwise would be obscure. Where the tumour is supposed to be fluid, it may be tapped with a grooved needle, or a fine trocar and canula, and a syringe or aspirator may be attached to this with advantage. A grooved needle often suffices, but in deep collections of fluid, the solid tissues through which it passes may press into and block up the groove, and for this reason an ex- hausting syringe is much to be preferred. In the case of ulcers or ulcerated tumours, the surface should be cleaned and gently scraped with a clean knife, and the scraping so obtained may then be examined microscopically in a drop of glycerine or saline solu- tion. Where the tumour is solid and not ulcerated, s 13 274 Sl'KGlCAL DlAGNOSJS. [Chap. XV. a harpoon may be introduced, by means of which a small fragment of the tissue can be removed, and ex- amined microscopically.* The fluid removed should be tested microscopi- cally and chemically. In withdrawing fluid from any swelling, not only is the nature of the fluid to be investigated, but also its mode of escape, and the effect of its withdrawal upon the tumour. Ptis will be recognised by its colour and opacity, and by the presence of very numerous globular nu- cleated granular cells. It may be of the natm'e of thick pus, curdy pus, sero pus, etc. A peculiar penetrating and very offensive odour, quite sui generis, indicates that the pus is connected with necrosed bone. This odour is especially observed in connection with necrosis of the lower jaw and of the teeth. A faecal odour indicates that the abscess has formed close to the alimentary canal, as around the caecum or rectum. Where the abscess communicates with the bowel, the pus not only smells faeculent, but contains faecal matter mixed with the pits. The pus from an urinary ab- scess, whether renal or urethral, may smell urinous, and show the characteristic test of urea. (See page 161.) A brown colour, when not attended with a faecal odour, indicates an admixture of broken-down blood with the pus, as in a suppurating /icematoma. The pus formed in connection with caries or necrosis of bone, when chemically examined, shows the pre- sence of bone salts, even to the extent of 2 per cent. Milk, when concentrated, may closely resemble pus. When allowed to stand a layer of cream rises to the top ; tander the microscope, the characteristic molecular basis, fat particles and globules, and large cells full of fat in fine division, are characteristic. * For the microscopical characters of the various tumours, the reader is referred to Pepper's "Manual of Surgical Pathology." chap, xv.i BLOOD CYSTIC FLUIDS. 275 When mixed with pus, the smaller pus-cells are also present. Blood is recognised by its colour, by the well- known red corpuscles it contains, by its spontaneous coagulability, and by its characteristic spectrum. By the rapidity with which it flows some estimate may be formed of the vascularity of the tissues pierced, and if it flow out forcibly and in a jetting stream, it is evident that an artery or an aneurism has been per- forated ; the colour of the blood may indicate whether the vessels opened are arterial or venous ; the blood in the capillaries is bright in colour like that in the arteries. The escape of blood in any quantity indicates either that very vascular tissues, such as tissues acutely inflamed, soft sarcomata, carcinomata or nsevi, or some larger blood-vessel has been punc- tured. If the tissues be acutely inflamed a drop of pus may be detected in the blood; if the needle or trocar have pierced a soft neoplasm some of its cells or distinct shreds of the growth may be recognised among the blood corpuscles. Altered blood is recognised by its darker colour, sometimes brown, at others black; by its non-coagula- bility; by the corpuscles being converted into shrunken gramiled debris (perhaps unrecognisable) ; and by the spectrum being that of methsemoglobin.* Such blood is obtained from old hsematomata, hsematoceles, and blood extravasations into tumours. Where the blood is withdrawn from the circula- tion no alteration in the bulk of the tumour is pro- duced, but when a circumscribed collection of blood is tapped some lessening of its bulk or tension may be noticed. Cystic fluid varies greatly in its characters. It should be examined mieroscopically for any formed elements, such as cells, booklets, hairs, spermatozoa, or See Ralfe's " Clinical Chemistry," page 77. 276 SURGICAL DIAGNOSIS. ' [Chap. xv. crystals of cholesterine and fatty granules ; and chemi- cally for albumen, mucin, urea, chloride of sodium.* If the fluid be clear, free from formed elements, and the addition of silver nitrate to it show the presence of traces of chloride of sodium, while on boil- ing it gives but a slight precipitate of albumen, it is what is known as serous fluid; or the fluid from a serous cyst. If the fluid be quite clear and watery, but become opalescent on standing, is alkaline in reaction, give no precipitate of albumen on acidulation and boiling, but a dense precipitate with nitrate of silver, it is pro- bably hydatid fluid, and if the microscope reveal the presence of echinococcus booklets in it, the diagnosis is certain. If the fluid be clear or slightly turbid, viscid, and yield an abundant precipitate of mucin on the addition of acetic acid, it shows that it was obtained from a mucous or synovial cavity, and the position of the tumour will at once enable the surgeon to distinguish between these two. Fluid removed from tumours of the head or back should be examined for sugar, by Fehling's, or some similar test, as the detection of sugar in siich fluid would show it to be cerebro-spiiial fluid, provided that the patient were not the subject of diabetes, when any of the fluids of the body may contain sugar. To examine a fluid for urea, nitric acid should be added to it, and the mixture evaporated, when crystals of nitrate of urea may be recognised under the micro- scope in the form of shining colourless rhombic plates. If the fluid be turbid and contain shrunken epi- dermic scales, cholesterine crystals and granular fatty matter, it has been removed from a sebaceous * For full details as regards these fluids the reader is referred to Ralfe's "Clinical Chemistry." Chap, xv.] CYSTIC FLUIDS, 277 cyst. But if such a fluid be found acid in reaction, and hairs be seen in it, it shows the cyst to be a dermoid cyst; the contents of such cysts vary much; as a rule they are more fluid than those of sebaceous cysts. If the fluid removed have the appearance of oil and solidify when cold, and again melt on the applica- tion of heat, and be entirely soluble in ether, it has been removed from an oil cyst, which is probably a variety of dermoid cyst. (For Spermatic cysts, see page 517.) The withdrawal of a notable quantity of fluid from a tumour may cause its entire disappearance, showing it to be simply a collection of fluid ; or it may cause a general and uniform diminution of the tension of the swelling, showing the tumour to consist of a single fluid-containing cavity ; but if it lessen the tension or cause the collapse of one part only of the swelling, it shows that the collection of the fluid tapped is but a portion of the entire mass; the re- mainder may be of similar nature as in compound cystic tumours, or solid. Tapping a swelling may permit the detection and examination of parts of the tumour which were before inaccessible, as e.g. in tapping a hydrosarcocele, or when, after tapping an ascitic belly, cancerous masses in the omentum are felt. It is well, therefore, to remember the twofold object of exploratory puncture of tumours from a diagnostic point of view. XV. The age of the patient is of importance in the diagnosis of tumours. In infancy we meet with congenital tumours of all kinds, such as nsevi, dermoid cysts, cystic hygroma, spiiia bifida, menin- gocele,and encephalocele ; swellings resulting from con- genital malformations, such as hernia and hydrocele ; swellings due to inherited syphilis or to rickets, and occasionally with fatty tumours and sarcomata. In childhood and youth, glandular enlargements, abscesses 278 SURGICAL DIAGNOSIS. [Chap. xv. acute and chronic, and cartilaginous and bony tumours are most common. In early adult life, syphilitic and venereal affections, traumatic and inflammatory swell- ings, together with fatty, mucous, and fibrous tumours prevail. And in late adult life, malignant tumours of all kinds, and other senile swellings, such as those of rheumatoid arthritis and hydrocele become common. Age is of most direct value at the two extremes, in aiding the diagnosis of congenital tumours and of malignant tumours. XVI. Sex seems to have little or nothing to do directly with thd, etiology, and therefore the diagnosis of tumours, apart from the affections of the organs peculiar to the two sexes. Aneurisms, with the ex- ception of those of the carotid artery, and cancer of the lips and tongue, are much more frequent in men than women, but this is probably not due primarily to sexual difference. A case in point, however, is afforded by the much greater prevalence of femoral hernia in women than in men. XVII. The previous history of the patient may aid in the diagnosis of tumours. In diathetic diseases such as struma and syphilis, evidence may thus be obtained of the existence of those diatheses. In the infective diseases, such as sarcoma and carci- noma, light may be thrown upon the nature of a secondary tumour arising after the removal of the primary focus of disease ; thus, where a cancerous tongue has been excised, a progressively enlarging gland in the neck will not be mistaken for a strumous gland or some other simple tumour. 279 CHAPTER XYT. DIAGNOSIS OP GENERAL TUMOURS. HAVING in other chapters treated of the diagnosis of fluctuating and pulsating swellings, of swellings con- nected with bone, and of swellings of special regions, it remains for us here to speak of those swellings which have not these particular features, and which occur more or less generally over the body. In in- vestigating such tumours, the first point to be deter- mined will be the history of the growth, especially whether congenital or acquired ; if the latter, whether traumatic or idiopathic ; a ad if idiopathic, whether accompanied by signs of inflammation or not ; in any case, whether it is stationary, continuously pro- gressive, or receding. Then the surgeon should examine the swelling, and first of all notice to what structures it is adherent (skin, superficial fascia, muscle, gland) and its de- gree of adhesion to or mobility in these ; whether it have a sharply marked outline and if so, the character of its edge or gradually fades off into the healthy parts around. Then observe its consistence, whether hard, firm, soft, or gelatinous, whether com- pressible or not, and if it fill out and become more tense on strong expiratory efforts, and particularly whether the surface be smooth or lobulated at any part ; in some cases the colour of the swelling is character- istic. If the skin be ulcerated over the tumour, the characters of the ulcer will of course attract attention. Then the surgeon should feel the lymphatic glands connected with the swelled part, and notice whether 280 SURGICAL DIAGNOSIS, [Chap. xvi. they are enlarged or not. Lastly, evidence of con- stitutional diathesis (syphilis, struma) should be care- fully sought for. The bearing of many of these facts upon diagnosis has been already discussed, but we may here add something to what has been previously said. (a) It must be borne in mind that congenital tumours may not be noticed until some time after birth : this is not infrequently the case in very small dermoid cysts. Similarly, it is not infrequent to find that some trivial injury has called attention to a swelling or a lump, which, from not being painful or conspicuous, had previously escaped notice, and which the patient may be inclined to consider as actually caused by the injury. Inflammation may be the exciting cause, or may accompany a swelling from its first commencement, but in other cases it comes on later, and as a secondary condition; this is par- ticularly seen in such cases as sloughing gumma, cystic hygroma (where repeated attacks of superficial inflam- mation are very characteristic phenomena), and in large sebaceous cysts. (6) Inflammatory growths, gummata, and ma- lignant tumours tend to infiltration in their growth, and to involve rather than to displace surrounding tissues, while the benign tumours displace tissues, and are encapsuled. The degree of mobility of tumours varies much, and it is important to notice the direction of mobility, and also what may be called its character. As already pointed out, neuromata and some tumours connected with vessels, have free mo- bility in one direction only (across the nerve or vessel) and none in the other. By the character of mobility is meant whether it is a mobility of the entire part, or of the tumour in the tissues amid which it is growing ; a cancerous tumour of the breast, for ex- ample, may be freely movable with the mamma over the chest, but careful examination will show it to be Chap. XVI.] NMWS. 28l quite immovable in the breast itself. Some fatty tumours show the greatest freedom of mobility, and the way in which the smooth rounded edge of these growths slips from under the finger is quite character- istic. The most noteworthy feature of the outline of tumours is the characteristic lobulation of fatty tu- mours ; the lobules are ovoid or rounded, and some- what loosely adherent one to another ; this sign is pathognomonic of fatty tissue. (c) In regard to the lymphatic glands it is to be remembered that they may be enlarged from causes other than the tumour; but excluding these, the glands may be enlarged by inflammatory swelling, or by a secondary growth of the actual tumour tissue ; in the early stage it is quite impossible to distinguish between them ; but progressive and then infiltrating growth indicates secondary infection of the glands. The surgeon should first notice whether the swelling be reducible or yield under compression, and then fill out again when the force is removed ; excluding fluctuating and pulsating tumours giving this sign, we have ncemis and hernia. The signs of hernia are fully discussed in chapter xxxv., and we need not repeat them here. Nsevus is a congenital formation, or appears soon after birth ; it may be stationary, or grow with various degrees of rapidity, or undergo spontaneous recession and cure ; very commonly the diagnosis is rendered very easy by the nsevoid condition of the skin, at other times the blue colour of the tumour is visible through the thin skin. Although these swell- ings are largely fluid, they do not fluctuate, and as they are connected with veins they do not pulsate. They may be met with in any region of the body. Under compression they yield gradually (not sud- denly) and without any gurgle or slip, as is common in hernia, and they at once fill out again when the 282 SURGICAL DIAGNOSIS. [Chap. xvi. force is removed, and become especially full and tense under any effort or strong expiration. Then the surgeon should ask himself whether the swelling is connected with any of the special struc- tures of the part, veins, nerves, or lymphatic glands, and for this he must look to its position, connections, and outline. 1. If the swelling be elongated, cylindrical in shape, and in the course and position of a vein, it is a thrombus. If the swelling have recently appeared, and is painful and tender, it is a recent thrombus. While if to these signs there be added an ill-defined outline of the swelling, obscuring its original form, and pyrexia, there is also phlebitis and periphlebitis, which may run on to suppuration ; if the swelling be chronic, painless and of stony hardness, it may be recognised as a phlebolith. In the acute conditions there is generally more or less oedema of the parts returning their blood through the occluded vein, but this largely depends upon the site of the obstruction. In the case of super- ficial veins the diagnosis will rest upon the character of the swelling ; in thrombosis of deep veins it rests rather upon the occurrence of local cede ma, with pain and tenderness along a vein ; for often the actual swelling of the vessel and its outline cannot be made out, and owing to the danger of detaching a por- tion of the clot, only the gentlest manipulation is warranted, 2. If the tumour be situated in the course of a nerve, is firm, clearly outlined, globular, or ovoid in form, with its long axis parallel to the axis of the limb, movable transversely, but immovable vertically ; and, furthei*, if there be pain of a neuralgic character along the terminal branches of the nerve in question, sometimes coming on in violent paroxysms, or excited by pressure upon the swelling, it may be recognised as a neiiroma. These tumours vary much in size and Chap, xvi.] SWELLINGS OF GLANDS. 283 consistence, and they are often multiple, affecting one or several nerves. They may be met with on the ends of nerves in stumps or seal's. 3. If the swelling occur in the site of lymphatic glands, and have the ovoid or globular outline of these bodies, and especially if it be multiple, and movable under the skin and over the neighbouring deeper parts, and there be some obvious exciting cause, it may be diagnosed as lymphatic glandular. It is only in quite a few regions that there is any difficulty in arriving at a correct diagnosis, and these cases are discussed in other chapters. Having determined that the swelling is glandular, the surgeon must next proceed to deter- mine its cause, or the variety of glandular enlarge- ment he has before him. (a) If the swelling be acute, following an injury or an inflammation of some part pouring its lymph into the affected gland, and the gland be painful, tender, more or less fixed in the surrounding tissue, and espe- cially if the skin over it be red and cedematous, it is inflammatory. (6) If the enlargement be chronic, slowly pro- gressing from gland to gland, forming firm, painless, rounded swellings, which exhibit a tendency to slow disintegration, and especially if it occur in the neck, and there are scars of old abscesses in the neighbour- hood, or thin unhealthy scars of ulcers, or other signs of the strumous cachexia, such as disease of the bones or joints, ulcer of the cornea, strumous lip, etc., and the dull complexion and pallid anaemic state so common in these cases, the condition is to be regarded as stru- mous. (c) If the affected glands are multiple, firm, freely movable in the connective tissue around, not painful or tender, and if the glandular swelling be accom- panied by other signs of constitutional syphilis, they are to be regarded as syphilitic. In the groin or 284 SURGICAL DIAGNOSIS. [Chap. xvi. in other regions where they are associated with a sore which may be a hard, chancre, it is the fact that there are many glands enlarged (in both groins), that they are hard and shotty, not blended together into one ill- defined mass, that they do not exhibit a tendency to suppurate, that they are accompanied or followed by the usual manifestations of secondary syphilis, and that they yield to antisyphilitic treatment, which renders the diagnosis certain. But they occur in syphilis quite apart from primary sore, especially in the posterior triangle of the neck and above the in- ternal condyle of the humerus, and the swellings there have the same general characters which, with the ac- companying signs of syphilis (rash, sore throat), make the diagnosis clear. (d) If the glandular swelling progressively in- crease, spread from gland to gland, infiltrate the neighbouring tissues, involving the skin, muscle, etc., and if there be or have been a malignant tumour in the neighbouring parts, it is malignant in its nature ; these infective malignant growths are most often carci- nomatous, but they may be sarcomatous, and in all cases they are of the same nature as the primary tumour. (e) If the glandular swelling be a primary and chronic growth, affecting many glands and many groups of glands, forming large, rounded, lobulated masses, inconvenient only by their size, steadily and persistently growing, but not showing any tendency to soften or suppurate, and if with that there be progressive debility and anaemia, and especially if the spleen be at the same time enlarged, the disease is lympliadenwna. The blood should be examined, and if there be a great increase of white corpuscles, the disease is leucocythcemia, while if there be no notable increase in these cells, it is pseudo-leucocytficemia or Jfodgkin's disease. The cervical glands are those most chap, xvi.j CYSTIC HYGROMA LIPOMA. 285 often and first affected, and the disease may remain limited to them for some time, and then suddenly spread to other groups of glands, causing rapid en- largement. When removed the glands are not found to have undergone fatty or caseous degeneration. 4. Some of the remaining tumours may be at once separated as congenital, and if the tumour be irre- gular in outline, very soft and loose, but incompressible, with parts that fluctuate and others that are solid, and especially if there have been repeated attacks of inflam- mation of the skin over it, it is a cystic hygroma. These tumours are most common in the neck, axilla, and groin, are often multiple, and may attain a large size. 5. But if the tumour be wholly solid, soft, and incompressible, and its surface or edge be felt to be lobulated, it may be diagnosed as a lipoma. The congenital fatty tumours may be placed deeply under muscles, and may be attached to or involve muscles, or even be attached to bone ; and hence they are not so freely movable as the acquired tumours in the subcutaneous tissue. Their tabulation, however, is just as characteristic. If the tumour be soft, it may yield a sensation so like fluctuation that puncture may be required to show whether it is solid or fluid. 6. Of the acquired tumours there are certain forms that may be easily recognised by certain well- marked characters. (a) If the tumour be an outgrowth from the skin, entirely raised above its surface, and therefore clearly marked off at its attached base ; firm, dry, and hard (unless in a situation where it is kept moist by secre- tion), granular or branched on the surface, it is a wart or papilloma. These vary much in appearance, according to whether the branching processes of which they are composed are more or less blended together, and according to the density of their tissue. 286 SURGICAL DIAGNOSIS. [Chap. xvi. (b) If the tumour be fixed to and infiltrate the skin, and spread both laterally and deeply, be firm, ulcerated on the surface, the ulcer having thick everted edges and an irregular granular base, a sei-ous discharge, and if the lymphatic glands of the pai't be enlarged, hard, and progressively increasing in size, it is an epitlieli- oma. A scraping from the ulcer will show under the microscope large and irregular epithelial cells with large clear nuclei, and possibly also parts of epithelial "nests." (For diagnosis between epithelioma and chancre see page 336.) (c) If the tumour be a small nodule raised above the surface, globular or ovoid in shape, of a glistening white colour like white wax, umbilicated in the centre, firm and fixed in the skin, it is molluscum contagios : >i/n. These tumours may be single or multiple, and they ai'e most common on exposed parts of the body. (d) If. the tumour take the form of a pedunculated pendulous outgrowth of the skin, soft, elastic, and smooth, it is called molln-scum fibrosum. When of large size, or exposed to friction, these growths may \ilcerate on the surface. (e) But when the swelling is in the form of pendulous folds of firm thickened skin and subcutaneous tissue hanging from the buttock, back, shoulders, and thighs, while sometimes called by the same name as the pedunculated variety described above, it is better known as diffuse fibroma. Both forms are very chronic in their course, and do not recur upon com- plete removal. (f) If the tumour be ovoid or rounded in. shape, tabulated on the surface, with a shallow rounded edge, and be freely movable in the subcutaneous tissue, but slightly connected with the skin as shown by its dimpling over it when the tumour is compressed, it is a lipoma. These growths are most common on the posterior part of the body, and about the shouldei-s and Chap. XVI]. LlPOMA FlBROMA GUMMA. 287 waist. They are not unfrequently multiple, and may be very numerous ; they vary in size within very wide limits, and are usually painless, and often remain stationary for years. They have been known to change their position, moving downwards. If the swelling be soft, granular, or lobulated, adherent to the skin, but without a distinct edge, movable over the deeper parts, but not movable in the subcutaneous fascia, it is a diffuse lipoma, which is most common as " double-chin," or at the back of the neck, or in the belly-wall. The feature by which fatty tumours are to be recognised with most confidence is the soft lobulation of their surface, which is eminently characteristic. (g) If the tumour be of chronic course, of very slow growth, or perhaps have remained stationary for some time, rounded in outline, smooth or lobulated, firm, adherent to the tissue from which it grows whether skin or fascia, but freely movable over the surrounding parts it may be recognised as a fibroma. Many neuromata are of this nature, and are distinguished from similar growths unconnected with nerves, by their peculiar kind of mobility and by the character of the pain associated with them. (A) If the tumour be of recent growth, of ill-defined outline, immovable in the tissue in which it is placed, and having a tendency to infiltrate neighbouring tissues, involving, perhaps, skin, fascia, and muscle, and especially if the growth slough, or soften at one or more places, leaving a sloughy sinus or ulcer, it is a gumma. Evidence of other syphilitic affections past or present, and the disappearance of the tumour under antisyphilitic treatment, will materially support and confirm the diagnosis. The absence of a sharply-de- fined outline, the thin, flattened, or ovoid, and not globular shape, and the evidently infiltrating mode of growth, together with a somewhat rapid formation 288 SURGICAL DIAGNOSIS. [Ch ap . xvi. compared with other chronic tumours, will usually lead to a correct diagnosis. (i) Similar swellings affecting the skin alone, or the .skin and subcutaneous tissue, occurring in children and young people, and quickly breaking down into fluc- tuating collections of thin pus, are scrofnlides. They are usually, but not always, multiple, and the varioiis swellings may show their different stages. The patient may or may not show other distinct signs of the scrofulous diathesis. (j) If a tumour have grown steadily and rapidly, and be found immovable in the part from which it has grown, and still more, if it have spread to and infil- trated neighbouring parts, such as skin and muscles, and if there be progressive enlargement of the neigh- bouring lymphatic glands, or secondary growths can be detected in the lungs, liver, or other organs ; or if after apparently complete removal the tumour have recurred in or close to the cicatrix, it may be recognised as a malignant tumour. These tumours vary much in their characters and in their degree of " malignancy." In some it is only after removal and microscopical examination that their true nature is known, while in others their " malignancy " is unmistakable. They sometimes show other signs more or less chai'acteristic, such as ulceration and fungating growth, softening and cyst formation. While met with at all ages, they are decidedly more common after thirty-five years of age. In some cases the influence of heredity seems to be very marked ; but in no case should it be relied upon to any extent for purposes of diagnosis, while no weight whatever is to be attached to the absence of such a history. The much -spoken- of "cancerous cachexia" is purely the result of the pain and ex- haustion caused by the tumour, or of its direct or mechanical interference with nutrition, and is there- fore of no value for diagnosis. chap, xvi.] MALIGNANT TUMOURS. 289 The signs upon which reliance is to be placed are : (a) the infiltrating mode of growth ; (0) the persistent enlargement of the tumour in spite of any palliative treatment (there are a few exceptions to this in some instances of " withering " scirrhus) ; (Y) the spread to neighbouring tissues ; (5) the formation of secondary growths in the lymph glands or other parts ; and (e) the local recurrence after removal. In some cases there are certain special signs, such as the retraction of the nipple in a mammary scirrhus, and pulsation in sarcoma of bone. To distinguish between sarcoma and carcinoma, the recognition of the tissue in which the neoplasm started will be of great value, as it is generally held that sarcomata originate only in tissues of the con- nective-tissue type, and that carcinomata spring only from tissues of the epithelial type. Where these tissues are intimately blended together, as in the breast, this test cannot be applied, and we have to rely upon other signs, but in such cases as the skin, muscle and fascia, it is a test of extreme importance and value. The infection of lymph glands is another impor- tant sign, for while this does occur in sarcomata, it is much more common in carcinomata, although Mr. Butlin has shown that the site of the malignant growth plays a large part in determining the infection of the lymphatics. Age is another factor which may be of value, for while carcinomata are essentially tumours of middle and later life, sarcomata are met with at all ages, although becoming more common in later life. To distinguish between the varieties of sarcoma may be quite impossible without the aid of the micro- scope ; but the firmer and slower the growth of a tumour, the more likely is it to be formed in part of fibrous tissue and of spindle cells, while the round T 13 290 SURGICAL DIAGNOSIS. [Chap. xvn. cell sarcomata are softer and of more rapid growth. A black colour of the growth will of course indicate a melanotic sarcoma. In some very soft and veiy vas- cular sarcomata haemorrhage into the growth may occur, and either before or during operation the surgeon may mistake them for blood cysts ; an examina- tion of the wall of the supposed cyst, and noticing the fact that the swelling does not collapse when tapped, will guard against this error. The great hardness of some forms of carcinoma, together with signs of contraction of the growth, will enable the surgeon to recognise scirrhus ; while in softness of tissue, rapid growth, and globular outline, he will see evidence of enceplialoid. When the cancer attacks an. epithelial surface and rapidly ulcerates, it is an epithelioma. CHAPTER XVII THE DIAGNOSIS OF FLUID OR FLUCTUATING SWELLINGS. THE detection of fluctuation, in a swelling merely indicates its fluid nature, it tells us nothing with re- gard to the character of the fluid contents, but nevertheless the sign forms a very useful and practical starting-point for the diagnosis of a large class of swellings, which we will now consider. The fluids met with in such swellings are blood, inflammatory effusions (serous, synovial, or purulent), cystic fluids of all kinds, dropsical effusion, and more rarely urine and bile. The first step in the diagnosis is to distinguish between the swellings which have arisen acutely and those which are chronic in their nature. Chap, xvn.j ACUTE FLUCTUATING SWELLINGS. 291 A. Acute fluctuating swellings. Hosmatoma. Serous or synovial effusion. Acute abscess. Distended bladder. Notice whether the swelling arose spontaneously, or as the result of an injury ; whether it formed sud- denly, or more gradually and progressively ; whether accompanied by any signs of bruising or ecchymosis ; whether attended with signs of inflammation, and, if so, whether these preceded the marked swelling, or vice versd ; the precise outline of the swelling, whether it corresponds with that of a serous or synovial cavity or the urinary bladder ; whether it is in the position of a lymphatic gland. If the swelling have arisen suddenly, and have immediately followed a blow, or strain, especially if there be any bruising of the surface, and there be an absence of all evidence of inflammation, or, if present, the inflammation have followed upon the swelling, the diagnosis of hcematoma is to be made. (See page 27.) If the swelling correspond in position and outline to a serous or synovial sac, and have formed with signs of inflammation (pain, tenderness, heat, per- haps redness, and pyrexia), it is serous or synovial effusion. And if the swelling progressively increase with deepening redness of the skin, superficial oedema, increased pain, tenderness and local heat, and especially if the fever rise to a high point, or rigors with sweat- ings occur, the fluid may be considered to have become purulent, or the case to be one of a serous or synovial abscess. If the fluctuation be detected in a swelling which is attended with redness, local heat, pain, tenderness, and pyrexia, and especially if it be known that these signs of inflammation preceded the existence of fluc- tuation, the diagnosis of an acute abscess is to be made. Local oedema is a valuable aid in some cases, as it 292 SURGICAL DIAGNOSIS. [Chap. xvn. greatly strengthens the evidence in favour of the presence of pus. If the swelling be situated immediately above the pubes, and correspond in outline with the urinary bladder ; especially if it be also detected bulging down against the rectum, with fluctuation between the two parts of it, and there be a history of the patient not having passed urine for many hours, the diagnosis of a distended urinary bladder is to be made, and this will be completely established if on passing a catheter and drawing off the urine the swelling disappear. B. Chronic fluctuating swellings. Haematoma. Serous effusion. Chronic abscess. Cyst. Aneurism. Varix. Distended urinary or gall- bladder. As an hcematoma may last for some time, even for months, unchanged, it must be included among chronic as well as acute swellings. In investigating these chronic fluctuating tumours, the surgeon should h'rst inquire into their history, and especially with the view of eliciting a history of injury or of inflam- mation ; he should then carefully notice whether there be at the time of examination any evidence of in- flammation in the swelling, or in any of the neigh- bouring parts, especially the bones and joints ; whether the swelling correspond in position and outline to a serous or synovial cavity, or the sheath of a muscle ; whether it be adherent to a vessel or a gland, or occupy the site of a vessel or a gland ; whether it be influenced by the surrounding fascia or not ; its outline, whether globular or more flattened ; whether adherent to the parts around, and if so in what directions it is movable ; whether the swelling fluctuate thi'oughout ; or whether part be solid, and if separate fluctuating areas can be detected in it. Chap. xvii. CYSTS. 293 In some cases puncture of the swelling, ov special signs, such as retention of urine, and the effects of catheterism may be necessary to clear up the diag- nosis. If the swelling immediately followed upon an injury or strain, particularly if it were attended with superficial bruising, but not with the signs of inflam- mation, and is more or less globular in outline, it may be diagnosed as an hceniatoma. (For Cephalhaematoma see page 77 ; for Hsematocele see page 509.) The soften- ing of the tissues around an inflammatory effusion is not met with in haematoma and cysts, and this accounts for the more globular outline of hsematomata and cysts as compared with abscesses. If the fluid tumour be in the position and of the shape of a serous or synovia! membrane, bursa, or sheath of a. tendon, or a hernial sac, it is to be re- cognised as a serous or synovial effusion. As examples of this may be cited housemaid's knee, miner's elbow, palmar ganglion, dropsy of the knee, and vaginal hydrocele. If there are no signs of inflammation of the part (heat, pain, redness, tenderness), and no history of such, and if the neighbouring parts, as the bones and joints, are free from disease, and if the tumour be of a globular shape, with distinct outline, movable over surrounding parts, and especially if it be tense, projecting from the surface, and not affected in its direction of growth by the muscles or fascia, it is to be diagnosed as a cyst. Where such cysts are met with in connection with glands, they may be retention cysts, as ranula, some cysts of the mamma, and the common sebaceous cysts of the skin. When occurring in the planes of cellular tissue unconnected with glands, and especially if they are found lax, with thin walls, and (if the test can be applied) translucent, they are what are known as serous or lymphatic cysts, and are sometimes 294 SURGICAL DIAGNOSIS. tchap. xvit. spoken of as hydroceles. These cysts are congenital. (See page 285.) When they are found over joints or synovial sheaths, when they are tense, firm, and fixed to the deeper structures, from which they cannot be entirely separated, they are to be recognised as synovial cysts, e.g. the common ganglion of the back of the wrist. Similar cysts are met with in connection with the larger joints, as the knee and the elbow, and they may be quite superficial, and have a long and very narrow pedicle leading down to the articulation ; but the sur- geon must be on his guard to recognise their true nature, or he may be led to open an articulation una- wares. The peculiar tenseness of these cysts, their mobility under the skin but their fixity on their deep aspect, are the points on which a diagnosis may be made to rest. The author recently met with one of these cysts some inches below the knee. Where there is a history of congenital origin, or where the tumours are noticed in eai'ly childhood and such an origin is therefore probable, especially when occurring under the occipito-frontalis or orbicularis palpebrarum, they may be diagnosed as dermoid cysts. These cysts are met with in every part of the body, but especially on the head and face, and in connection with the ovary. When opened, the peculiar nature of their contents (hair, teeth, pieces of bone, etc.) and the structure of their walls establishes the diagnosis. Where a swelling is found to be in some places solid, and in other places fluctxiating, or where two or more distinct fluctuating areas are found in the same tumour, the disease must be recognised as a cystic tumour or compound cyst. If there have previously been, or are at the time the patient is examined, any signs of inflammation of the part, especially pain, tenderness, or redness of the skin, or if there are any signs of inflammation of neigh- chap, xvii.] CHRONIC ABSCESS. 295 bouringor connected parts, particularly bones and joints, a chronic fluctuating swelling may be recognised as a chronic abscess. Examples of such are constantly met with in abscesses round diseased joints, psoas abscess, and many cases of strumous cervical abscess. If from the position and outline of the swelling it be evident that the fluid is contained within the sheath of a muscle, or has travelled along a plane of cellular tissue, and has been governed in its dii-ection of growth by the surrounding muscles and fasciae, even in the ab- sence of the above signs, the same diagnosis may be made. A third sign by which chronic abscesses may be recognised is their origin in solid swellings which undergo softening. For instance, when a strumous child presents two or more small firm swellings of the skin and subcutaneous tissue, if the surgeon find one of the smallest of the swellings firm and solid, and the larger and older ones fluctuating, he may be certain that he has to deal with chronic abscess, the common scrofulide. As a rule, chronic abscesses are less tense than cysts, though exceptions are met with, and their outline is not so characteristically globular ; they are always adherent to the tissue immediately surrounding them. In this particular, the distinction between a sebaceous cyst adherent to the skin in the centre only and a scrofulide adherent to and involv- ing the skin over its whole surface, is very marked. When the fluctuating swelling occurs over and adherent to a main artery, and exhibits an expansile pulsation, etc., it is an aneurism. (See Pulsating Tumours, page 296 et seq.) If the swelling be met with in the course of a vein, and is elongated in the direction of a vein, cylindrical in shape, compressible, and completely emptied by raising the part or by pressure, and especially if a blue colour be seen through the skin, or other superficial veins are seen coursing towards it, the diagnosis ofvarix is to be made. 296 SURGICAL DIAGNOSIS. [Chap, xvm. It is only rarely that the nature of this affection is not at once apparent. The case in which any diffi- culty of diagnosis is met with is that of a saccular pouching of the saphena vein close to the saphenous opening. (See page 530.) The signs of a distended urinary bladder are the same, whether acute or chronic, except that the pain and tenderness are much more marked in the former case. (See page 292.) If the swelling be found occupying the light hypochondrium, reaching up under the ribs, rounded in outline, not adherent to the abdominal-wall, and if there be a history of gall-stones or of attacks of pain with jaundice, the diagnosis of a dilated gall-bladder may be made. CHAPTER XVIII. THE DIAGNOSIS OF PULSATING SWELLINGS. THERE is no problem of greater importance to the surgeon than the correct diagnosis of a pulsating tumour ; in most instances its solution is easy if only care be taken, but from time to time cases present themselves which test to the utmost diagnostic skill and knowledge, if indeed a diagnosis be possible at all. The point upon which it is necessary to insist, first of all, is the necessity of not relying upon any single symptom, but of making a careful and complete ex- amination of the case, and of weighing all the signs. The tumours which pulsate may be thus enumerated : Tumours over arteries, in- Fusiform aneurism. Sacculated aneurism. Varicose aneurism. Cirsoid aneurism. Aneurismal varix. " Pulsating tumour." Encephalocele. eluding abscess, cyst, and solid tumours. Ruptured artery or ruptured aneurism. Tumours situated over aneu- risms, especially abscess. Chap, xvnt.] PULSATING TUMOURS. 297 The most important point to be determined in every such case is whether there be an aneurism present or not ; and then if an aneurism be present, whether the entire tumour be aneurismal. We will first refer to the examination that should be made, pointing out the bearing upon the diagnosis of each fact elicited, and then, putting these together, will mention the distinguishing features of each of the pulsating swellings. 1. Notice the position of the swelling; whether it corresponds to the known course of an artery of large or medium size, or whether far removed from such. Fusiform and sacculated aneurisms, and tumours with communicated pulsation are only found over arteries of some size. Cirsoid aneurism and "pulsating tumours" may occur in these situations, but also quite removed from main arteries, e.g. a pulsating swelling in the ham may be an aneiirism, a " pulsating tumour," or a tumour with communicated pulsation ; a similar swelling on the outer side of the lower end of the femur can only be a " pulsating tumoiir," or a cirsoid aneurism. 2. Feel the pulsation and determine (a) whether the tumour is filled out at each beat of the heart, and is expanded in all its diameters, or whether it is simply thrust forwards. For this purpose, place a finger of each hand on opposite sides of the swelling, and notice whether they are thrust apart by the impulse or are simply raised ; or the same thing may sometimes be plainly demonstrated by fixing a piece of strapping with a slit in its middle over the swelling, when, if the impulse be expansile, the slit will open out with each beat of the heart. An expansile impulse is caused by the forcing of more blood into the swelling, and is therefore a sign common to aneurisms of all kinds, aneurismal varix and " pulsating tumours " which are so vascular that the change of tension of their numerous vessels affects 298 SURGICAL DIAGNOSIS. tcW. xviti. the entire mass. A non-expansile or a fteaving im- pulse shows that it is communicated, and not intrinsic. Should an aneurism become shut off from the artery which remains pervious, its pulsation, which was for- merly expansile, would become heaving. (A) Notice whether the pulsation is felt as a wave passing through the swelling, or is simultaneous in every part ; the former is characteristic of aneurism, the latter of " pulsating tumour ; " too much reliance must not be placed upon this sign, and it is of positive rather than of negative value. (c) Then examine to see if the pulsation be uniform throughout the whole swelling ; this is usually the case in aneurism. If the pulse be only or mainly felt along the line of the artery, and not in the lateral expansions of the swelling, it indicates that the tumour is lying over the artery, and not communicating with it ; while if the pulsation be felt in parts of the swelling only, but these parts do not correspond with the line of the artery, it would be strong evidence in favour of the swelling being a " pulsating tumour," as it often hap- pens that only parts of these tumours present this sign. (d) Lastly, notice whether the pulsation can be abolisJied in the swelling by any manipulation which does not interfere with the circulation in the main vessel, such as lateral or vertical movement of the swelling, or, if the swelling be in the abdomen, turn- ing the patient on his hands and knees with the belly- wall lax, and allowing the tumour to fall away from the aorta. The pulsation in an aneurism or " pulsating tumour " is quite unaffected by the position of the part ; that in a case of communicated pulse may be greatly altered by changes in its position which vary the pressure with which it rests upon the artery ; and it may therefore be asserted that whenever, in any par- ticular position of the parts, the tumour loses its chap, xviii.i PULSATING TUMOURS. 299 pulsation while the flow of blood through the artery, as shown by the pulse below, is not stopped, it is demon- strative proof that it is a case of communicated or extrinsic impulse only. 3. Compress the main artery of the limb above the swelling. This will in every case stop the pulsation, and by itself tells us nothing. But now notice (a) whether the swelling spontaneously col- lapses ; if so it plainly indicates a free communication between the artery and the swelling. (b) Then compress the tumour, and notice if and to what extent it yields to tlie pressure. Compressi- bility (or reclucibility) of a tumour shows that the tumour is partly fluid, and that it communicates with a vessel or some other cavity ; such a tumour may be an aneurism, aneurismal varix, pulsating synovial cyst (if near a joint), or meningo-encephalocele (if in connection with the head) ; the amount of the tumour that is irreducible will form a guide to the amount of solid matter in the tumour, whether blood- clot or brain ; if the tumour be entirely unyielding to pressure or wholly irreducible, it may still be an aneu- rism nearly or wholly solidified, or a " pulsating tumour," or a tumour with communicated pulsation not opening into a cavity. (c) Then remove the compression from the artery, and notice how the pulsation returns in the swelling. If the tumour be again filled out in two or three strong bounding beats it indicates an escape of blood from the vessel into a partially empty cavity, such as an aneurismal sac. If, on the other hand, the pulsation at once returns as before, gently, without forcible bounds, and simultaneously over the whole swelling, it indicates that it is due solely to the move- ment of blood in the arteries, and that the pulsation is either communicated or that of a " pulsating tumour." It is to be remembered that in the cases of aneurism SURGICAL- DIAGNOSIS. tchap. xviii which an- not compressible pulsation may return at once with its usual force. Should the tumour be re- duced by pressure but return to its normal size while the compression of the artery is still kept up, it shows that the swelling is not an aneurism; this may be observed in cases of reducible pulsating synovial cysts. Some cases of encephalocele have an impulse and are partially reducible within the cranial cavity, the pulsation becoming more marked as the reduction is accomplished. 4. Compress the artery beyond the swel- ling, and if an aneurism, its size and tension will be to some extent increased ; a " pulsating tumour" will be unaffected by such pressure. 5. Examine carefully in all these cases to deter- mine whether there is any mobility of the swel- ling apart from the neighbouring artery* Arteries admit of a limited amount of lateral move- ment, but of none in their length, and therefore having relaxed as far as possible all the fasciae and muscles of the region, the surgeon should try whether the swelling under consideration is movable in the line of the artery. When this mobility is present it is very strong evidence of the pulsation being communicated ; on the other hand, some swellings with communicated impulse are quite immovable, e.g. abscesses over arteries. " Pulsating tumours" are immovable because of their growth from bone. As examples of the great diagnostic value of this sign may be mentioned the rise and fall of a thyroid swelling during degluti- tion, which absolutely distinguishes it from a carotid aneurism, and the mobility of enlarged glands in the ham when the knee is flexed ; some abdominal tumours may be moved from over an artery, and so lose their pulsation. 6. Attempt to reduce by compression the swelling without compression of the main artery above. Chap. xviii.] PULSATING TUMOURS. 301 This manipulation, like all the others, must be carried out with great gentleness and care. If successful it shows that the reduced part of the swelling is not an aneurism, and also that it is fluid, and further, that it communicates with a cavity such as the cranium or a joint. By this sign, then, we can diagnose a sy no vial cyst communicating with the knee-joint and with com- municated pulsation, from a popliteal aneurism, or an encephalocele from a " pulsating tumour " of the cranium. Part of a pulsating swelling may be thus reducible in the case of two tumours of different nature blended into one swelling. 7. Examine for a bruit and a thrill, feel the pulse beyond the swelling, and the outline of the swelling whether denned or not j examine the condition of the superficial arteries and the heart (see page 265), and enquire carefully into the history of the affection. It is necessaiy to remind the surgeon that all manipulations of an aneurismal tumour should be con- ducted with the utmost gentleness and care, and that when once the diagnosis of an aneurism has been made no further manipulations of the part are justifiable ; it is not intended that all the above procedures are to be gone through in every case of pulsating swelling. The surgeon has to answer the question, Is the swel- ling an aneurism 1 and it is only when that question cannot be at once answered in the affirmative that such varied and prolonged manipulations are necessary to clear up the diagnosis. It may be well to state here that an aneurism may lose its pulsation (a) from solidification of its contents, (b) from occlusion of the mouth of the sac by coagu- lum, (c) by compression of the artery iab$v by the sac, (d) or by its rupture and diffusion, which may take place slowly, the blood clotting in the tissues, or rapidly and even suddenly, the blood infiltrating the tissues far and wide. 302 SURGICAL DIAGNOSIS. tchap. xvm. We will now briefly describe the diagnostic signs of the individual pulsating swellings. 1. If, in a person with signs of general arterial degeneration, an elongated pulsating swelling be found in the position of one of the large arteries, which tapers at each end into the artery, and the pulsation in which diminishes towards each end and has only a slight lateral extent, it is a fusiform aneurism. 2. An ii-regular compressible swelling, obviously formed of tortuous and sacculated tubes, with marked expansile pulsation, and loud systolic bruit, is a cirsoid aneurism. This affection is most common in the scalp and the hands, though it may occur in deeper situa- tions, as the orbit and iliac fossa. Sometimes con- genital, it is more common before than after thirty years of age. As it grows it extends superficially, and does not exhibit a tendency to form a globular tumour. The skin covering the swelling is hotter than the sur- rounding skin ; it may be thickened, but is often thinned, inflamed or ulcerated. The arteries leading to the swelling are often found dilated and tortuous. 3. If the vein or veins of a part be found greatly dilated, with expansile pulsation, well-marked thrill, and a loud rasping or hissing continuous murmur, increased in intensity at each cardiac systole, this murmur being conducted along the veins for some distance, it is an aneurismal varix. If, in addition to these signs, there be a more or less distinct tumour at the spot where the murmur is most intense, fixed to, but distinct from, the artery and vein, with ex pansile pulsation, compressible, it is a varicose aneu- rism. These diseases generally follow an injury, though at an interval of many years. The bruit is not uncommonly so loud as to be audible to the patient, and sometimes even to bystanders. The two affections are also known as arterio-venvut aneu- rism. Chap, xviii.j ENCEPHALOCELE ANEURISM, 303 4. A congenital sessile tumour fixed to some part of the skull, more or less globular in shape, becoming fuller and tenser during strong expiratory efforts, par- tially reducible within the skull, fluctuating, with more or less well-marked expansile pulsation, is an encephalocele. These tumours are most frequent over the middle of the occipital bone, then at the root of the nose, or at either fontanelle ; but they may occur in connection with the base of the skull projecting into the pharynx. Pulsation may be absent owing to the amount of fluid in the sac (meningo-encephalocele), and they are veiy generally, but not always, associated with hydrocephalus. (See page 385.) 5. A circumscribed globular or ovoid tumour over a large or medium-sized artery, immovable apai-t from this vessel, with expansile pulsation in every part, unmodified by position, collapsing to some extent when the artery above is compressed, and then yield- ing to pressure, filling out again when the compression is removed with a single, or two or three strong bounding pulsations, becoming a little tenser and fuller when the artery below is compressed, with a well-marked bruit conducted along the artery, and a thrill, the pulse in the artery beyond the swelling being retarded, smaller and of less tension than in the corresponding vessel of the sound side, is a saccu- lated aneurism. Should there be a history of an injury or strain, of alcoholism, syphilis, or gout, or of a sense of something giving way at the seat of the swel- ling; and should the heart show signs of hypertrophy while the arteries show signs of general degenerative disease, this diagnosis will be confirmed. An aneurism may not be compressible if there be a great deposit of clot in its cavity, although there will be slight modifi- cation of tension produced by compression of the artery above or below. Bruit and thrill may both be absent, but not often. If punctured, bright-red blood spurts 304 SURGICAL DIAGNOSIS. [Chap. xvm. out in jets as from a wounded artery. If it be noticed that the aneurismal tumour becomes more clearly de- nned, firmer, with a less superficial and a less clearly expansile fluctuation, while it is less compressible and reducible, it indicates the gradual obliteration of its cavity by clot. When the tumour is firm, incompressi- ble, and exhibits a heaving and not an expansile pulse, [it shows that the aneurism is entirely obliterated, but the artery on which it is placed is pervious. Such a tumour, if seen for the first time in this condition, would have to be distinguished by its fixity to the artery from an independent solid tumour over the vessel. When all pulsation ceases in the firm contracting tumour, it shows that the artery also is obliterated. Should it be found that the tumour grows somewhat rapidly, and that its outline becomes less defined and its pulsation less distinct, a small rupture of the sac or bursting of the aneurism may be recognised. But if either spontaneously, or after some injury or strain, the tumour become greatly and rapidly increased in size, with an entire loss of its clearly-marked outline, an alteration in the tone of its murmur, and it be in- compressible and unaltered in tension by compression of the artery above, with great weakening or loss of its pulsation, loss of pulse in the arteries below, ecchy- mosis of the skin, with rapid cedematous swelling, it is to be recognised as a ruptured or diffused aneurism. 6. If a tumour fixed to a bone have an expansile pulsation which is uniform or present in certain situations only, and is unmodified by position, and if it neither collapse nor be compressible when the artery above is pressed upon, the pulsation returning at once when the pressure is removed, and do not become more tense when the main artery below is compressed, it is a "pulsating tumour" If the tumour have been first noticed away from the chap. Xvni.] TUMOURS OVER ARTERIES. 305 site of a main vessel, or have shown piilsation only late in its history, if the bone can be traced over its base or surface for any distance, if there be " egg-shell crackling," or spontaneous fracture of the bone, a fungous protrusion of the tumour through the skin, or other growths in different parts of the body, the diagnosis is rendered much more certain. These tumours are often of irregular outline and of varying consistence at different places ; a soft blowing mur- mur may be heard in them. 7. If a tumour be found over a large artery, with a heaving impulse, neither collapsing nor compressible when the artery above is controlled, nor increasing in tension when the artery below is compressed, and if the impulse at once return in its original force on removing the pressure upon the vessel, and if there be no murmur, or a systolic murnrar not of the blowing character met with in aneurisms, and es- pecially if the pulsation be lessened or lost with altera- tion in the position of the tumour, or it can be moved apart from the artery, it is a solid tumour over an artery with communicated pulsation. A bruit and thrill are usually absent in such cases, as well as the charac- teristic alterations in the arterial pulse beyond the tumour ; but each may be met with or may be pro- duced by pressing the tumour more firmly against the vessel. Should the tumour fluctuate, and be incom- pressible and immovable, with an ill-defined outline, unaltered except in the one matter of pulsation by control of the artery on the cardiac side, and especially if there are signs of inflammation in the part (redness, heat, pain, fever), it is an abscess over an artery with communicated pulsation. If, however, the tumour, with these general characters, be found to be com- pressible and reducible, whether the artery above is controlled or not, and it till out again gradually are not per saltum, a reducible tumour over an artery, u 13 306 SURGICAL DIAGNOSIS. [Chap, xviil. which, if in the ham, will probably be found to be a synovial cyst, is to be diagnosed. A cyst over an artery not communicating with a joint or other cavity resembles an abscess, except that it is more denned in outline, very chronic in its course, without signs of inflammation ; it may be translucent, or situated in some part, e.g. the thyroid gland, in which cysts are common. 8. If, after an injury or strain, an ill-defined swelling suddenly or rapidly develop over a large artery, with expansile pulsation, rough bruit, and thrill, with gradually increasing tension and cutaneous ecchymosis, and the tumour be not compressible when the artery above is controlled, and there is abolition of the pulse and venous obstruction with oedema below the swelling, it is a ruptured artery. If an aneurismal swelling suddenly and rapidly increase, losing its clearly-marked outline, with an alteration in the tone of its murmur, and the other signs mentioned above, it is a diffused or ruptured aneurism. If the case be seen for the first time when the aneurism has ruptured, the diagnosis between a ruptured artery and a diffused aneurism Avill rest upon the history ; in the one case an injury or strain, in the other a history of a swelling of some long standing, in which the patient has perhaps noticed a " beating " neuralgic pain down the limb from pressure on the nerves, or venous distension from pressure on the veins, and the vessels may be found atheromatous and the heart hyper- trophied. As regards the abolition of the pulse in the arteries below an aneurism, it must be remembered that while this, when taken with other signs, is a most characteristic sign of a ruptured artery or diffused aneurism, alone it must not be depended upon, for it may be caused by the gradual growth of an aneurismal tumour compressing and then obliterating the mouth of an artery, or by plugging of the artery by chap, xviii.] TUMOURS OVER ANEURISMS. 307 a portion of clot displaced from the sac. Where an artery is ruptured completely across, or an aneurism ruptured by a large aperture, the tumour is devoid of pulsation. 9. The diagnosis of abscess or other tumour associated with aneurism is fraught with great difficul- ties. The presence of an abscess will have to be determined by the usual signs of that affection, the ill-defined swelling, fluctuation, redness, heat, severe pain, and pyrexia. The association of aneurism with it may be suspected from the history of the case, and the suspicion becomes confirmed if a blowing bruit be detected ; and if, in addition to that, it be found that the swelling collapses somewhat, and is compressible when the artery above is controlled, and then fills out again with successive thuds when the compression is removed, the diagnosis of abscess aver an aneurism becomes certain. If one part of a pul- sating swelling be found to be more or less clearly mai-ked off from the rest, and to have a heaving and not an expansile impulse, to be unyielding when the artery above is compressed, and to be movable apart from the rest of the swelling, a solid tumour over an aneurism is to be recognised. Should a swelling with these general characters be found to fluctuate (there being no signs of inflammation), and especially if it be found compressible quite apart from controlling pressure on the artery above, and that it fills out gradually, a cyst and aneurism must be diagnosed. Finally, it is to be pointed out that in every case of swelling over an artery careful auscultation is to be practised to determine whether the soft blowing murmur so characteristic of aneurism is present, and in no case is a diagnosis to be arrived at until aneurism has been excluded. Careful punc- ture with a fine-grooved needle may be of use in diagnosing the more difficult cases. CHAPTER XIX. THE DIAGNOSIS OF SWELLINGS IN CONNECTION WITH BONES. IN this chapter it is intended to discuss the diagnosis of that large and very important group of swellings which are fixed to, and immovable apart from, bone. In the case of deep and infiltrating tumours of the soft parts great care may be required to distinguish them from tumours growing from and adherent to the bone ; but the dia'gnosis is of great importance, as the treatment in the two cases might and probably would seriously differ. It may be quite impossible to distinguish between some swellings connected with bone, and those of similar nature immediately sur- rounding the bone, as e.g. between a periosteal and parosteal abscess, and between a periosteal and paros- teal sarcoma ; and it is only by an exploratory incision into the swelling that the diagnosis can be made with certainty. The special tumours of particular regions, such as spina bifida, tumours of the jaws or the skull, will be discussed in the chapters on regional diagnosis. Having determined that a given swelling is connected with the adjacent bone, the surgeon should proceed with his examination in the following way. 1. Ascertain the history of the swelling. First, whether it is traumatic or spontaneous, then whether it is acute or chronic, and finally whether it has con- tinuously enlarged, remained stationary, or receded. Traumatic swellings may be dislocations, fractures, haematomata, inflammatory, or neoplastic, for an injury may be the true starting point of a tumour- growth, or a tumour may only become apparent when chap, xix.] MULTIPLE TUMOURS OF BONE. 309 some trivial injury has broken across the thin shell of surrounding bone, as in cases of central sarcoma of the shaft of a bone; where a history of injury is given, care must be taken to ascertain whether there were any symptoms, such as local pain, previous to the injury, and whether the injury is a sufficient explana- tion in itself of the subsequent course of events. Spontaneous swellings are inflammatory, neoplastic, and diathetic. The acute specific fevers are liable to be followed by inflammatory swellings of the peri- osteum. Acute swellings are either the direct results of injury (dislocation, fracture, effusion of blood), or inflammatory. Chronic swellings may be the secon- dary results of injury, such as the thickening round a badly-set fracture, inflammatory, neoplastic, or diathetic. Swellings that progressively enlarge may be inflammatory or neoplastic ; very rapid steady growth is a sign of inflammation, while steady enlargement over a long period and to a great size is a frequent and sometimes very characteristic feature of new growths. Stationary swellings may be the result of injuries, of chronic inflammation, or some forms of benign tumour. Iteceding swellings are always inflammatory or the result of injuries, as e.g. callus round a fracture, and nodes. 2. Examine the tumour and ascertain the following facts : (a) Whether single or multiple. Multiple swellings indicate the influence of a diathetic cause, as struma, syphilis, rheumatism, gout; or of infection, as in some cases of secondary sarcoma and carcinoma of bone ; multiplicity is also a frequent feature of some simple tumours, such as enchondroma and exostosis. Inquiiy should be made to ascertain whether the mul- tiple tumours originated simultaneously (pointing to some diathesis) or appeared successively, and at such a period subsequent to the formation of a first tumour as 310 SURGICAL DIAGNOSIS. [Chap. xix. to support the view of infection. When multiple, too, it should be noted whether the swellings are sym- metrical or not ; rachitic tumours are symmetrical, those of congenital syphilis generally are not. (6) Ascertain whether there are many of the usual signs of inflammation, such as local heat, redness, oedema, pain, tenderness on pressure, loss of function apart from gross mechanical causes, and fever with its attendant effects. This will, of course, have great in- fluence upon the diagnosis, as separating at once the large groups of inflammatory affections. The pain of inflammation of bone is usually (not always) a marked feature, and is of a deep boring or aching character, and is very often worse at night or under any influence increasing the local vascular engorgement. (c) Examine the consistence of the swelling, to determine whether it is solid or fluid, uniform or of varying consistence in different parts. Fluid swellings are either abscesses or cysts ; variation in the con- sistence of a swelling in different parts is a charac- teristic sign of sarcomatous tumours of bone, but may be caused also by inflammation at one part running on to suppuration. (d) Pulsation is a striking feature of some sarco- matous tumours of bone, and is never met with in other bony swellings. (See page 304.) (e) Notice the part of the bone affected, whether the epiphysis, the diaphysis, or the line of junction of the two. Rachitic, congenital syphilitic, rheumatic, gouty, chronic inflammatory processes, abscess and central sarcomata, affect epiphyses ; inflammation acute and chronic, sarcomatous, fibrous, and cystic tumours, attack diaphyses ; exostoses grow most often opposite the line of junction of the two parts. (f) Notice the relation of the swelling to the soft parts over it, whether infiltrating or merely displacing (inflammations and sarcoma infiltrate), and also the Chap, xix.] ACUTE SWELLINGS OF BONE. 311 shape of the swelling, whether enlarging away from the bone as an exostosis, or spreading along the bone as a subperiosteal sarcoma, or expanding the bone over it as a central sarcoma ; this may occasion egg- shell crackling. (o diagnosed. If the swelling of the cord be fluctuating, opaque, without impulse on coughing, immovable, irreducible, painful, tender, with the skin over it bulging, reddened and perhaps O3dematous, the part being hot to the touch and the general temperature raised, and the internal abdominal ring be free, the diagnosis of acute abscess of t/te cord should be made. If the swelling be elongated, rounded and smooth on the surface, opaque, fluctuating with a distinct expansile impulse on coughing, reducible into the belly through the inguinal canal but without any gurgle, it is a pelvic or abdominal abscess which has escaped along the spermatic cord. The abdominal or pelvic part of the abscess will be felt as a rounded, tense, fluctuating swelling with a distinct wave of fluctuation passing between it and the inguino-scrotal swelling. The abscesses which may thus make their exit are, psoas abscess, suppuration in connection with disease of the acetabulum, suppuration of the cellular tissue in front of the bladder, and abscess of the vesicula semiiialis spreading up along the vas deferens to the abdominal ring. In the female, abscess may spread from the pelvis along the round ligament. For the diagnosis of these various forms of abscess, see page 528, Chap. XL.] INGUINO-SCROTAL TUMOURS. 523 B. Solid tumours. Inflammation of the cord. Diffuse hydrocele of the cord. Diffuse haematocele of the cord. Lipoma of the cord. Malignant tumour of the cord. (1) If the onset of the swelling have been acute it is inflammation or hcematocele. If the swelling have come on independently of injury or strain, but in connection with urethritis, and the swelling be along the whole length of the cord, very painful, tender and firm, it is acute inflammation of the spermatic cord, which quickly spreads to the epididymis, and is rarely seen as an independent affection. If the swelling appeared suddenly after an injury or strain and was associated with superficial ecchy- mosis, be irreducible, without impulse on coughing, stationary in size, or gradually or intermittently en- larging, it is diffused luematocele of the cord. (2) The onset of the tiimour has been slow and gradual. If the tumour be of very slow growth or stationary, lobulated, freely movable under the skin and over the testicles, but loosely fixed to the cord, and if the tumour be irreducible, without impulse on coughing, opaque, and do not extend up to the in- ternal abdominal ring, it is a lipoma of the cord. If the tumour progressively and rapidly enlarge upwards along the cord, attaining a great size, be- coming fixed to the surrounding tissues, and at length to the skin over it, and be attended with enlargement of the iliac and lumbar glands, it is a malignant tumour of the cord (sarcoma or carcinoma). If the tumour be of small size, elongated, with a rounded contour, soft, pitting slightly upon pressure, it is oedema or diffused hydrocele of the cord. The swelling may have an impulse on coughing if it extend up to the internal abdominal ring, or may fluctuate at its lower part ; it is particularly seen after wearing a truss. 524 CHAPTER XLL DIAGNOSIS OP DISEASES OF THE GROIN. A. The affections of the skin. Intertrigo is common in the fold of the groin of fat corpulent people; for its diagnosis, see page 501. Mucous patches (see page 475) may be met with. B. Ulcers of the groin. The ulcers met with are the primary, glandular, and late venereal ulcers, and those formed by the breaking down of epithelial or other cancerous growths in the inguinal glands. If the ulcer be acute, with a depressed spongy base, sharply cut, irregular, worm-eaten or undermined edge, with abundant purulent discharge which irritates the skin around and produces similar ulcei-s when inocu- lated, it is a soft cJutncre. The diagnosis is confirmed by finding similar chancres on the genitals or else- where, or enlargement of the inguinal glands. If the ulcer be deep and uneven, with a soft spongy base, livid red greatly undermined edge, profuse purulent discharge which is inoculable and irritates the skin with which it is in contact, and if the patient have at the time a chancre on the genitals, or a recent cicatrix left by one, it is an ulcer due to the forma- tion and opening of a virulent bubo. If the ulcer be covered with a black or white slough adherent to the base, and rapidly extend in area and depth, with formation of new sloughs at first white and then black, with profuse sero-purulent discharge, livid red swelling of the skin around, great pain, and severe constitutional disturbance (rapid weak pulse, anorexia, thirst, dry brown tongue, and pyrexia) it is a slough- ing phagedcenic cliancre. This may be a complication of a simple chancre, or of a virulent bubo. Chap. XLL] 5/A r A? W THE GROlM. $25 If the ulcer spread slowly, advancing by one (often undermined) edge, healing at the other, and in this manner affect wide areas of tissue, leaving behind it as it travels a firm adherent white scar, mottled with brown patches, it is a serpiginous ulcer. If the ulcer be chronic, steadily progressing, with a very irregular base, being at places deeply excavated, at places nodular or fungating, with profuse foetid watery or sanious discharge, and the surrounding tissues be infiltrated and thickened or form a consider- able tumour, it is a malignant ulcer. This may be a primary growth in the groin, or a secondary glandular infection subsequent to malignant disease of the genitals or of the lower limb. The surgeon should examine for enlargement of the iliac and lumbar glands. C. Sinus in the groin. The discharge should be examined for fsecal matter and urine ; a probe should be passed to determine the depth and direc- tion of the sinus ; the neighbouring parts, especially the spine, pelvis, genitals, and hip joint should be examined. Sinuses may be divided into superficial (those not under the deep fascia) and deep (those running through the deep fascia). The sinus is superficial. If the sinus be covered with thin livid skin, unattended with much induration, and follow upon an acute abscess asso- ciated with gonorrhoea, chancre, an irritable sore 011 the heel or foot, or a strain, it is a sequel to a simple bubo. If the sinus be irregular, multiple, running in a mass of indurated glands in which the individual glands are not to be distinguished ; and if it be the sequel to a slow, painless enlai-gement of these glands with very chronic suppuration, the disease is known as scrofulous bubo. (See page 528.) 526 SURGICAL DIAGNOSIS. [Chap. XLI. Artificial anus is recognised by the faecal dis- charge, and by the continuity of the mucous mem- brane with the skin. (See pages 162, 454.) The sinus is deep. Faecal fistula. Urinary fistula. Dei-moid cyst. Morbus coxae. Necrosis of pelvis or femur. Pericaecal abscess. Iliac abscess. Psoas abscess. If the discharge contain faecal matter and flatus, it is & faecal fistula. This may follow upon strangu- lated hernia, or on the right side upon a perictecal abscess with perforation of the caecum. If the discharge contain urine, proved by the de- tection of urea (see page 161), it is an urinary fishda. The communication may be with the bladder, in which case the probe will pass over the brim of the pelvis ; but the fistula more often communicates with the urethra, in which case there will be other urinary fistulae in the perineum, and the probe will pass downwards and inwards outside the pelvis to the perineum. The escape of hair, teeth, foetal bone or masses of fatty matter and epithelial debris, would show it to be a sinus in connection with a dernwid cyst. If the probe pass towards the acetabulum or along the inner surface of the pelvis and there be evidence of hip disease (see page 365) there will be no diffi- culty in associating the sinus with the joint disease. If the sinus pass down into the pelvis of a woman, and a vaginal examination show considerable indura- tion around the uterus, and especially if the illness followed upon parturition or mi scarriage or gonorrhoea, it is a sinus left from a pelvic abscess. If the probe strike bare bone, the diagnosis of ne- crosis will be established, and the surgeon must then determine, by the direction and length of the sinus, Chap. XLI.] ABSCESS IN THE GROIN. 527 where the sequestrum is ; if it be the femur, the se- questrum will move when that bone is moved at the hip joint. If the sinus open above Poupart's ligament, or below that ligament outside the line of the femoral artery, and extend upwards into the iliac fossa, it is the sequel of an iliac abscess ; and if on the right side, and the pus be foetid, and there be a history of consti- pation and bowel trouble preceding the abscess, the diagnosis of jwriccecal abscess may be made. Failing that, and failing to find necrosis of bone and disease of the spine or sacro-iliac joint, the diagnosis of simple iliac abscess must be made. (See page 529.) If the sinus open below Poupart's ligament internal to the femoral vessels, and run up into the belly, it is a sinus left by the opening of a psoas abscess. (See page 528.) D. Tumours of the groin. TJie tumour is flnid. Abscess. Cystic tumour. Varix. Aneurism. Hydrocele of hernial sac. If the swelling be accompanied with obvious signs of inflammation, either local or in some adjacent part, as the spine, the pelvis or the hip joint, or if the outline of the collection of fluid correspond with the sheath of a muscle, it is an abscess. (For further dis- tinctions between chronic abscess and cyst see page 295.) The abscess may be acute or chronic. When superficial to the deep fascia, and forming a prominent swelling in the groin, covered with more or less acutely inflamed skin, it is a bubo, which may be in connec- tion with the inguinal or the femoral glands, and arise in consequence of a sore on the foot or leg, gonor- rhoea, balano-posthitis, or soft chancre ; when, in con- nection with a soft chancre, a gland becomes acutely 528 SURGICAL DIAGNOSIS. [Chap. XLl. inflamed and rapidly runs on to suppuration, and on being opened itself shows all the features of a chancre, it is a virulent bubo. Where the inflam- mation is less intense and the pus forms around the gland, it is a sympathetic bubo ; and when the abscess is more chronic still, fluctuation appearing at several places in a large ill-defined boggy swelling, it is a scro- fulous bubo. (See page 532.) The deep abscesses are either femoral or pelvic, and the diagnosis is readily made by noting the position of the swelling, and the presence or absence of fulness, resistance, and fluctuation in the iliac fossa and time pelvis. Morbus coxca (page 365) is the most frequent cause of femoral abscess, and the surgeon should therefore examine the joint for signs of that disease. If, when fully flexed, movement of the joint laterally and in rotation be free and painless, and pres- sure upon the trochanter or lower end of the femur does not excite pain, but extension is painful and limited, a deep fluctuating swelling in Scarpa's triangle is suppuration in the ilio-psoas bursa. (See page 371.) When, with signs of morbus coxae, the swelling occupies the fold of the groin and bulges above that fold, it points particularly to disease of tJie acetabulum. If the swelling be mainly in the belly, along the course of the psoas muscle, and be pointing in the thigh internal to the femoral artery, and there be a wave of fluctuation between the two parts of the swelling, and a distinct impulse in the femoral swelling when the patient coughs, it is a psoas abscess. To discover the cause of a psoas abscess, examine the spine for caries (page 397), the sacro-iliac joint, and the chest on the same side for fluid in the pleura ; examine the urine for pus, albumen, casts, blood, gravel or crystalline deposit, and enquire for a history of attacks of pain shooting from the loin into the gi-oin and testicle. Chap. XLI.] PSOAS AND ILIAC ABSCESS. 529 Caries of the spine is the most common cause of psoaa abscess ; an empyema may burst into the sheath of the muscle and point at the groin, as may also a perinephritic abscess whether primary or secondary. An abscess from sacro-iliac disease may form in the psoas muscle. In some cases neither of these causes is to be made out, and the suppuration may be as- cribed to an injury to the muscle or to a primary psoitis. If the abscess fill out the iliac fossa, and project above Poupart's ligament near the iliac crest, with or without a part extending beneath that ligament to the thigh outside the femoral vessels (this femoral swelling having an impulse 011 coughing, being in part or in whole reducible, and having a wave transmitted to it from the swelling in the belly), it is an iliac abscess. This may be connected with disease of the sacro-iliac joint or spine, necrosis of t/ie ilium, injury, inflammation or ulceration of the caecum, or rupture of part of the muscle. Perityphlitis will be recognised by the abscess filling out the right iliac fossa, and not spreading down into the thigh, for the pus is not beneath the iliac fascia; there may be emphysematous crackling of the swelling, or a tympanitic percussion note which will render the diagnosis very certain. The author recently saw a faecal abscess in this situa- tion following a blow in the groin. Where an abscess pointing in the groin is asso- ciated with symptoms of pelvic mischief, a careful examination should be made of that cavity per anum or per vaginam, and where a swelling is found with a wave of fluctuation passing from it to that in the groin, it will be recognised as a pelvic abscess. Pelvic cellulitis is much more common in women than in men. These abscesses may point in the inguinal canal and pass into the scrotum (page 522). If the swelling be placed below the fold of the n13 53 SURGICAL DIAGNOSIS. [Chap. XLI. groin internal to the femoral artery, be smooth, and rounded in outline, compressible and easily reducible by direct pressure, and reappear from below when pressui'e is made just above it, it is a varix of the saphena vein. A.ny of the superficial veins of this region may be varicose. (See page 295.) If there be a history of a femoral hernia (see page 464), and this have been succeeded by a tense fluctua- ting swelling at the same situation, without cough- impulse, not reducible, and there be no signs of stran- gulated hernia, it is a hydrocele of the sac of a femoral /ternia. This is very closely simulated when a small knuckle of intestine is nipped in the femoral ring, and the .sac beyond becomes distended with fluid ; there will, however, be the signs of intestinal ob- struction to guide the surgeon. Hydrocele of the sac may be attended with constipation and vomiting. If a tense fluctuating swelling be found occupying the inguinal canal, without signs of intestinal ob- struction, it is an encysted hydrocele of the cord. (See page 521.) If the tumour be congenital or first noticed in early life, be soft, lax, irregular in outline, more or less adherent to the surrounding tissues, stationary or slowly enlarging, and perhaps attended with attacks of inflammation from time to time, it is a cystic hy- groma. If the tumour be chronic, adherent to the skin, fluctuating, tense, globular in shape, painless 4 and free from tenderness, it is a sebaceous cyst. (For the diagnosis of pulsating tumours, see chapter xviii. ) The tumour is solid. It may be a hernia, an imperfectly descended testicle, or a solid enlarge- ment of one or more of the tissues of the part. If there be congenital absence of the testicle from the scrotiim, and an ovoid firm tumour of about the MISPLACED TESTICLE. 531 size of the testicle be felt in the inguinal or crural canal, or in the iliac fossa close to Poupart's ligament, and especially if pressure upon it cause the peculiar "testicular sensation," it is an undescended testicle. If an undescended testicle be not in either of these situations it may be found in the perineum. The testicle may be fixed or may slip up and down the inguinal canal and give a thrusting impulse on coughing. Hernia is often associated with this condi- tion ; a softer consistence, a gurgle, a tympanitic per- cussion note, or a granular feel, together with true reducibility and expansile impulse, will distinguish it from the testicle. A misplaced testicle may be acutely inflamed, or the seat of malignant disease. The congenital absence of the testicle from the scro- tum on the same side will be the key to the diagnosis. An inflamed retained testicle may simulate a strangulated hernia, and the latter may coexist with an undescended testicle. In orchitis, the local pain and tenderness are greater than in hernia ; if there be nausea and vomiting the latter does not become stercoraceous, nor is it urgent, and the constipation is not absolute, while the general symptoms are febrile. The surgeon may also find an urethral discharge, or a history of direct violence. If, therefore, the suspected tumour be tense, well defined, with dragging pain referred to the umbilicus, moderate tenderness, urgent vomiting which becomes stercoraceous, and ab- solute constipation with signs of collapse, the diagnosis should be strangulated Jiernia. Having excluded this condition, the inguinal and crural canals should be examined for hernia. (See page 463.) It is only needful here to refer to hernia of the ovary into the inguinal canal (it may pass into the labium), which is recognised by the presence of a small ovoid tumour which swells and becomes painful at each menstrual period, and by the absence of the 532 SURGICAL DIAGNOSIS. tchap. XLI. ovary in the pelvis, as proved by bimanual examina- tion. A swelling deep under the origin of the adductor muscles, and fixed to the pelvis, may be an obtiirator liernia. (See page 464.) The lymphatic glands are arranged in two sets in superficial fascia, one along Poupart's ligament (in- guinal), the other along the saphena vein (femoral), and there is a deep gland occupying the crural canal ; by pressure in the iliac fossa the deep inguinal (or iliac) glands when enlarged can be felt along the ex- ternal iliac artery. The position and the outline of the swelling, together with, in most cases, some local cause of infection in the urethra, penis, scrotum, perineum, buttock, groin, or lower limb, or the co- existing enlargement of other groups of glands, will enable the surgeon to diagnose a glandular swelling. (See page 283.) When many glands are moderately enlarged, firm, quite movable under the skin and over the deep fascia, without pain, tenderness, or other obvious sign of inflammation, they are known as in- dolent buboes; these are met with following hard chancre, and are sometimes spoken of also as amygda- loid. When a gland is enlarged, painful, tender, fixed to the skin and deep fascia, and its outline, owing to sur- rounding oedema, is ill-defined, and a source of infection such as a sore on the toe, gonorrhoea, or a soft chancre is found, it is known as a sympathetic bubo ; the skin over it is hot and reddened, and there is a tendency for the gland to suppurate. Exactly similar enlarge- ments are sometimes seen as the result of strain and over-exertion. If the swelling spread from gland to gland, and they are massed together into one irregular tumour, which slowly enlarges and then softens and fluctuates at places, it is a scrofulous bubo; this condition may be started by infection, simple or chap.xui.] PAIN IN URINARY DISEASES. 533 syphilitic. In some cases of malignant disease the glands are enlarged from simple irritation, and the swelling subsides when the primary tumour is re- moved. Of the remaining tumours in this situation it is only necessary to point out that a hard swelling in the adductor muscles, close to the pubes, chronic and painless, is a " rider's bone" or an ossification of the tendon of the adductor longus or magnus muscle. " Rider's sprain " (see page 35) may occasion a consider- able firm swelling in the adductor muscles, lasting some time after the injury. Lipoma may be met with in the superficial fat, and enchondroma or sar- coma may be found growing from the pelvis or thigh bones, and the latter also from the fascia and mus- cular aponeurosis. (See chapters xvi. and xix.) CHAPTER XLIL DIAGNOSIS OF DISEASES OF THE URINARY ORGANS. IN investigating any case of disease of the urinary organs the surgeon should proceed systematically, for this will both guard him from error and economise time. Although the symptoms and signs of these affections are numerous, they may all be grouped into four classes, and the surgeon should con- duct his examination in four directions. He should first investigate the patient's pain, then study the act of micturition, then examine the urine passed, and, lastly, proceed to investigate directly the urinary passages, tJie bladder, and the kidneys. I. Pain is associated with nearly all diseases of the urinary organs. It owns the same causes and has 534 SURGICAL DIAGNOSIS. [Chap. XLII. the same general significance here as elsewhere, but the seat, time, and character of the pain are of con- siderable diagnostic importance. Pain may be either local, i.e. produced at the painful part, or referred, i.e. produced at a distance. The referred pains are recognised by the absence of all other signs of disease at the painful parts, and also by the special seats of these pains. They are experienced at the end of the penis, usually just behind the glans, which is found quite normal, being "referred" there from the neck of the bladder; or they are felt in the testicle, groin, and down the thigh, being " referred " to these regions from the kidney, the pelvis of the kidney, and the ureter; this is commonly associated with marked re- traction of the testicle. These " referred pains " are especially caused by the irritation of calculi and other foreign bodies. In children the pain " referred " to the end of the urethra is shown by the patient pulling at the penis, often drawing out the foreskin to a considerable length, or by scratching at the vulva. Of the local pains it is only necessary to say that pain in the prostate is felt in the perineum and rectum, and is excited by the passage of large and hard motions, or by the contact of the finger in the rectum ; pain in the bladder is felt above the pubes, deep in the perineum, and also extending to the groins, and rcmnd the back to the sacrum ; renal pain is felt in the loins. When the pain is felt. The pain may be sponta- neous, i.e. quite independent of movement on the part of the patient, of micturition, erection, or defeca- tion ; such pain may be due to inflammation of the organs, to the contact of foreign bodies and calculi, to the growth of tumours and to over-distension. Many painful conditions do not give rise to " sponta- neous pain." When pain is increased during mictu- rition it shows that either the contraction of the Chap.XLii.] PAIN IN URINARY DISEASES. 535 bladder or the passage of the urine along the urethra is painful, and we therefore have this symptom in acute cystitis, acute prostatitis, urethritis, and stricture of the urethra, and sometimes also in phymosis. . When pain is increased at tJie end of micturition it shows that the contraction of the bladder down iipon its neck is painful, and we therefore meet with this in stone in the bladder, in prostatitis, and in ulcer and fissure of the neck of the bladder. A dragging pain in the bladder, felt only at the end of mictu- rition, may be caused by adhesion of the bladder to surrounding structures : the diagnosis will be assisted by evidence of pelvic cellulitis or peritonitis. Where pain is diminished after micturition it points to the contact of the urine with the bladder, or the distension of that organ as the cause of the pain, and this we see exemplified in acute cystitis and in re- tention of urine. Nearly all pain is increased by movement, but where this is a marked symptom it points to the cause of the pain being a movable body, and hence we find this especially in cases of stone in the bladder and in the pelvis of the kidney. Adults are usually able to give clear information on this point at once, as they have noticed the influence upon their sufferings of a railway journey, or a ride in a rough cart, or coming downstairs. In children the same thing is shown by the patient avoiding rough games or any unnecessary movements, or crying when made to move, and it may be tested by getting them to jump down from a table and chair ; if they do this freely and without any sign of pain, stone in the bladder may be excluded with almost absolute cer- tainty. When the pain is increased by defoecation it shows that the painful part is at the base of the bladder or the prostate, as in prostatic inflammation. The pain is, of course, more marked when the motions are large and hard. Erection of the penis causes pain, either 536 SURGICAL DIAGNOSIS. [Chap. XLII. by stretching an inflamed urethra, by adding to the congestion of an inflamed prostate, or, when part of the erectile tissue cannot expand, by the great tension to which it is subjected. It is an indication, therefore, of urethritis, of prostatitis, or of an obliteration of part of the corpus spongiosum or corpus cavernosurn. When due to stretching of the urethra, a tight pain is felt all along the under surface of the penis, and the organ is more or less curved down ; when due to prostatitis, the erection of the penis is perfect, and the pain is felt deep in the perineum ; when due to obligation of part of the erectile tissue, the penis is sharply bent to one or other side or directly downwards. This symptom is commonly known as clwrdee, although this term should only be used when the penis is bent, as well as painful in erection. The character of tJie pain. The pain of acute in- flammation is described as sharp, pricking or smart- ing, while that of chronic inflammation is of a dull aching character ; that due to foreign bodies or cal- culi is more often spoken of as sharp, cutting or burn- ing ; a straining pain, or " tenesmus," which may be very severe, is particularly experienced in acute cystitis and in foreign bodies in the bladder. When pain becomes throbbing in character it is an useful indication of suppuration having occurred. Severe colicky pain in the loin and shooting down to the groin and testicle attends the impaction or passage of a calculus in the ureter. II. The act of micturition. In health, when the urine has distended the bladder to a certain extent, a stimulus is transmitted to a centre in the lumbar enlargement of the spinal cord and there reflected along motor nerves to the muscular coat of the bladder, and at the same time the contraction of the sphincter muscles is inhibited. This reflex centre ia under the control of the will, and the act can be THE ACT OF MICTURITION, 537 excited or inhibited by the will, which also increases the expelling force by throwing into contraction the abdominal muscles. The resistance to be overcome is that offered by the urethra, and the shape of the issu- ing stream is determined by the meatus urinarius. A knowledge of these facts enables us to understand how the act may be modified. Nearly all the affections of the ui-inary organs cause frequency of micturition. This may be caused by increased stimulation of the bladder by acid urine, or by calculi and foreign bodies; by undue irritability of the bladder, as in all forms of cystitis, and also prostatitis ; by a small size of the bladder, so that a few ounces of urine distend it ; by failure to empty the bladder, when, as in the last case, the addition of a small quantity of urine to that re- tained in the bladder distends it to the full ; by irrita- tion of otJier parts of the urinary apparatus, as in renal inflammation and calculus, urethritis, and phymosis ; by instability of the centre in the spinal cord whereby it responds to stimuli of too feeble force ; this is seen in the nocturnal " incontinence " of children, and in the effects of sexual excess ; and, lastly, by stimuli from the brain, as in some cases of hysteria and some forms of " nervousness." The frequency due to the irrita- tion of calculi and foreign bodies is increased by move- ment ; that due to over-distension of the bladder and atony is increased by rest, and is therefore more marked at night. Micturition should be a conscious act ; it may be unconscious, through an interruption in the path of sensation in the cord (see page 102), or through the reflex centre responding to a stimulus not powerful enough to excite sensation, as is seen in the nocturnal " incontinence " of children ; or by the bladder leaking, as occurs in cases of great over-distension from atony, when the sphincter action is interfered with and urine leaks or dribbles out into the urethra ; this leaking must 538 SURGICAL DIAGNOSIS. [Cha P .xui. be distinguished from the expulsive act of micturi- tion. Unconscious micturition is often spoken of as " involuntary." The surgeon must not mistake fre- quency of micturition or unconscious micturition for "incontinence of urine," a condition of extreme rarity only met with in extroversion of the bladder, large recto-vesical or vesico-vaginal fistula, and in paralysis. The force of the stream depends upon the expelling power of the bladder and abdominal muscles, and the obstruction offered by the urethra ; this force is esti- mated by the distance to which the stream can be propelled from the body. It may be increased by very powerful contraction of the bladder, as is sometimes seen in vesical calculus ; it is far more often dimin- ished by atony of the bladder, hypertrophy of tlie prostate or tiyht stricture. The size and shape of the stream depend upon con- ditions in the urethra. Where there is stricture the stream may not fully distend the meatus, and then will not be shaped by it, but may be twisted or bifid. The stream may be reduced to a mere succession of drops. The duration of micturition is increased by stric- ture, by atony of the bladder, and by enlarge- ment of the prostate. Patients often complain of a difficulty in beginning to pass water, this is owing to an interference in the nervous mechanism ; a difficulty in " leaving off," or a dribbling continuing after the close of the voluntary act is seen in cases of over-dis- tension of the bladder with " residual " urine. A sudden interruption in the act is a very rare symptom caused by a stone in the bladder blocking up the neck. The escape of urine from other orifices than that of the urethra is evidence of urinary fistula, which will be named according to its position, viz. perineal, scrotal, rectal, vaginal, etc. Chap.XLii.] RETENTION OF URINE. 539 Retention of urine is a condition characterised by inability to empty the bladder. It may be com- plete or partial, and as the latter is often associated with involuntary or frequent micturition, it is over- looked by the patients, and may be mistaken by the surgeon unless he remember that " dribbling arises from overflow " in the vast majority of cases. Com- plete retention has only to be distinguished from sup- pression of urine, rupture of the bladder, and extrava- sation of urine. It is characterised by the presence of a full bladder, as felt per rectum and above the pubes, and usually by a painful desire to pass water, while the introduction of a catheter is followed by the escape of a large quantity of urine, and relief of the pain. In the other conditions there is no bladder tumour, and on passing a catheter, either no urine, or only a few di'ops of bloody urine are drawn off ; or it may be impossible to get the catheter into the bladder when the uretha is quite torn through. In suppression of urine there are characteristic general signs, such as coma and convulsions ; in rupture of the bladder there is a his- tory of an accident or of long previous retention, with a sense of sudden yielding (see page 167), and in extra- vasation of urine there is the characteristic swelling. (See page 502.) Partial retention is characterised by frequency of micturition, by loss of force in the stream, and often by dribbling of urine or inability to prevent the escape of a few drops of urine during coughing or effort. These symptoms are worse at night ; after the patient has tried to empty his bladder the catheter draws off the "residual urine." The causes of retention are nervous, muscular, or obstructive. Nervous retention is caused by inhibition of the micturition centre by some strong stimulus, such as that caused by an operation on the rectum or uri- nary organs, or even any injury or operation, by severe 546 SURGICAL DIAGNOSIS. [Chap. XLII. pain in the act of micturition as in aciite urethritis, and also in hysteria. The retention sometimes seen in acute over-distension may be in part due to exhaus- tion of the lumbar centi-e. This form of retention is characterised by its suddenness, its completeness, its evident relation in most cases to an injury or operation, and the absence of all " obstruction." Muscular reten- tion is due to over-distension of the bladder paralysing the muscle, to atony of the bladder, and perhaps to pros- tatic growths interfering with the action of the muscle. It is characterised by being chronic (except in cases of acute distension), generally partial, or attended with " dribbling," and by the feeble power with which the urine flows from a catheter ; indeed, the bladder may be quite unable to expel its contents, and the sur- geon may have to force out the urine by pressure above the pubes. Obstructive retention may be traumatic or idiopathic ; fracture of the pelvis, subpubic dislocation of the hip, and rupture of the urethra are the injuries leading to it. The idiopathic causes are calculi and foreign bodies blocking the passage, inflammatory swelling, or stricture of the wall of the urethra, and tumours pressing upon and blocking up the passage. The obstruction from calculi, etc., is sudden; from in- flammation it is acute and attended with other obvious signs, such as pain, swelling, and discharge ; from stricture or tumours it is chronic, or preceded by diffi- culty in micturition or diminution of the force or size of the stream. The history of the case and the age of the patient usually suffice to enable the surgeon to diagnose the case ; the previous occurrence of urethral discharge, or of a small or feeble stream, of pain after micturition, or renal colic, or the operation of lithotrity, is to be enquired for. In children, retention is most often due to impaction of a calculus ; in young men it is generally due to urethritis, prostatis or abscess ; in middle-aged men it is most often due to stricture Chap. XLII.] EXAMINATION OF URINE. 541 and in elderly men to hypertrophy of the prostate, or stone. III. The urine. A full consideration of the best modes and the diagnostic value of an examination of the urine would demand far more space than can be allotted here, and for this the reader is referred to the many well-known manuals on the subject, and especially to Ralfe's " Clinical Chemistry." An examination of the urine should consist of a quantitative estimate of the normal constituents of the fluid, and then of a search for any adventitious substances added to it, or for changes occurring in it before it is voided. Of the first we shall say nothing here, except to emphasise the fact that few observations are of greater clinical importance than the estimation of the daily excretion of urea. Urine is normally an acid fluid ; if passed alkaline it may be from an alteration of the secretion and dependent upon excess of fixed alkali, or from decomposition of urea into volatile alkali or carbonate of ammonia. The odour and general appearance of the urine will distinguish between these two states, and if a slip of test-paper discoloured by the alkali be gently warmed over a spirit lamp it will regain its original colour if the alkali be volatile, but will retain its new colour if the alkali be fixed. For purposes of quantitative analysis a sample from the whole amount of urine passed in twenty-four hours should be examined. For qualitative examination, the urine should be passed in three separate glasses, the first to contain the first two ounces passed, the next the great bulk of the urine, and the last few drops or so should be passed into a third glass. In the first glass will be bladder urine plus adventitious matters from the urethra ; in the second glass will be the average urine ; and in the third glass will be the urine plus any sedi- ments deposited in the bladder, or blood escaping at the end of the contraction of the bladder. 542 SURGICAL DIAGNOSIS. [Chap. XLII. Albuminuria may be due to the admixture of blood or pus with the urine, or to some coudition of the kidneys, their blood-vessels, or the blood, leading to a filtration of blood serum. Wherever albuminuria is unattended with the presence of blood or pus cells in the urine, it is due to some original fault in the renal excretion, and this is corroborated if "tube-casts" of any kind be found. And where the amount of albumen is out of proportion to the number of blood or pus cells seen, the same inference is to be drawn. For further information on simple albumi- nuria the reader must consult works on medicine. llii'iiiaturia is most certainly shown by the detection of blood corpuscles in the urine. The surgeon must first decide the source of the blood, whether urethral, vesical, or renal. If the blood escape involuntarily and independently of the act of micturition, or pass with the first few drops of urine only, or if the escape of urine be preceded by the passage of a long clot the size and shape of the urethra, the blood is urethral. The most common cause of urethral haemorrhage is injury, catheterism, etc. When the blood flows with the last few drops of urine, it certainly comes from the prostate or neck of the bladder, and its cause will be inflammation or congestion of the prostate or calculus. The history of the case, par- ticularly the existence of urethritis, gleet or stricture, the examination of the prostate or the passage of a sound will decide the diagnosis. In extensive bleeding from the prostate the blood flows back into the bladder, and it is not then to be distinguished from vesical haemorrhage except by other signs of prostatic disease. When the blood is not intimately mixed with the urine, but becomes more abundant towards the end of the act, or when the urine contains flat or irregular- shaped clots, or is reddish in colour, it may be assumed to be vesical hcenwrrhage. The causes of Chap.XLII.l H&MATURIA. 543 vesical haemorrhage are stone in the bladder, tumours of the bladder, acute cystitis, tubercular and cancerous ulceration of the bladder, rupture of a vesical varix, and perhaps haemophilia, purpura, and scurvy. The haemorrhage from stone is moderate and often veiy small in amount, intermittent, especially excited by exercise and accompanied by the characteristic pain, etc. The haemorrhage of vesical tumour is often very abundant, indeed, the source of the most abundant vesical haemorrhage is bladder tumour, especially "fimbriated papilloma,".of which it is the first and most marked symptom, and it is very characteristic for the urine to become more and more bloody as micturition proceeds, until at length pure blood is passed as the bladder contracts upon the growth. The haemorrhage of acute cystitis is moderate in amount and accompanied by intense pain and frequency of micturition, and the urine contains mucus and pus. In tubercular ulceration there are generally signs of tubercle in the kidney, prostate, testicle, or vesiculae seminales. The urine should be examined for bacilli. In cancerous ulceration there is often profuse haemorrhage at intervals, generally the patient has previously suffered from pain and frequency of micturition, and there may be cachexia. Vesical varix is a very rare condition characterised by occasional profuse haemorrhages, and only to be diagnosed when all other causes of haemorrhage can be certainly excluded. Other signs of purpura, scurvy, aud fuemophilia accompany bleeding from these causes. Where the blood is intimately mixed with the urine, there being no difference in colour in that con- tained in the three vessels, or if the urine have a smoky tint, or if there be long narrow clots ("casts" of the ureter), it is certainly renal in origin. Renal and prostatic haemorrhage may closely simulate vesical haemorrhage, and be only 544 SURGICAL DIAGNOSIS. [Chap. XLII. distinguishable from it by other signs of disease of these organs. Renal haemorrhage may be due to injury, acute inflammation, stone, tubercle, cancer, parasites, or blood changes. The history of the case decides whether it is due to injury. When due to inflammation, it is accompanied by excess of albumen, by tube casts, and is usually associated with oedema and other signs of blood change. Haemorrhage due to stone is chiefly characterised by its being increased by exercise or movement, by the pain, and sometimes by the passage .of gravel. Haemorrhage due to tubercle, is recognised by the detection of tubercle elsewhere, by fever, and by the admixture of pus with the blood. The haemorrhage of renal cancer may be very profuse or very slight ; the formation of a renal tumour leads to its diagnosis. The signs of haemophilia, scurvy, purpura, fever, and the causes of renal congestion are so apparent that the diagnosis of haemorrhage from these sources is easy. Haemorrhage as a part of chyluria, is recognised by the tibrinous coagula, the milky colour due to fat, and possibly by the detection of filarise in the blood. Pyuria. Pus is a frequent addition to urine, and is recognised by turbidity of the urine, by the presence of albumen and pus cells, and, when the pus deposits in quantity, by the fact that liquor potassae converts this deposit into a very ropy tenacious fluid. If the pus be found only in the first of the three glasses of urine, or escape from the penis independently of micturition, it is urethral, either due to catarrh of the mucous surface, or to abscess opening into the urethra. Small opaque threads and flakes passed with the first few drops of urine are evidence of gleet with lodging of the discharge in the deeper parts of the urethra. A sudden discharge of pus in the urine indicates the bursting of an abscess, the seat of which will be shown by swelling and pain ; if the act of micturition end in Chap, x LI i.] URINARY DEPOSITS, 545 the passage of a small quantity of pus, it points to suppuration in the prostate. The passage of very ropy muco-pus in alkaline foul-smelling urine shows that there is catarrh of the bladder; where the pus is in excess of the mucus it is called suppuration of the bladder. Pus without mucus in acid, undecomposed urine, is derived from the pelvis of the kidney, or more rarely, from an abscess opening into the bladder or ureter. Mucus is a normal constituent in urine : it is increased in amount in inflammation of any part of the urinary tract. Semen may normally be found in small amount in urine, but especially after a seminal emission. The passage of flatus or of fcecal matter recognised by the animal and vegetable fibres and cells as well as by its colour, consistence and odour, shows that there is a communication between some part of the alimentary canal and the bladder ; this condition is attended with extreme pain, sometimes by retention, and it always leads on to cystitis. The surgeon must endeavour to determine what part of the intestine opens into the bladder by the colour and consistence of the faecal matter. This communication may be a congenital malformation, but is more often due to cancerous ulceration,' to typhoid ulcer- ation, or to pelvic abscess : the history of the case clears up the diagnosis. For the diagnostic signifi- cance of bile in the urine, and of the various crystalline deposits, the reader must refer to other works. The passage of liair or of masses of sebaceous matter indicates the opening of a dermoid cyst into some part of the urinary apparatus. Echinoccus booklets have been found in urine and hydatid vesicles have been passed per urethram. Where the symptoms point to the presence of a tumour of the bladder, the deposit must be care- fully and repeatedly examined microscopically. The j j 13 546 SURGICAL DIAGNOSIS. [chap. XLII. presence of a large quantity of bladder epithelium or of irregular polynucleated cells corroborates the suspicion ; but if a villus or fragment of the growth can be detected, it establishes the diagnosis : such fragments are recognised by their shape and size, and especially by the regular arrangement of the epithelium, or by the detection of a capillary. The shreds may be found in the urine passed naturally, or one may be removed in the eye of a catheter ; but the best way to obtain them is, after emptying the bladder, to introduce an evacuating tube, and to wash the bladder out with warm water by means of an exhausting bottle. IV. Examination of the nrethra, prostate, bladder, and kidneys. A. The urethra and prostate. The orifice of the urethra may be found at the base of the glans penis (a very common defor- mity) or more rarely at the root of the penis, or in the perineum, the scrotum being split : these conditions are all varieties of hypospadias. The state of the orifice, and the presence of discharge, if any, are to be noticed. The orifice may be too small (stricture of tJie meatus), or warts, chancre or epithelioma may be seen on it. (See page 498.) Should the orifice be swollen and covered with a gummy discharge, and be the seat of itching and smarting, and these signs be noticed two to seven days after coitus, it is the initial stage of acute urethritis. If there be an abundant thick yellow or greenish discharge, and the penis be swollen, and the urethra feel hard and tender, there is acute urethritis; when the dis- charge becomes milky in colour, and the pain and swelling subside, it is called chronic urethritis; and if the discharge consist only of shreds voided in the first portion of the urine, or of a drop of gummy discharge at the meatus seen perhaps only in the morning, it is gleet. If the discharge be sanious, and Chap. XLII.J URETHRITIS PROSTATITIS. 547 an nicer is seen just within the orifice, it is a soft chancre. A sero-purulent discharge with little or no pain, associated with a firm lump in the urethra near the orifice, multiple enlargement of the inguinal glands, and followed by sore throat and a rash, is due to a hard chancre. Gonorrhoea is distinguished from other forms of urethritis by the long incubation period (from 2 to 7 days), and by the intensity of the symp- toms. A painless muco-purulent discharge is sometimes seen in secondary syphilis. Gouty, traumatic and non-specific urethritis are to be distinguished by the history and concomitant affections. Gleet may be caused by chronic urethritis or prostatitis, by a stricture, or an urinary fistula. Now let the surgeon pass his fingers back along the urethra to the perineum ; it is found swelled and tender in acute urethritis, or hard and knotty in severe stricture ; if a painful and tender ill-defined firm swelling be felt in the anterior perineum, it is a perineal abscess ; in its later stages fluctuation may be felt. A similar swelling with much surround- ing oedema may be found over the urethra where it is covered by the scrotum ; the pus being under the ejaculator urinse muscle, the abscess then points at the root of the penis. Then pass the finger into the rectum and feel the prostate ; if it be found acutely tender, hot and swelled, there is acute prostatitis, and if the swelling be soft and fluctuating it is a prostatic abscess. But if it be found enlarged, notice its size, outline and con- sistence. If the patient be over fifty-five years of age and the enlargement be firm and rounded, it is pro- bably hypertrophy of the organ ; but if the enlarge- ment be very great, or increase rapidly, be irregular in outline and consistence, and especially if there be hsematuria and enlargement of the pelvic and lumbar glands, it is malignant disease of the prostate. A nodular enlargement of the prostate in a young or 548 SURGICAL DIAGNOSIS. [Chap. XLII. middle-aged man is probably tubercular, and if tubercle be found in his lungs or testicle, or the vesiculse seminales are found enlarged, or the bladder and kidneys are affected, this diagnosis is certain. The prostate may be found atrophied. At the same time the finger should examine the base of the bladder and the seminal vesicles. The tense rounded base of a distended bladder, or a vesical calculus, or a vesical tumour, or a nodular enlargement of the seminal vesicles (one or both) from tubercle may thus be detected ; this examination is much facilitated by firm suprapubic pressure. If a firm, well-defined tumour be felt in the bladder it is cancerous; the benign tumours are softer and more ill-defined. A full-sized catheter or bougie should now be passed, and the fact of undue pain or of obstruction noticed. Sharp pain at a particular spot in the urethra points to a local inflammation, and is an useful indica- tion of the source of a gleety discharge or perineal pain. If obstruction be met within six inches of the meatus it is generally due to stricture ; obstruc- tion beyond that point is usually from prostatic enlargement, and if this obstruction be overcome by depressing the shaft of the catheter, or when an instrument is in the bladder the shaft be found to be greatly depressed, it points to what is called enlarge- ment of the middle lobe of the prostate. The length of the urethra is to be measured by the length of catheter introduced before the escape of urine. When stricture is met with the surgeon has to notice the position, size, and number of the narrowings. The examination is best made with " acorn " or "bullet-headed " graduated probes, or Otis's "urethra- meter "; if the meatus be narrowed this may have to be incised as a preliminary measure. The resis- tance offered by a stricture is more clearly perceived by one of these instruments than by an ordinary Chap. XLII.] STRICTURE OF T%E URETHRA. 549 bougie, but they are especially useful in the detection of multiple strictures, for a narrowing through which the bulb has passed does not grasp the slender stem, and so the onward movement becomes again easy, unless a further stricture is met with.* Any narrow- ing or resistance offered to the passage of an instru- ment, which passes off when the patient is under the full effects of an anaesthetic, is due to spasm. Spasm can also sometimes be diagnosed by noticing the sudden yielding of a stricture under the gentle continuous pressure of the end of a bougie. Obstruction to the passage of urine or of a bougie due to swelling of the mucous membrane is sometimes called congestive stric- ture; it is met with in urethritis, acute prostatitis, and peri-urethral abscess. Urethritis is recognised by the discharge ; prostatitis by the pain in and swelling of that organ ; peri-urethral abscess (prostatic or perineal) is recognised by pain, swelling, and in some cases by fluctuation. If in passing a catheter a grating be felt, it shows that there is an urethral or prostatic calculus, and the exact position at which the grating occurs, as measured by the stem of the catheter, distinguishes between these two. If, as the catheter is passed, a sudden flow of pus occurs, it shows that a peri-urethral abscess has been opened ; these are most commonly prostatic, but the position of the abscess is easily ascertained by the detection of swelling. If on passing a catheter the shaft be found to deviate from the middle line, or the instrument pass in to its full length without reaching the bladder (except in cases of pros- tatic hypertrophy), pass the finger into the rectum, and if the catheter be felt very superficial, or to one or other side, it has passed into a false passage. If, when the surgeon is trying to overcome an obstruction, * There is difference of opinion among surgeons as to what may be held to constitute a pathological narrowing of the urethra. 55 SURGICAL DIAGNOSIS. [Chap. XLII. the catheter suddenly slip on with a soft grating sensation, and blood escape, he knows that he has made a false passage ; an instrument is never grasped by a false passage as it is by a stricture or by the compressor urethra muscle. B. The bladder. For signs of a distended bladder, see page 292. The capacity, competence, and power of the bladder, and the presence in it of foreign bodies or tumours, are the facts to be ascer- tained by examination of the bladder. If, immediately after the patient has passed water, a catheter be passed and urine flow off, the bladder is incompetent, and the amount of the " residual urine " should be measured ; if the urine flow through the catheter slowly and feebly there is atony of tlie bladder, but should it be propelled with normal power the chronic retention of urine would then be due to obstruction to its outflow, either urethral stricture or hypertrophy of the prostate. In the large majority of cases " residual urine " is a sign of atony. If the amount of residual urine be added to that passed by the patient, and the total measured, it will give ihe capacity of the bladder. As we have seen, frequency of micturition is not a sure sign of small size of the bladder ; but if the frequency be chronic and the bladder be com- petent, the bladder is undoubtedly small ; the amount of fluid that can be injected into the bladder without meeting with resistance, and the freedom with which a sound or a lithotrite can be manipulated in the bladder, are other means of estimating the capacity of a bladder. A small bladder is met with in old tight stricture, in stone in the bladder, in some cases of chronic cystitis, and in long-standing vesical fistula. It is important to know the size of the bladder before performing lithotrity or lithotomy. If, on drawing off the water, the flow cease and the bladder apparently be empty, but on pushing the chap. XLII.] SOUNDING THE BLADDER, 551 catheter in a little farther or moving it in the bladder, some more urine flow out, especially if it be different in appearance to that before drawn (al- kaline, purulent), a sacculus may be diagnosed. A sacculus is also to be diagnosed when, on emptying the bladder, a fluctuating swelling is felt above the pubes, from which, by pressure, urine can be expelled through the catheter. The next step in diagnosis will be to explore the bladder with a sound. This should first be done with the bladder moderately full, and then, if no stone be detected, with the viscus empty, and for this reason a hollow sound is convenient. As the sound passes into the bladder it may grate over an urethal or prostatic calculus. If the end of the sound be freely movable from side to side the surgeon knows it is in the bladder. It is possible to fall into error by passing the sound into a false passage, or no farther than the dilated prostatic urethra. An audible click and a feeling of firm re- sistance are the signs of stone in the bladder. The surgeon must not mistake for this, mere roughness of the bladder, fasciculated bladder, which gives rise to no click ; or soft sabulous matter, which causes a soft grating sensation; or contact with the sacrum or ischial spine, which also does not give a click, but only a feeling of resistance ; or a tumour, which occa- sions more or less resistance to the free movement of the sound, but does not give a click or grating sensa- tion. The " sound " of a stone in the bladder, there- fore, is the safe test of its presence. A stone may be missed by an incomplete examination of the bladder, or by its being covered over with a fold of, the mucous membrane or a thick layer of blood clot or mucus. A stone in the bladder being diagnosed, the surgeon must determine the nature, size, number, and position 552 SURGICAL DIAGNOSIS. [Chap. XLII. of the calculi. An examination of the urine will deter- mine the composition of the outer crust of the stone, while the history of the case, and the prevailing con- dition of the urine, if known, will tell the probable composition of the nucleus and bulk of the calculus. If the urine be acid, and deposit uric acid and urates on cooling, the calculus is uric acid and urates. If the deposit consist of oxalate of lime the cal- culus may be assumed to be of that nature ; while alkaline urine, with deposit of phosphates, will indicate that at any rate the crust of the stone is phosphatic. If the stone be felt to be smooth, and give a sharp click, it is uric acid ; if it be rough or nodular, and give a clear click, it is oxalate of lime, and if it give a softer duller sound, it is phospliatic on the exterior. Calculi known to be formed around foreign bodies in the bladder are phosp/tatic on the exterior. Calculi in children are generally composed of uric acid or urates. The size of a stone is best ascertained by grasping it in a lithotrite two or three times, and measuring the distance apart of the blades. It may be more roughly estimated by passing a sound to one extremity of it, and marking the level of the urinary meatus on the stem, and then drawing the sound over to the opposite end, and again marking the meatus; this should be done in two directions. The number of stones present. Usually there is but one. The sound may at once detect a great number, giving a sensation as if in a bag of small marbles or a small " gravel pit." Or the signs of stone may be detected in two or more distinct parts of the bladder. The most certain evidence, however, is to grasp one stone in a small Hthotrite, and then iisc that as a sound, and if it be felt and heard to tap against another stone, it shows that two at least are present. The position oft/te stone is a matter of great im- portance in view of operation. If the stone be found Chap. XLII.] TUMOURS OF THE BLADDER. 553 in different, places at different times, or if the sound pass over a great area of stone, or if the stone can be grasped in a lithotrite, it is certainly in the bladder, But if it be detected with difficulty, or only occasionally, especially if the sound cannot be passed over more than one side of it, or if it cannot be grasped in a litho- trite, it is probably sacculated. If no stone be detected the surgeon must notice carefully whether the sound meet with resistance at any part, or whether contact with a particular spot causes sharp pain (a sign of ulcer of the bladder), and whether the examination occasions smart haemorrhage, which indicates a vesical tumour. If the resistance to the sound be distinct and firm, and an induration be plainly felt from the rectum, while the pelvic glands are enlarged, the patient emaciated, the urine containing blood, much epithelium and some muco-pus, it is to be diagnosed as cancer of the bladder; there is usually great pain and frequency of micturition, and these precede the occurrence of haemorrhage. Where haemorrhage from the bladder is the first and chief symptom, and is subsequently followed by frequency and pain, a benign tumour of the bladder is to be sus- pected, of which fimbriated papilloma is the com- monest variety, and the one attended with most haemorrhage. Where a tumour of the bladder is suspected or diagnosed, or in any case of persistent pain in the bladder, or of chronic cystitis, for which neither cause nor cure can otherwise be found, digital exploration of the bladder should be made. In the female the urethra is dilated to admit the finger; in the male the membranous urethra is opened from the perineum, and the forefinger passed in ; with the left hand or by an assistant, pressure is made above the pubes, in this way the whole interior of the bladder can be well examined. The finger will first pass over the neck of 554 SURGICAL DIAGNOSIS. [Chap. XLII. the bladder, and should feel for prostatic outgrowths, fissures and ulcers. In the bladder, tumours of various kinds, sacculated stones, stones impacted at the orifice of the ureter, sacculi and ulcers are the conditions that may be met with. The nature of most of them will be at once evident. Stone at the orifice of the ureter will be felt as a hard lump at the base of the bladder, covered all over with mucous mem- brane, and with the finger nail, or a pointed probe, the latter may be pierced and the stone actually felt. Care must be taken not to mistake a bladder inverted by firm suprapubic pressure for a tumour. If a tumour be found, its consistence, size, shape, exact position, and especially its mode of attachment to the bladder, must be carefully ascertained. In children, a soft, pedunculated mucous polypus, like those common in the nose, may be found. In adults, if the tumour be very soft, flocculent, and peduncu- lated, it is a fonbriated papilloma; if firmer and sessile, but not ulcerated, it is probably either "Jibro-papil- loma " or the transitional tumour of Thompson.* Scirrhus will be recognised by its hardness ; epithe- lioma by its ragged, ulcerated surface and indurated edge and base ; encephaloid by its rapid growth ; all these three alike will be found in elderly adults, and there will probably be glandular enlargement, wasting, and cachexia. Mr. Bryant has found and removed a dermoid cyst. The structure of the tumour should be proved by removal of a fragment, and its microscopical examination. C. The kidney. For the methods and results of examination of the kidney, the reader must consult works on medicine. In cases of stone in the kidney, a long needle may be thrust into the organ from the loin, in the hope of striking the calculus. In the female the ureters may be catheterised after dilatation * See " Tumours of the Bladder," by Sir H. Thompson. chap. XLIII.] URETHRAL FEVER. 555 of the urethra, and the urine from each kidney col- lected separately in cases where it is important to determine which kidney is the seat of suppuration, and whether the other organ is functionally sound, e.g. tubercular disease. Uretliral fever. When, soon after the passage of a catheter, the operation of lithotrity, or some simi- lar local irritation, the patient is seized with a rigor, followed by great heat of skin, and then by a profuse sweat, the temperature rising considerably during the rigor and falling to the normal during the sweat, and the whole illness passing off in a few hours, the illness is acute urethral fever. The attack may vary much in intensity ; it resembles a paroxysm of ague or a pyaemic rigor, but is characterised by its transient character and its connection with urethral irritation. When the attack is repeated at the interval of a few hours or a few days, it is called recurrent urethral fever. When a patient who is using a catheter suffers from chronic pyrexia, with marked asthenia, a dry brown tongue, anorexia, mental stupor, or a low muttering delirium, it is chronic urethral fever. The temperature may be but little raised or vary much from time to time. This form of fever is generally met with in the subjects of chronic vesical incom- petency with deficient excretion of urea. Some cases of so-called urethral fever are septic in origin. CHAPTER XLIII. DIAGNOSIS OP DISEASES OF THE HAND. THE hand is sometimes greatly distorted by the contracting scars of a burn ; to be distinguished from this is a spontaneous disease of the skin lasting many 556 SURGICAL DIAGNOSIS. [Chap. XLIII. years, which gradually draws the fingers together and finally converts the hand into an irregular club-shaped mass, from which the ends of the fingers project ; the part, which is covered by a reddish cicatricial skin, is ulcerated or covered with thick yellow crusts ; this disease is a form of lupus. Another deformity coming on, especially in men of middle or later life, is that characterised by flexion of the fingers at themeta- carpo-phalangeal joint; on attempting to straighten the digit great resistance is met with in the palm, and the palmar fascia is felt to be tense and firmly adherent to the skin, which is marked with transverse creases ; this is known as Dupuytrerfs contraction. Acute inflammation may attack any of the structures of the hand, and is characterised by its usual signs; but the surgeon must endeavour to determine its exact seat. If the pain and swelling be in the urrist, the joint should be very gently moved, and then while the wrist joint is fixed by grasping it firmly in the hand, the fingers should be carefully flexed and extended ; should it be found that every movement of the wrist joint is very painful, but that when it is held fixed the fingers can be moved without causing pain, it will show that there is acute inflammation of tlie wrist joint. If, however, movement of the fingers be found to be painful when the wrist joint is fixed, it points to acute teno-synovitis, and if soft grating or fric- tion be felt during the movement this diagnosis becomes certain. In some cases of joint disease the sheaths of the tendons become involved. In teno-synovitis the pain is more exactly localised than in arthritis and no pain is caused by gentle vertical pressure of the hand up against the fore-arm. The actual tendon affected will be ascertained by the position of the pain and swelling and by noticing what movement it is that causes the acute pain. The palm. When a swelling extends up under Chap. XLIII.] WHITLOW, 557 the anterior annular ligament to the lower part of the fore-arm it indicates affection of the common palmar synovial sheath. It is impossible to detect fluctuation from small collections of pus through the tense and redematous palmar fascia and the surgeon must rely for the diagnosis of suppuration upon other signs ; of these the best are oedema of the back of the hand, throbbing pain, increased swelling and pyrexia. Abscess is often met with at the clefts of the fingers. The digits. Acute inflammation of the digits is usually called whitlow or paronychia, as it is much most frequent in the last joint. Four forms are to be recognised. Where there are a sharp, stinging, smart- ing pain, moderate swelling and the quick formation of a flat bleb containing milky pus, it is the most superficial form, a simple dermatitis. On removing the raised cuticle the derma is seen bright red and glazed ; if the disease spread to the nail that structure is shed. If the end of the finger be greatly swelled with severe aching and throbbing pain, the inflamma- tion is deeper ; if, when opened or allowed to burst, a slough of cellular tissue escape, and the sore heal up, the probe not detecting any bare bone, it is phlegnio- nous paronychia ; but if, when the swelling bursts or is opened, the probe detect bare bone, and the sinus remain open until a sequestrum is removed, it is periosteal paronychia. When a finger or thumb is greatly swelled along its whole length, particularly on the palmar aspect where there is great pain and tender- ness, and any movement of the digit causes acute pain, it may be diagnosed as acute inflammation of the sheath of the flexor tendons or paronychia tendinosa. When occurring in the thumb or little finger it may spread to the common palmar sheath. Chronic disease. Inflammation of the joint-end of a bom is detected by finding marked pain on pressing the suspected bone vertically against the one above it, 55S SURGICAL DIAGNOSIS. [Chap. XLIII. while disease of the shaft is recognised by the swelling over and fixed to the bone. Occasionally soft grating is felt in a tendinous sheath due to chronic dry teno- synovitis ; but more often there is effusion, and a fluctuating swelling having the shape and position of the sheath is found ; when the fluid contains also ' small fragments of fibrin flattened out into " melon- seed bodies," the movement of the fluid imparts to the fingers a peculiar thrill-like sensation which is characteristic. These swellings may be met with on the palmar surface of the fingers or in the palm of the hand projecting below the annular ligament and also in the fore-arm above the ligament and extending usually into the thumb or little finger (palmar gan- glion) ; occasionally such a swelling is seen over the back of the wrist. A tense ovoid or globular fluctuating swelling on the back of the hand is a circumscribed ganglion, which may be connected with one of the extensor tendon sheaths, or an articular synovial membrane. A chronic inflammatory enlargement of a phalanx is known as dactylitis. If the swelling be smooth and uniform, affecting the entire bone, fusiform in shape and not showing any tendency to suppurate, it is probably syphilitic, and other signs of this dyscrasia must be sought to support this diagnosis. If the swelling be less regular, affecting alone or chiefly one part of the bone, and showing a tendency to soften or suppurate, it is strumous ; this disease may lead to great shortening of the finger. An exactly similar disease is met with in the metacarpus. If one or more of the bones of the hand undergo a steady painless enlargement, forming ovoid or globular swellings, at first firm and unyielding, but later on giving " egg-shell crackling " or becoming slightly elas- tic, and not yielding to treatment, the disease will be recognised as enclwndroma. This tumour grows more chap. XLIV.] ENCRONDROMA OF HAND. 559 often from the interior than from the surface of these bones, is often multiple, and occurs in early life. When it appears as a pedunculated outgrowth from the surface of the bone at the junction of epiphysis and diaphysis it quickly ossifies; A commencing en- chondroma cannot be distinguished from periostitis; but the absence of injury as an exciting cause, of pain or tenderness, of the syphilitic or strumous dyscrasia, and also the persistent growth in spite of treatment, will clear up the case ; " egg-shell crackling " at once establishes the diagnosis of tumour. When the joints of the fingers become semi- flexed, adducted, stiff and painful, with creaking and grating in the joints, and nodular thickening around, the disease is arthritis deformans. (See page 362.) Tbe nails may be found very brittle or irregu- lar, with nodular thickening near the free edge ; both conditions are the result of syphilis; occasionally from syphilis the nail is partially or wholly separated from the matrix, and slowly shed. If the end of the finger be bulbous and reddened, the nail discoloured and out of shape, and beneath it is seen a foul ulcer of the matrix with dark discharge, it is onychia maligna ; enquiry should be made for evidence of syphilis and of struma ; the disease is often started by injury. CHAPTER XLIV. DIAGNOSIS OP DISEASES OF THE FOOT. Deformities. When the ankle joint is extended and the heel is raised from the ground in standing, the deformity is known as talipes equinus. This deformity varies much in degree, and the patient may 560 SURGICAL DIAGNOSIS. [chap. XLIV. walk on the ball of the toes or on the dorsum of the foot. The position of corns and callosities is a useful indication of the part of the foot upon which the patient walks. When the ankle is flexed, and the patient rests solely on the heel with the toes raised from the ground, it is talipes calcaneus. When the foot is rotated in at the transverse tarsal joint so that its inner border is raised and shortened, and is marked by a deep groove under the head of the astragalus, while the outer border is de- pressed and a corn or callosity is developed over the cuboid bone, it is talipes va/rus. If the foot be rotated out so that its outer border is raised from the ground and the peroneal tendons are tense while the inner border is depressed, it is talipes valgus. If the arch of the foot be abnormally deep, the patient resting merely upon the heel and the ball of the toes, it is talipes cavus ; while when the arch of the foot is lost so that in standing the whole length of the inner border of the foot rests upon the ground, and the head of the astragalus and tubercle of the scaphoid are unduly prominent, it is talipes planus, " flat-foot," or "spurious valgus." These forms of talipes are often combined ; thus, talipes equinus and varus are often associated, and talipes cavus maybe superaddedj talipes valgus and calcaneus are often found together, and in extreme cases of talipes planus some amount of equinus may be found. Talipes is either congenital or acquired. In the latter the history must be carefully investigated with a view to tracing the deformity to the contraction of cicatrices or injuries dividing nerves (traumatic} ; retention of the foot for a long period in one position (static) ; paralysis of muscles ( paralytic) ; and spasm of muscles (spastic] ; in the last case some source of reflex irritation or evidence of neuro mimesis, such as intermission of the deformity, must be sought. chap. XLIV.] IN-GROWING TOE-NAIL. 561 When the part is cold and livid, both smaller and shorter than its fellow, the skin rough and unhealthy, the talipes is certainly paralytic. The surgeon must notice how far and with how much force he can correct the deformity, and what tendons or bands of fascia become tense in so doing. The great toe is often found pushed out of the straight line, and then a bursa is apt to develop over the head of the metatarsal bone ; this is then known as a bunion ; this bursa may become inflamed and suppurate. If a toe be bent back at the metatarso- phalangeal joint, and flexed at the two terminal joints, the deformity is known as hammer-toe ; this may be accompanied by the development of a bursa over the head of the metatarsal bone in the sole. The skin of the sole is often the seat of corns or callosities over the points of greatest pressure. If it be found with the cuticle greatly thickened and fissured in various directions, it is known as psoriasis ; this is always syphilitic in nature. Irregular fissures and ulcers may be found between the toes in syphilitic patients, called rJiagades digitorum. An ulcer may be found at either side of the nail of the great toe, most commonly the outer side, into which the edge of the nail presses; this is a cause of great pain, and is at tended with discharge and the growth of a fleshy mass over the nail ; it is known as ingrowing toe-nail. Ulcers are sometimes met with in the sole of the foot in the centre of what look like corns ; they are very chronic in their course, and a probe is found to pass deeply in between the metatarsal bones, or to strike bare bone; they are known as perforating ulcers. The surgeon should examine the sensibility of the sur- rounding skin and the condition of the tendon reflexes, the gait and the pupil, and should enquire for "lightning-like pains in the legs," for these ulcers are often found in connection with local anaesthesia or K K 13 562 SURGICAL DIAGNOSIS. [Chap. XLIV. locomotor ataxy. Sinuses are also met with in con- nection with disease of the bones and joints. Tumours. Circumscribed ganglion may occur on the dorsum of the foot as on the hand. If a firm tumour be found rising up under and displacing the nail of the great toe it is a subungual exostosis. The bones and joints of the foot can easily be individually examined and any swelling or tender- ness to pressure or movement can be readily deter- mined, while the probe passed into sinuses may detect either necrosed or carious bone. By pressing each toe separately back towards the heel evidence of inflammation of the bases of the metatarsal and anterior carpal bones can be obtained. Strumous disease of a tarsal bone is very prone to spread to one of its joint surfaces, and from the large size and complexity of the synovial membranes in- flammation quickly spreads from them to several bones. The surgeon will be chiefly interested in ascertaining, by testing the movement of the foot upon the leg, whether the ankle joint is involved ; then grasping the heel and instep in one hand and the metatarsus in the other, he will try to get movement between them at the great transverse tarsal joint. Gout attacks the metatarso-phalangeal joint of the great toe with great frequency. If the great toe be chronically displaced outwards, and the usual promi- nence of the head of the metatarsal bone be greatly swelled, very painful, tender, reddened and fluctu- ating, there is a suppurating bunion. The abscess may burst and leave a sinus or may spread into the joint ; this will be shown by the occurrence of grating and of great pain on moving the phalanx on the metatarsus. The acute inflammation of the bunion will be dis- tinguished from gout by the history of the case and by the absence of the premonitory signs of gout. (See page 359.) INDEX. Abdomen, Injuries of, 146 Abdominal hernia, 163 wall, Abscess of, 161, 455 , Inflammation of, 161 , Tumours of, 455 Abrasion of oesophagus, 121 Abscess, Abdominal, 155 , Acute, 291 , Alveolar, 387, 409, 414 , Anal, 475 , Chronic, 295 , Deep, 312 , Iliac, 369 , , Causes of, 529 in abdominal walls. 161, 156, 455 in bone, 315 in brain, 97 in breast, 445, 449 in lung, 143 in sheath of rectue, 455 in spermatic cord, 522 -, Ischio-rectal, 475 , Labial, 499 , Mammary, 445 , Mediastinal, 144 of face, 407 of groin, 527 of scalp, 79 of scrotum, 502 of tongue, 424, 425 opening in urethra, 544 over aneurism, 307 over artery, 305 , Parotid, 408 , Pelvic, 529 , Perineal, 547 , Periostea], 312 , Peripleuritic, 141 , Peritoneal, 156 , Peri-urethral, 549 , Prostatic, 547 , Psoas, 369 , , Causes of, 528 , Retropharyngeal, 421 Abscess, Serous, 291 , Subaponeurotic of abdominal wall, 456 SiibiTm.Tnma.ry, 4J5 Subpectoral, 140 Subperitoneal, 156 Subphrenic, 157 Supramarnmary, 443 Synovial, 291 Temporal, 386 Accumulation of secretion, Dia- gnosis of, 245 Accurate observation, Importance of, 6 Acetabulum, Fissure of, 215 , Fracture of, 164, 210, 214, 215 Acquired hernia, 465 Acromion, Fracture of, 179 Acute abscess, 291 bursitis, 360 congestion, 244 epiphysitis, 360 gout, 359 hydrocele, 508 inflammation, 242 osteo-myelitis, 48 periostitis, 312 rheumatism, 359 swellings of bone, 311 synovitis, 358 Adenoid vegetations, 416 Adenoma of breast, 450 Adhesion of swellings, 252 Age in diagnosis of ulcers, 333 Air, Entrance of, into veins, 41, 59 passages, Foreign bodies in, 122 Albumiuuria, 542 Alcoholism, 59 , Diagnosis of, from injuries of brain, 94 Alveolar abscess, 387, 409, 414 Anaesthesia in gangrene, 342 with pain, 25 5 6 4 SURGICAL DIAGNOSIS. Anal abscess, 475 chancre, 475 ' erythema, 475 fissure, 477 herpes, 475 stricture, 477 ulcer, 477 Anchylosis, 376 of ankle, 379 of digits, 379 of elbow, 378 of hip, 379 of knee, 379 of lower jaw, 378 of shoulder, 378 of tarsus, 379 of wrist, 378 Aneurism, 295 , Abscess over, 307 , Arterio-venous, 302 , Carotid, 435 , Cirsoid, of scalp, 302, 382 , Cyst and, 307 , Diffused, 241, 304, 306 , Fusiform, 302 , Innominate, 435 , Obliterated, 304 , Euptured, 241, 304, 306 ,' Sacculated, 303 , Subclavian, 435 , Tumour over, 307 , Varicose, 302 Angina Ludovici, 431 Ankle, Anchylosis of, 379 , Injuries of, 229 -joint, Effusion into, 374 Annulus migrans, 429 Antrum, Empyema of, 390, 414 , Polypus in, 414 , Tumours of, 389 Anus, Artificial, 162, 454, 526 , hernia of, 162 , prolapse of, 162 , Eczema of, 478 , Epithelioma of, 479 , Gumma of, 478 , Narrowing of, 489 , Patulous, 478 Aphthse of tongue, 427 Apoplexy, 59, 94 Arachnoid haemorrhage, 93 Areola, Affections of, 442 Arm, Examination of, 172 , Lawn-tennis, 35 Arrest of circulation in gangrene, 342,346 Arterio-venous aneurism, 302 Artery, Abscess over, 305 , Compression of, 36 Artery, Cyst over, 306 Dilatation of, 244 Occlusion of, 36 Beducible tumour over, 305 Euptured, 36, 241, 306 Secondary occlusion of, 37 Solid tumour over, 305 Arthritis, Chronic strumous, 361 deformans, 362 of hand, 558 , Gummatous, 361 Arthropathy, Ataxic, 362 Artificial anus, 162, 454, 526 Astragalus, Dislocation of, 236 , Fracture of, 230 Ataxic arthropathy, 362 Atony of bladder, 550 of bowel, 461 of rectum, 489 Balano-posthitis, 492 Barbadoes leg, 503 Bartholine's gland, Suppuration of, 500 Base of skull, Fracture of, 83 of ulcers, 320 Bed-sores, 104 Biceps tendon, Dislocation of, 185 Bile in urine, 545 Biliary fistula, 162 Black eye, 84 Bladder, Atony of, 538, 550 Cancer of, 553 Capacity of, 550 Catarrh of, 545 Dermoid cyst of, 554 Digital exploration of, 553 Distended, 292 Epithelioma of, 554 Failure to empty, 537 Fasciculated, 551 Incompetence of, 550 Irritability of, 537 Leaking of, 537 Polypus of, 554 Eupture of, 167 Sabulous matter in, 551 Sacculus of, 551 Scirrhns of, 554 Small size of, 537 Sounding the, 551 Stone in the, 551 Suppuration of, 545 Tumour of, 543, 551, 553 Ulceration of, haemorrhage in 543 Uloerof, 553 Varix of, haemorrhage in, 543 INDEX. 565 Bladder, Wound of, 160, 168 Blebs in fracture, 28 Blood, Altered, 275 clot, Organisation of, 47 cysts, 280 , extravasation of, Signs of, 243 in tumours, 275 , rapid effusion of, Sums of, 240 Boil, 432 Bone, Abscess of, 315 , Aneurism of, 319 , articular, Disease of, 356 , Caries of, 316 , Congenital syphilis of, 313 , Contusion of, 80 , Enchondroma of, 316 , Exostosis of, 316 , Fibroma of, 318 , Hydatid cyst of, 319 , Hypertrophy of, 313 , Necrosis of, 315 , Paget's disease of, 315 , Rickets of, 313 , Eider's, 533 , Sarcoma of, 317 , Sclerosis of, 314 , Spontaneous fracture of, 317, 319 , Wound of, 43 Brain, Compression of, 93 , Concussion of, 91 , Contusion of, 91 , Injuries of, diagnosis from alcoholism and apoplexy, 94 , Laceration of, 92 Branchial fistula, 436 Breast, Adenoma of, 450 , Cancer of, 450 , Chronic abscess of, 449 , Cystic sarcoma of, 450 , Discharges from, 447 , Diseases of, 440 , Encephaloid cancer of, 453 , Enchondroma of, 450 , Fibre-cystic tumour of, 450 , Fibroma of, 450 , Hydatid cyst of, 449 , Hypereesthesia of, 444 , Hypertrophy of, 445 , Induration of, 446 , Lipoma of, 450 , Mucous cyst of, 449 , Myxoma of, 454 , Neuralgia of, 444, , Neuroma of, 444 , Physiological changes in, 440 , Sarcoma of, 453 Breast, Scirrhus of, 450 , Serous cyst of, 448 , Strnmous abscess of, 449 , Tumours of, 446 Bronchocele, 434 Bruise, Deep, 27 of lung, 130 of muscle, 34 of periosteum, 29 of synovial membrane, 31 , Signs of, 26 Bruit in tumours, 265 Bryant's line, 204 Bubo, 496, 527 , Indolent, 532 , Scrofulous, 525, 532 , Sympathetic, 532 , Virulent, 524 Bubonocele, 464 Bunion, 561, 562 Bursa, Infrapatellar, 373 over olecranon, Disease of, 365 over vertebra prominens, 404 , Pendulous growth in, 364 , Popliteal, 374 , Prepatellar, 373 , Suprapatellar, 373 under biceps, 374 under deltoid, Disease of, 365 under sartorius, 374 under tendo Achillas, 375 Burs around knee joint, 373 , Diseases 9f , 353, 356 , Suppuration in, 360 , Wounds of, 44 Bursitis, Acute, 360 , Chronic serous, 364 , Dry, 360 , Plastic, 360 Buttock, Flattening of, 368 Cachexia in diagnosis ,of ulcers, 334 Calculus, Nasal, 416 Preputial, 491 Pro-static, 549 Salivary, 417 Urethral, 549 Urinary, 552 Callosities, 561 Callous ulcer, 326 Cancer, 289 , Heredity of, 13 of bladder, 553 of breast, 541 of colon, 462 of rectum, 487 of testicle, 515 5 66 SURGICAL DIAGNOSIS. Cancerous glands, 284 Cancrum oris, 352 Carbuncle, Facial, 352 of neck, 431 Caries, 316 of spine, 396, 399, 439 , Sinus in, 341 Carpus, Dislocation of, 195 , Fracture of, 196 Cartilage, Disease of, 356 loose in joint, 363 Cellulitis of scalp, 79 , Pelvic, 168 Central sarcoma, 317 Cephalhaematoma, 76 Cerebral abscess, 97 localisation, 89 Cerebro-spinal fluid, Escape of, 82 -85,92 under scalp, 82 , Tests for, 83 Chancre and phymosis, 491 , Hard, on face, 405 , Inflamed, 496 of anus, 475 of groin, 524 of rectum, 485 of scrotum, 501 on penis, 495 , Recurrent, 497 , Sloughing, 496 Changes, Post-mortem, in gan- grene, 343 Charbon, 351 Charcot's disease of joints, 362 Chest, Contusions of, 125 , Cutaneous emphysema of,127 , Bupture of a muscle of, 125 Chordae tendineae, Bupture of, 133 Chordee, 536 Chronic abscess, 295 of breast, 449 catarrh of rectum, 483 gout, 363 infln.TTiTnnf.inTi Diagnosis of , 244 mammary tumour, 450 meningo-myelitis, 106 ostitis, 314 periostitis, 314 " peritonitis, Intestinal ob- struction from, 462 swellings of bone, 313 synovitis, 360 tumours, 243 ulcer, 326 Chyluria, 544 Cicatrices, Diseases of, 48 on penis, 499 Cirsoid aneurism, 302, 382 Clavicle, Dislocation of, 176 , Examination of, 170 , Fracture of, 176, 178 Cleft palate, 417 Coagulated haematoma, 27 Coccidynia, 400 Coccyx, Fracture and dislocation of, 108 Cold ulcer, 335 Collapse, 56, 57 from haemorrhage, 58 Colles's fracture, 194 Colon, Cancer of, 462 Colour, Change in, in gangrene,343 Comminuted fracture, 31 Compound cyst, 294 fracture, 31 of skull, 82 Compression of brain, 59, 92 Concussion of brain, 58, 91 of spine, 100 Condition of ulcer, Diagnostic value of, 331 Confrontation, 493 Congenital deformities of anus and rectum, 489 hernia, 465 hydrocele, 508 of cord, 520 intestinal obstruction, 462 syphilis, Skull in, 81 tumours, 239 Congestion, active, Diagnosis of, 244 Connections of swellings, Dia- gnostic value of, 251 Consistence of tumours, 254 Constipation in diseases of rectum, 471 Constitutional effects of injuries, 55 of pain, 25 Contusions of abdomen, 147 , Sequelae of, 154 of ahdominal wall, 149 of bone, 80 of brain, 91 of chest, 125 of hip, 216 of neck, 117 of pelvis, 163 of skull, 80 of uterus, 153 Contused wounds, 39 Coracoid process, Fracture of, 184 Coronoid process, Fracture of, 187 Corns, 561 Coryza, Chronic, 413 INDEX. 567 Cranial contents, Lesions of, 87 nerves, Lesions of, 95 Craniotabes, 81, 385 Cuboid, Dislocation of, 238 Cuneiform, Dislocation of, 238 Cutaneous emphysema of chest, 127 Cyst and aneurism, 307 , Blood, 290 , Compound, 294 , Dentigerous, 389 , Dermoid, 294 , , of mouth, 417 , , of scalp, 383 , , of testicle, 516 , Hydatid, of breast, 419 , Labial, 407 , Lymphatic, 293 , Milk, 448 , Mucous, 449 of face, 407 of testicle, 516 over artery, 306 , Parotid, 407 , Retention, 293 , Sebaceous, in groin, 530 , , in scalp, 383, 384 , Seminal, 517 , Serous, 293, 383 , , of breast, 448 , Synovial, 294, 364 , Urinary, 157 Cystic fluid, 275 hygroma, 285, 530 sarcoma of breast, 460 tumour of testicle, 515 Cystitis, Hsematuria in, 543 Cystocele, 466 Dactylitis, 558 Defecation, Involuntary, 103 Deformities of foot, 559 Degeneration, Reaction of, 88 Delirium tremens, 71 Deltoid, Disease of bursa under, 365 De Morgan's spots, 452 Dentigerous cyst, 385 Dermoid cyst, 294 , Contents of, 277 of bladder, 554 of scalp, 383 Diabetic gangrene, 349 Diaphragmatic hernia, 152 Diarrhoea in diseases of rectum, 471 Diastasis, 31 Diffused aneurism, 241, 304 Diffused haematoma, 27 Digestive system, 53 Digital exploration of bladder, 553 Digits, Anchylosis of, 379 Dilatation of artery, 244 of vein, 245 Direct hernia, 465 Discharge from anus, 472 of ulcers, 323 Dislocation at mediotarsal joint, 32,232 , Complete, 32 , Diagnosis of, 32 of astragalus, 236 of biceps, tendon of, 185 of carpus, 195 of clavicle, 176 of coccyx, 108 of cuboid bone, 238 of cuneiform bone, 238 of elbow, 186 of fibula, head of, 224 of foot, 232, 233, 234 , Subastragaloid, 231, 232, 234 of hip, 210, 213 , with fracture of aceta- bulum, 210, 214 of jaw, lower, 115 of metacarpal bone of thumb, 197 of metatarsus, 238 of os calcis, 235 of os magnum, 196 of patella, 221, 222 of peroneus longus, tendon of, 230 of phalanx (fingers), 197 (toes), 238 of radius, head of, 190, 195 and ulna, 187, 188 of scaphoid bone, 238 of scapula, 178 of semilunar cartilage, 225 of shoulder, 179 , with fracture of neck of humerus, 183 of tibia, 219, 220 of tibialis posticus, tendon of, 230 of ulna, 187 of wrist, 193 Displacement of parts, Signs of, 240 Distended bladder, Diagnosis of, 292 Double fracture, 31 Dry gangrene, 344 568 SURGICAL DIAGNOSIS. Dupuytren's contraction, 566 fracture, 231 Dura mater, Fungus of, 382 Ecchymosis, Sub-conjunctival, 84 Eczema of scrotum, 501 over breast, 443 Eczematous ulcer, 334 Edge of ulcer, 321 Effects of pain, Constitutional, 25 , Pressure, of tumours, 272 Effort, Effects of, on tumours, 271 Effusion of blood, Rapid, 240 , Serous, 291, 293 , Synovial, 291, 293 Egg-shell crackling, 259 Elbow, Anchylosis of, 378 , Disease of, 365 , Examination of, 172 , Fracture and dislocation of, 186 Electricity in diagnosis,"87 Elephantiasis scroti, 503 Embolic pyaemia, 67 Embolism, Fat, 70 Emphysema, Facial, 112 , Subcutaneous, 127, 130 Ernpyema, 141, 142, 340 of antrum, 390, 414 Encephalocele, 303 Encephaloid tumour of breast, 453 Enchondroma of bone, 316 of breast, 450 of hand, 558 of testicle, 515 Encysted haematocele of cord, 522 hydrocele, 509 of cord, 521 Endocarditis, Traumatic, 145 Engorgement of veins, 268 Enterocele, 466 Entero-epiplocele, 466 Epicondyle of humerus, Fracture of, 191 Epididymis, Gumma of, 513 Epididymitis, Acute, 511 , Chronic, 512 Epiglottis, Wound of, 116 Epilepsy, 59, 73 Epiphysis, Separation of, 31 Epipbysitis, Acute, 360 of femur, 370 Epiplocele, 466 , Umbilical, 466 Epistaxis, 410 Epithelioma, 286 of anus, 479 of gum, 393 Epithelioma of lip, 406 of penis, 492497 of scalp, 384 of scrotum, 503, 504 of tongue, 428, 429 Of vulva, 500 Epitheliomatons ulcer, 337 Epulis, 393 Erysipelas, 68 of scalp, 79 Erythema inarginatum of anus, 475 Examination of patient, 16 Exophthalmic goitre, 434 Exostosis, 316 of skull, 384 , Subungual, 562 Extra meningeal haemorrhage, 93 Extraperitoneal rupture of blad- der, 168 Extravasation into penis, 168 of blood, 243 of faeces in hernia, 468 of urine, 166, 242, 502 Face, Examination of bones of, 113 , Injuries of, 111 Facial carbuncle, 352 Faecal fistula, 166, 526 impaction, 461 Faeces, Incontinence of, 103 in urine, 545 False passages, 549 Family history, 10 Fasciculated bladder, 551 Fat embolism, 70 Femoral hernia, 464 , Hydrocele of sac of, 530 Femur, Epipbysitis of, 370 , Fracture, 211, 215, 217, 218, 220 , Separation of epiphysis of great trochanter, 215 , of lower epiphysis, 220 Fever, Asthenic, 62 , Causes of, 50, 60 , Diagnosis of, 64 , Hectic, 68 , Inflammatory, 64 , Modifications of, 61 of tension, 65 , Septic, 62 , Sthenic, 62 , Suppurative, 70 , Traumatic, 63 , Urethral, 555 Fibroma, 286, 287 of bone, 318 INDEX. 569 Fibroma of breast, 450 Fibro-cystic tumour of breast, 450 Fibula, Dislocation of head of, 224 , Fracture of, 228 Fissure of acetabulum, 164, 215 of anus, 477 of prepuce, 495 of radius, lower end, 196 Fissured fracture, 29 Fistula, 339 , Biliary, 162 , Branchial, 436 , Fiscal, 156, 526 , Gastric, 162 in ano, 476 in groin, 526 , Intestinal, 162 , Oro-nasal, 340 , Pleural, 340 , Becto-vaginal, 340 , Eecto-vesical, 340 , Salivary, 112, 407 , Urachal, 454 , Uriaary, 162, 526, 538 , "Vesico-vaginal, 340 Flap wounds, 39 Flat foot, 560 Fluctuation, 255 , Fremitus, 256 wave, 257 Fluid, Cerebro-spinal, 276 , Hydatid, 276 in swellings, 254 , Mucous, 276 , Sebaceous, 276 , Serous, 276 , Synovia!, 276 tumours, Diagnosis of, 290 , Urinous, 276 Foetal tumour of spine, 404 Follicular vulvitis, 500 Foot, Deformities of, 559 , Dislocations of, 231, 232, 231 , Injuries of, 236, 237 , Subastragaloid dislocation of, 231234 Fore-arm, Examination of, 173 , Fracture of, 192 Foreign bodies in air passage, 119, 122 in heart, 139 in lung, 122, 139 in nose, 416 in oesophagus, 120 in pharynx, 120 in pleura, 139 lin rectum, 169 in urethra, 169 in vagina, 169 Fracture, 31 , Complicated, 43 , Compound, 31, 43 , Dislocation of spine, 107 , Dupuytren's, 231 , Examination for, 28 , Fissured, 29 , Gosselin's, 227 , Impacted, 30 , Incomplete, 30 into a joint, 33 into frontal sinus, 81 into tympanum, 84 near a joint, 33 of acetabnlum, 164, 210, 214, 215 of acromion, 179 of astragalus, 230 of base of skull, 83, 85 of body of scapula, 185 of carpus, 196 of clavicle, 176 of coccyx, 108 of elbow, 106 of facial bones, 113 of neck of femur, 211, 214, 218 through neck and great trochanter, 215 , shaft, 217 of fibula, shaft, 228 of fore-arm, 192 of humerns, 182, 183, 184, 185, 188, 189, 191, 192 , with dislocation at shoulder, 183 of larynx, 118 of lower jaw, 114 of malleolus, 230 of metacarpus, 197 of metatarsus, 237 of nose, 84 of olecranon, 186, 191 of orbit, roof of, 84 of os calcis, 233, 235 of pelvis, 164 of phalanx, 197, 237 of radius, 192, 196 and ulna, 193, 194 of ribs, 129 of scapula, 179, 181, 184, 185 of shoulder, 181 of sternum, 128 of skull, Compound, 82, 86 of sustentaculum tali, 236 of tibia, shaft, 227 and fibula, 227 , lower end, 233 SURGICAL DIAGNOSIS. Fracture of tibia and fibula, pos- terior part of, 235 of ulna shaft, 193 , coronoid process of. 187 , olecranon process of, 186, 191 of wrist, 193 , Spontaneous, 317, 319 Fremitus, Hydatid, 256 fluctuation, 256 Frontal sinus, Fracture into, 81 , Suppuration in, 414 Function, Loss of, in gangrene, 343 Fungous ulcer, 325 Fungus of dura mater, 382 testis, 505 Funicular hernia, 465 Furuncle, 432 Fusiform aneurism, 302 Galactocele, 448 Gall bladder, Distended, 296 , Wound of, 160 stone, Impaction of, 459 Ganglion, 558, 562 Gangrene, Acute septic, 358 , Anaesthesia in, 342 , Arrest of circulation in, 342 , , Cause of, 346 , arterial thrombosis, Cause of, 347 , Causes of, 345 , Change of colour in, 343 , Diabetic, 349 .Dry, 344 , function, Loss of, in, 343 , Hospital, 351 inflammation, Cause of, 346 injury, Cause of, 345 , Local traumatic, 349 , Mixed, 344 , Moist, 344 of contents of hernia, 468 of face, 351 of lung, 143 of scrotum, 505 , Post-mortem changes in, 343 , Primary, 346 , Kaynand's, 348 , Secondary, 346 , Senile, 348 , Signs of, 342 , Spontaneous, 347 , Spreading traumatic, 349, 350 Gangrene thrombosis, Cause of, 347,349 , Traumatic, 349 , Trophic, 348 , venous thrombosis, Cause of, 349 Gas in swellings, 254 Gastric fistula, 162 General tumours, Diagnosis of, 279 Gingivitis, 391 Glands, Distended, 243 , lymphatic, Tumours of, 283 Gleet, 456, 544 Glenoid cavity, Fracture of, 181 Glossitis, Acute, 424 , Superficial, 429 Goitre, 434 Gonorrhoea, 547 Gosselin's fracture, 227 Gout, Acute, 359, 363, 562 , Heredity of, 12 Gouty induration of penis, 408 orchitis, 514 ulcer, 335 Granulations, Diseases and varie- ties of, 321 Greenstick fracture, 30, 178, 193 Groin, Abscess in, 527 , Sinus in, 525 , Tumours of, 527 , Ulcers of, 524 Gumma, 287 of anus, 478 of epididymis, 513 of penis, 498 of tongue, 424, 425 , Sloughing, 353 Gummatous arthritis, 361 ulcer of penis, 497 Gums, Diseases of, 391 Gunshot wound of neck, 116 Hsemarthrus, 357 Haematemesis in head injuries, 85 Hsematocele, 509 , Parenchymatous, 510 of spermatic cord, 523 , Encysted, 522 Haematoma, 27, 240, 291 , Circumscribed, 27 , Coagulated, 27 , Diffuse, 27 of chest, 126 of face, 112, 407 of nasal septum, 112 of pelvis, 164 , Suppurating, 27 INDEX. Hsematuria, 642 Haemomediastintun, 134 Haemopericardium, 134 Haemophilia, Heredity of, 13 Hsemopneumo-thorax, 132 Haemoptysis in injuries of the lung, 130 Haemorrhage, Arachnoid, 93 , Arterial, 41 , Capillary, 41 in fracture of base of skull, 83 in wounds of chest, 133 , Intermediary, 47 , Internal, 132 .into spinal meninges, 106 , Intracranial, 93,' , Parietal, 134 , Pulmonary, 135 , Eecurrent, 47 , Secondary, 47 , Venous, 41 Hsemorrhagic ulcer, 327 Haemorrhoidal varix, 483 Haemorrhoids, External, 478 , inflamed, 478 , Internal, 484 , Intero-external, 481 Haemothorax, 131 Hammer-toe, 561 Hand, Arthritis deformans of, 559 , Enchondroma of, 558 , Lupus of, 556 , Periostitis of, 559 Head, Diseases of, 379 , Examination of, 75 , Injuries of, 75 , Tumours of, 380 Healing of wounds, 46 ulcer, 325 Heart, Foreign body in, 139 in diagnosis of tumours, 267 , Wound of, 137 Hectic fever, 68 Heredity, Influence of, upon dia- gnosis, 10 of cancer, 13 of gout, 12 of haemophilia, 13 of struma, 12 of syphilis, 10 Hernia, Abdominal, 163 , Acquired, 465 cerebri, 96 , Congenital, 465 , Diaphragmatic, 152 , Direct, 465 , Femoral, 464 Hernia, Funicular, 465 , Gangrene of, 468 , Hydrocele of, 520 , Inflamed, 469 , Inguinal, 464 , , Varieties of, 465 , Internal, 459 , Irreducible, 467 , Oblique, 465 , Obturator, 464, 532 , Obstructed, 468 of lung, 127, 136 of ovary, 531 , Reducible, 467 , Signs of, 463 , Strangulated, 467 , Testis, 505 , Umbilical, 464 , Ventral, 464 Herpes, 409 , Preputialis, 495 Hip, Contusion of, 216 , Injuries of, 209 Hip joint, Abduction of, 366 , Anchylosis of, 379 , Dislocation of, 210213 , Eversion of, 367 , Examination of, 365 , Flexion of, 366 , Inversion of, 367 , Bigidity of, 367 History, Family, 10 of the affection, 14 , Personal, 13 Hodgkin's disease, 284 Horse-shoe fistula, 476 Hospital gangrene, 351 Humerus, Fracture of articular process of, 192 of condyle, 189, 191 of epicondyle, 189, 191 , intercondyloid, of, 189 of neck of, 182 , Impacted, 184 , with dislocation. 183 - of shaft, 185 , supracondyloid, of, 191 tnberosity of, 183 Separation of lower epiphy- sis of, 190 , of upper epiphysis of, 182 Hunterian chancre, 336, 496 Hydatid cyst of bone, 319 of breast, 449 of tongue, 425 fluid, Characters of, 276 fremitus, 256 Hydrarthrus, 360 572 SURGICAL DIAGNOSIS. Hydrocele, Acute, 508 , Congenital, 508 , , of spermatic cord, 520 , Chronic vaginal, 503 , Encysted, 509, 517 , , of cord, 521 of cord, Diffused, 523 of hernial sac, 521 of neck, 432 of sac of femoral hernia, 530 , Opaque, 510 , vaginal, Fluid of, 517 , Water-bottle, 522 Hydrocephalus, 385 Hydrohaematocele, 510 Hydrophobia, 73 Hygroma, Cystic, 285, 530 Hyoid bone, Fracture of, 117 Hyperaemia over tumours, 263 with numbness, 21 Hyperaesthesia, 22 of breast, 444 Hypertrophy of bone, 313 of breast, 445 of gum, 392 of mucous membrane of nose, 415 of prostate, 548 of skull, 385 of tonsils, 420 , Signs of, 245 , Strumous, of lip, 408 Hypospadias, 490, 546 Hysterical joint, 354 Hystero-epilepsy, Diagnosis from tetanus, 73 Ichthyosis linguae, 429 Iliac abscess, 369, 529 Impacted fracture, 30 Imperfect development of testicle, 506 Incised wounds, 39 Incontinence of faeces, 103 of urine, 102 Incubation of sores on penis, 493 Indolent ulcer, 326 Induration of sores on penis, 494 Infection, Septic, 66 Inflamed hernia, 469 ulcer, 326 Inflammation, Acute, 242 , Cause of gangrene, 346 , Chronic, 244 , Intracranial, 97 Infraction of skull, 81 lugrowing toe-nail, 561 Inguinal hernia, 46 it, 465 Injuries, Constitutional effects of, 55 of ankle, 229 of foot, 237 of knee, 218 of leg, 226 of lower limb, 198 of nerves, 37 of pelvic viscera, 165 of spinal muscles and liga- ments, 109 of thigh, 216 of upper limb, 169 of vertebrae, 106 Injury a cause of gangrene, 345 , Influence of, 15 of lung, Signs of, 130 Intercondyloid fracture of hu- merus, 189 Internal haemorrhage, 152, 161 haemorrhoids, 484 hernia, 459 strangulation, 458 Intertrigo, 501 Intestinal fistula, 162 obstruction, 456 , Acute, 457 , Chronic, 460 , Congenital, 462 Intestine, Laming of, 470 , Rupture of, 150 , , in hernia, 469 , Wound of, 160 Intoxication, Alcoholic, 59 , Septic, 65 Intracoracoid dislocation of shoulder, 180 Intracranial haemorrhage, 93 inflammation, 97 lesion, Nature of, 88 , Position of, 87 lutraperitoneal rupture of bladder, 168 Intrascrotal tumours, 507 Intussusception, 459, 461, 480 Involuntary defalcation, 103 Irreducible hernia, 467 Irritable testicle, 519 ulcer, 324 Irritation, Spinal, 105 Ischio-rectal abscess, 475 Jaw Acute periostitis of, 387 Chronic periostitis of, 388 Cystic tumours of, 389 Multilocular cyst of, 389 Necrosis of, 388 - Tumours of, 388 INDEX, 573 Joint, atlo-axoid. Disease of, 439 , Charcot's disease of, 362 , Diseases of, 353 , Fracture into, 33 , near, 33 , hip, Disease of, 370 , Hysterical, 354 , Loose body in, 363 , occipito-atloid, ^Disease of, 439 , Pyaemia of, 358, 359 , sacro-coccygeal, Disease of, 400 , sacro-iliac, Disease of, 370 , Sprain of, 34 , Suppuration in, 358 , temporo-maxillary, Disease of, 391 , Wound of, 44 Keloid scar, 49 Kidney, Cancer of, 544 Exploration of, 554 Rupture of, 151 Stone in, 544 Tubercular disease of, 544 Wound of, 160 Knee joint, Anchylosis of, 379 , Disease of, 371 , Examination of, 218 , Injuries of, 218 , Sprain of, 226 Labial abscess, 499 cyst, 407 tumour, 409 Lacerated wounds, 39 Laceration of brain, 92 Laming of intestine, 470 Larynx, Foreign bodies in, 122 , Fracture of, 118 , Scald of, 124 , Wounds of, 116 Lawn-tennis arm, 35 Leg, Injuries of, 226 , Length of, 206 Leontiasis, 390 Leucocythsemia, 284 Leucoplakia, 429 Ligaments, Disease of, 356 , lateral, of knee, Rupture of. 226 of spine, Injury of, 109 , Rupture of, 34 Ligamentous pain, 24 Ligamentum patellae, Rupture of, Lip, Epithelioma of, 406 , Strumous, 408 Lipoma, 286 , Congenital, 285 , , of spine, 404 .Diffuse, 287 of abdominal wall, Subcuta- neous, 466 of breast, 450 of scrotum, 504 of spermatic cord, 523 , Snbperitoneal, 466 Liver, Rupture of, 149 Local traumatic gangrene, 349 Localisation, Cerebral, 89 Lower jaw, Anchylosis of, 378 , Dislocation of, 115 , Fracture of, 114 Lower limb, Examination of, 198 , Injuries of. 198 , Measurements of, 201 Loss of smell, 95 Lung, Abscess in, 143 , Bruise of, 130 , Foreign bodies in, 123, 139 , Gangrene of. 143 , Hernia of, 127 , , with wound of pleura, 136 , injury of, Signs of, 130 , Rapture of, 132 , Wound of, 137 Lupus, 336 of face, 405 of hand, 556 Luxatio erecta of shoulder, 180 Lymphadenoma, 284 Lymphatic cysts, 293 glands in diagnosis of ulcers, 332 Lymph scrotum, 503 Macroglossia, 4241 Ma.1a.ria1 orchltis, 514 Malignant carbuncle, 352 disease of glands, 284 pustule, 351 tumour, 288 ulcer, 334 of groin, 525 Malleolus, Fracture of, 230 Mammary abscess, 445 Measurements of upper limb, 174 of lower limb, 202 Meatus urinarins, Papilloma of, 500 , Stricture of, 548 Mediastinal abscess, 144 574 SURGICAL DIAGNOSIS. Melanesia of penis, 499 Melanotic sarcoma, 290 Meningeal haemorrhage, Spinal, 106 Meningitis, Diffuse traumatic, 97 , Spinal, 105 Meningocele, 381 Meningo-encephalocele, 381 myelitis, Chronic, 106 Metacarpal bone of thumb, Dis- location of, 197 Metacarpus, Fracture of, 197 Metatarsus, Dislocation of, 238 , Fracture of, 237 Micturition, Act of, 536 Duration of, 538 Frequency of, 537 Interruption of, 538 Involuntary, 538 Unconscious, 537 Milk congestion, 444 cyst, 448 in tumours, 274 Mixed chancre, 496 gangrene, 345 Mobility of tumours, 254 Moist gangrene, 344 Molluscum contagiosuru, 286 fibrosum, 286 Morbus coxae, 370 Motor area of brain, 89 , to map out on skull, 90 Mouth, Dermoid cyst of, 417 , Diseases of, 417 Movement, Effect of, upon pain, 23 Mucous cyst, Fluid of, 276 of breast, 449 patches on lips, 409 on scrotum, 503 Multiplicity of ulcers, Diagnostic value of, 328 Mummification, 344 Mumps, 408 Muscle, abdominal, Eupture of, 149 , Contusion of, 34 of chest, Bruise and rupture of, 125 , Rupture of, 35 , Strain of, 34 Muscles of spine, Injuries of, 109 Muscular pain, 24 Myelitis, Spinal, 105 Myocarditis, 145 Myoma of testicle, 516 Myxoma of breast, 454 Neevoid skin over tamottrs, 263 Nsevus, 281 of oesophagus, 423 of rectum, 483 of spine, 404 of tongue, 424 , Subcutaneous, 382 Nails, Syphilitic disease of, 559 Nasal calculus, 416 polypus, 415 septum, Abscess of, 416 , Deflection of, 113 , Fracture of, 113 , Heematoma of, 112 , Tumour of, 416 Natifonn swellings, 383 Nature of a wound, 39 Neck, Acute swellings of, 430 , Aneurisms of, 435 , Bursal cyst of, 432 , Cellulitis of, 431 , Chronic abscess of, 433 , Dermoid cyst, 433 , Diseases of, 430 , Fluid tumours of, 432 , Glandular abscess of, 430 , Hydrocele of, 432 , Hygroma of, 432 , Lipotna of, 433 , Lymphatic glands of, 430 , Pulsating tumours of, 434 , Rheumatism of, 438 , Rigidity of, 436 , Sebaceous cyst of, 432 , Solid tumours of, 433 , Thyroid cyst of, 432 , Wounds of, 115 Necrosis, 315 of jaw, 392 of skull, 86, 386 of spine, 421 , Phosphorus, 392 , Sinus in, 340 Nelaton's line, 203 Neoplasms, Characters of, 245 Nerves, cranial, Lesions of, 95 , Division of, 48 , Injuries of, 37 of neck, Injury of, 117 , Wounds of, 42 Neuralgia of breast, 444 of cicatrix, 48 of rectum, 4S9 of testicle, 519 Neuralgic ulcer, 326 Neuroma, 282 of heart, 444 Neuromimesis, 354 Nipple, Diseases of, 441, 442 INDEX. 575 Nodes, 314 of skull, 383 Norna vulvte, 500 Non-penetrating wound of chest, 134 Nose, Deformity of, 412 , Discharge from, 411 , Diseases of, 410 , Examination of, 412 , Foreign body in, 416 , Fracture of roof of, 84 , Obstruction of, 411 , Polypus of, 415 Numbness with hypereemia, 21 Oblique hernia, 465 Obliterated aneurism, 304 Observation, Accuracy of, 6 Obstructed hernia, 468 Obturator hernia, 464, 532 Odontome, 393 (Edema, Causes of, 258 - , Signs of, 243, 257 of scrotum, 502 (Esophagus, Abrasion of, 121 , Congenital stricture of, 421 , Foreign bodies in, 120 , Nsevus of, 423 , Stricture of, 423 , Wound of, 116, 138 Oil cyst, Contents of, 277 Oleeranpn, Fracture of, 186, 191 , Disease of bursa over, 365 Omentum, Protrusion of, 45, 151 Onychia maligna, 559 Orbit, Fracture of roof of, 81 Orchitis, Acute, 511 , Chronic, 513 , Gouty, 514 , Malarial, 514 , Secondary, 516 , Strumous, 516 , Syphilitic, 516 Organisation of blood clot, 47 Orison of ulcers, Diagnostic value of, 329 Oro-nasal fistula, 340 Os calcis, Dislocation of, 235 , Fracture of, 235 magnum, Dislocation of, 196 Osteitis deformans, 315, 385 Osteo-aneurism, 319 phlebitis of skull, 86 myelitis, Acute, 48 of skull, 86 Ostitis, Chronic^ 314 Ovarian cyst, Enpture of, 135 Ovary, Hernia of, 531 Ozaena, 414 Paget's disease of bone, 315 of breast, 443 Pain with anesthesia, 25 at end of micturition, 535 , Central, 21 , Characters of, 25 , Constitutional effects of, 25 , Diagnostic value of, 21 , Diminished after micturi- tion, 535 , Effect of movement upon, 23 , Exact seat of, 21 in disease of anas and rec- tum, 478 of urinary organs, 533 increased by defaecation, 535 by movement, 535 during micturition, 534 Ligament eras, 24 Muscular, 24 Peripheral, 21 Referred, 534 Eeflex, 22 Painful erection of penis, 535 ulcer, 324 Palate, Diseases of, 417 Palm, Suppuration in, 556 Papilloma, 285 of bladder, 553 , Vascular, of meatus nrina- rius, 500 Paralysis, Spinal, 98 Paraphyinosis, 490 Parenchymatous haematocele, 510 Paronychia, 557 phlegmonosa, 557 tendinosa, 557 Parosteal sarcoma, 318 Parotid abscess, 408 cyst, 407 gland, Wound of, 112 tumour, 408 Parotitis, Acute, 408 Patella, Dislocation of, 221, 222 , Floating of, 371 , Fracture of, 222, 223 Patient, Examination of, 16 Pectoralis major, Rupture of, 125 Pelvic cellulitis, 168 viscera, Injuries of, 165 , Wounds of, 168 Pelvis, Contusions of, 163 , Fracture of, 164 , Hsematoina of, 164 576 SURGICAL DIAGNOSIS. Penetrating wound of chest, 134 Penis, Chancres on, 495 , Cicatrices on, 499 , Epithelioma of, 492, 497, 498 , Extravasation into, 168 , Gangrene of, 497 , Gouty induration of, 498 , Gnmma of, 498 , Melanesia of, 498 , Eecurrent chancre of, 497 , Scirrhus of, 498 , Thrombosis of, 498 , Tumours of, 497 , Ulcers of, 492 , Warts on, 492 Perforating ulcer, 335, 561 Pericarditis, 144 with effusion, 145 Pericardium, Wounds of, 137 Pericranium, torn. Diagnosis of, from fracture, 82 Periosteal abscess, 312 Periosteum, Bruise of, 29 Periostitis, Acute, 312 , Chronic, 314 , Circumscribed, 312, 314 , Diffuse, 312 of jaw, Acute, 387 , Chronic, 388 , Strumous, 314 , Syphilitic, 314 Periphlebitis, 282 Peripleuritic abscess, 141 Peritoneum, Wound of, 159, 169 Peritonitis, Acute, 161 , Chronic, 462 , Traumatic, 154 Periurethral abscess, 549 Personal history, 13 Phagedsenic ulcer, 327 Phalanx, Dislocation of, 239 , Fracture of, 197, 237 Pharyngitis, Acute osdematous, 419 Pharynx, Foreign bodies in, 120 , Wound of, 116 Phlebitis, 282 Phlebolith, 282 Phymosis, 490 J Pigmentation over tumours, 263 Pitting on pressure, 257 Plautaris, Rupture of tendon of, 229 Pleura, Foreign bodies in, 139 , Wound of, 136 Pleural fistula, 340 Pleurisy, 142 Pleuro-pneumonia, 143 Pneumatocele, 127 Pneumocele, Secondary, 145 Pneumonia, Traumatic, 143 Pneumothorax, 127 131 Poisoned wounds, 40 Polypus in antrum, 414 , Fibrous, 415 of bladder, 554 of gums, 393 , Mucous, of nose, 415 , , of rectum, 481, 484 of umbilicus, 454 Position of swellings, Diagnostic value of, 251 of ulcer, Diagnostic value of, 327 Pott's disease of spine, 396 fracture, 230 tumour of skull, 78 Pregnant uterus, Wound of, 169 Prepuce, Discharges from, 491 Preputial calculus, 491 fissure, 495 Pressure, Pitting on, 257 Previous history in diagnosis of tumours, 387 Primary gangrene, 346 union of wounds, 46 Progress, Mode of, 15 Prolapsus recti, 479 , Strangulated, 480 Prostate, Abscess of, 547 , Atrophy of, 548 , Hypertrophy of, 547, 548 , Malignant disease of, 547 , Tubercular disease of, 548 Prostatic calculus, 549 pain, 534 Prostatitis, Acute, 547 Prostration, with excitement, 60 Protrusion from anus, 473 of intestine, 45 of omentum, 45 Prurigo of scrotum, 503 Pruritus ani, 470 Pseudo-leucocytheemia, 284 Psoas abscess, 369 , Causes of, 528 bursa, Eifusion into, 371 Pulsating cephalhaematoma, 78 sarcoma of cranium, 382 tumours, 296, 297, 304 of neck, 434 Pulsation, Characters of, 297 in tumours, 264 , Venous, 267 Pulse, The, 51 , Arterial, in tumours, 266 Puncture of tumours, Diagnostic value of, 273 INDEX. 577 Punctured fracture of skull, 83 wounds, 39 Pus under scalp, 79 , Varieties of, 274 Pustule, Malignant, 351 Pyaemia, 67, 68 after injuries of skull, 86 Pycemic synovitis, 353 Pyarthrus, 358 Pyopericardium, 145 Pyuria, 544 Quadriceps extensor, Eupture of, 222 Eachitic spine, 395 Eadius and ulna, Dislocations of, 187 , Fracture of, 193, 194 , Dislocation of lower end of, 195 , of upper end of, 190 , Colles's fracture of, 194 , Fracture of head of, 192 , of lower end of, 195 , cf neck of, 192 , of shaft of, 193 , of styloid process of, 196 , Separation of lower epiphysis of, 194 Eanula, 417 Eayuaud's disease, 348 Eeaction, 59 of degeneration, 88 Eecto-vaginal fistula, 340 Eecto-vesical fistula, 340 Eectum, Atony of, 489 , Cancer of, 487 , Chancre of, 485 , Chronic catarrh of, 483 , Commencing cancer of, 487 , Congenital deformities of, 489 , Dysenteric stricture of, 487 , Examination of, 481 , Faeces in, 489 , Foreign bodies in, 169, 489 , Nsevus of, 483 , Neuralgia of, 489 , Polypus of, 481, 484 , Simple stricture of, 488 , Strumpus ulcer of, 485 , Syphilitic stricture of, 487 , olcer of, 485 , Ulcer of, 485 Recurrent chancre, 497 Redness and heat, 20 L L 13 Eedness and swelling, 20 , Causes of, 18 , Colour of, 19 due to dyes, 19 , Effects of pressure upon, 18 Eeducible hernia, 467 tumour over artery, 305 Eeducibility of swellings, 269 by position, 2n9 hy pressure, 270 Eeduction en bloc, 469 Beflexes, Spinal, 101 Reflex pain, 22 Residual urine, 538, 539 Respiration in fracture of cervical spine, 53 in laryngeal obstruction, 53 in peritonitis, 53 in rickets, 53 Eetention cysts, 293 of urine, 539 Ehagades digitorum, 561 of lip, 409 Eheumatism, Acute articular, 359 , Muscular, of chest, 140 , , of neck, 438 Eib cartilages, Separation of, from ribs, 128 Bibs, Fracture of, 129 Bickets, 313 Bickety skull, 385 Eider's bone, 533 sprain, 35, 533 Eigidity of neck, 436 Rodent ulcer, 334, 406 Bupture of abdominal muscle, 149 of aneurism, 241, 304 of artery, 36, 241, 306 of bladder, 167 of chordae tendinese, 133 of diaphragm, 152 of intestine, 150 in hernia, 469 of kidney, 151 of large vessels of chest, 133 of lateral ligament of knee, 226 of ligament, 34 of liver, 151 of lung, 132 of muscle, 35 of ovarian cyst, 153 of patellar ligament, 222 of plantaris, 229 of quadriceps extensor, 222 of semilunar valves, 133 of spleen, 151 of stomach, 150 of tendo Achillis, 228 578 SURGICAL DIAGNOSIS. Rupture of tendon, 35 of ureter, 157 of urethra,, 165 of uterus, 153 of vas deferens, 166 of vein, 37 Saccnlated aneurism, 303 Sacculus of bladder, 551 Sacral tumour, Congenital, 403 Sacro-iliac disease, 370 Saliva, Tests for, 112 Salivary calculus, 417 fistula, 112, 407 Sarcocele, Gummatous, 514 , Syphilitic, 513 Sarcoma, Central, of bone, 317 of bone, 317 of breast, 453 of cranium, 384 , Pulsating, 382 of testicle, 515 , Parosteal, 318 -, Subperiosteal, 317 , Varieties of, 289 Saucer fracture of skull, 83 Scald of larynx, 124 Scalp, Abscess of, 79 , Bruise of, 76 -, Cellulitis of, 79 , Cerebro-spinal fluid beneath, 82 , Erysipelas of, 79 , Hsematoma of, 77 , Injuries of, 76 , Pott's tumour of, 78 , Pus beneath, 79 -, Tumours of, 38i , Wounds of, 76 Scaphoid, Dislocation of, 238 Scapula, Dislocation of, 178, 233 , Examination of, 171 , Fracture of, 179 , of acromiou process of, 181 , of body of, 185 . of coracoid process of, 181 , of neck of, 184 Scar in scalp. Diagnostic value of, 78 , Keloid, 49 -, Neuralgia of, 48 Scirrhe en cuirasse, 453 Scirrhus of breast, 451 of penis, 498 Sclerosis of tongue, 430 Scoliosis, 396 Scorbutic ulcer, 334 Scrofulide, 288 Scrofulous bubo, 525, 532 glands, 288 Scrotum, Abscess of, 502 Chancre of, 50 1 Eczema of, 501 Elephantiasis of, 503 Epithelioina of, 503, 501 Erysipelas of, 502 Gangrene of, 505 Intertrigo of, 501 Lipoma of, 504 lymph, 503 Mucous patches of, 503 (Edema of, 502 Prurigo of, 503 Sebaceous cyst of, 503 Sinus in. 504 Ulcers of, 504 Sebaceous cyst, Fluid of, 276 of groin, 530 of scalp, 383 of scrotum, 503 Secondary gangrene, 346, 350 hscmorrhave, 47 orchitis, 517 union of wounds, 47 Secretion, Diagnosis of accumula- tion of, 245 Semen in urine, 545 Semilunar cartilage, Displacement of, 225, 373 valves, Rupture of, 133 Seminal cy^t, 517 Senile gangrene, 348 Separation of epipliysis, 31 of femur, lower, 220 of great trochanter, 215 of hunierus, lower, 190 , upper, 182 of radius, 194 , tibia, 233 of gangrenous tissues, 343 of inanubnum from gladiolus, 128 of rib cartilages from ribs, 128 Septicaemia, 63 Sjptic gangrene, Acute, 350 infection, 66 iutoxicatiou, 65 Septum nasi, Abscess of, 415 , Deviation of, 415 , Enchoudroma of, 41o , Fracture of, 113 , Osteouia of, 416 Sequence of symptoms, 15 Serous cavities, Wounds of, 44 cysts, 293 INDEX. 579 Serous fluid, 276 Serpiginous ulcer, 327, 525 Sex in diagnosis of tumours, 278 Shape of ulcers, Diagnostic value of, 329 Sheath, peroneal, Effusion into, 375 , posterior tibial, Effusion into, 375 Shock in abdominal contusions, 148 , Nature of, 56 Shoulder, Anchylosis of, 378 , Disease of, 364 , Dislocations of, 180 , Examination of, 170 -, Fracture of, 181 Significance of clinical phenome- na, 9 Simple fracture, 31 Sinus, 339 , Causes of. 340 in caries, 341 in face, 407 in groin, 525 in gum, 392 in necrosis, 340 in scrotum, 504 Skin, Colour of over tumours, 263 Skull, Contusion of, 80 , Examination of, , Fracture, Compound, 82 , , Depressed, 81 , , Fissured, 81 , of hose of, 83 , of inner table of, 83 , of posterior tout a, of base of, 86 , Hypertrophy of, 385 , Infraction of, 81 , Injuries o f , 80 , , Pyaemia after, 86 , , Secondary effects of, 86 , Necrosis of, 86, 386 , Osteo-myelitis of, 86 , Osteo- phlebitis of, 86 , Separation of tables of, 83 , Sutures of, 81 , , Separation of, 81 , , Thrombosis of, 86 in congenital syphilis, 81 Sloughing gumina, 353 phagedaenic chancre, 524 ulcer, 327 Smell, Loss of, 95 Snuffles, Thf, 413 Soot wart, 503 Sounding the bladder, 551 Spermatic cord, Abscess of, 522 , Diffused haematocele of, 523 , hydrocele of, 523 , Encysted hydrocele of, 522,530 , Inflammation of, 523 , Lipoma of, 523 , Tumour of, 523 Spina biflda, 403 , False, 403 Spinal concussion, 100 cord, Crush of, 105 , Wound of, 111 debility, 395 haemorrhage, 100 irritation, 105 meningitis, 100, 105 , Diagnosis from tetanus, 73 myelitis, 100, 105 necrosis, 421 paralysis, 98 , Cause of, 99 , Extent of, 99 , Seat of, 100 reflexes, 101 Spine, Angular curvature of, 396 , Caries of, 396, o99 , Diseases of, 393 , Examination of, 98, 107, 394 , Hysterical, 399 , Injuries of, 98 , Lateral curvature of, 397 of scapula, Fracture of, 179 , Eachitic, 395 , Eheumatism of, 438 , Eotation of, 398 , Tumours of, 403 , Weak, 397 , Wound of, 110 Spleen, Eupture of, 151 Splintered fracture, 31 Spondylitis defonnans, 395 Spontaneous fracture, 317, 319 gangrene, 347 Sprain, 34 of ankle, 236 of knee, 226 , Eider's, 35, 533 of cpine, 109, 110 Spreading traumatic gangrene, 349,350 ulcer, 326 Stab of neck, 116 Starting pains in disease of joints, 356 State of circulation in diagnosis of ulcers, 332 S 8o SURGICAL DIAGNOSIS. State of nervous system in dia- gnosis of ulcers, 332 Steno's duct, Wound of, 112 Sterno-mastoid tumour, 433 Sternum, Fracture of, 128 Stomach, Enpture of, 150 , Wound of, 160 Stone in bladder, 551 , Hcematuria in, 543 , Pain in, 535 , Saccnlated, 553 Strain of muscle, 34 Strangulated hernia, 467 Strangulation, Internal, 458 Stricture of anus, 477 of meatus urinarius, 548 of rectum, 487 of urethra, 518, 549 Struma, Heredity of, 12 Strumous abscess of breast, 449 arthritis. Chronic, 361 glands, 283 nodes, 314 orchitis, 516 ulcer, 338 Strychnia poisoning diagnosis from tetanus, 73 Styloid process of radius, Frac- ture of, 196 Subacute pyuemia, 359 synovitis, 358 Subaponeurotic cepliallioemat o;iu> , 77 Snbcoracoid dislocation of shoul- der, 180 Subcutaneous emphysema, 127, 130 Subglenoid dislocation of shoul- der, 180 Submammary abscess, 445 Subpectoral abscess, 140 Subpericranial cephalhsematoma, 77 Subperiosteal sarcoma, 317 Subphrenic abscess, 157 Subspinous dislocation of shoul- der, 180 Subungual exostosis, 562 Suppurating hsematoma, 27 of scalp, 78 Suppuration in bursa, 360 in palm, 557 Suppurative fever, 70 Supracoudyloid fracture of hu- merus, 191 Supracoracoid dislocation of shoulder, 181 Supramarnmary abscess, 443 Sustentaculuin tali, Fracture of, 236 Suture, Separation of, 83 Sympathetic bHbo, 532 Symptoms, Sequence of, 15 , Relative intensity of, 16 Syncope, 57, 58 Synovial cysts, 276, 294, 364 membrane, Bruis of, 34 , Disease of, 356 , Wound of, 43 sheath, Disease of, 356 Synovitis, Acute, 358 , Chronic, 360 , Pyasmic, 358 , Subacnte, 358 , Syphilitic, 362 Syphilis, Heredity of, 10 , Tertiary, of face, 408 Syphilitic disease of bone, 313 of glands, 283 nodes, 314 orchitis, 516 sarcocele, 513 synovitis, 362 ulcer, 337, 338 Swelling arising rapidly, 242 Change of position of, 2 18 Continuity in, 247 Diminution of, 246 fluid, 254 Intermittent, 216 , Increase of, 218 Slowly-formed, 243 Solid, 258 Stationary, 246 suddenly increasing, 217 produced, 240 Tables of skull, Separation of, 83 Talipes, 559, 560 Tarsus, Anchylosis of, 379 , Disease of, 562 , Dislocation of, 232 Taxis, Effects of, 469 Temperature, local, Diagnostic value of, 20 , , in gangrene, 342 Temporal abscess, 386 Tendo Achillis, Rupture of, 228 Tendon, Dislocation of, 35 , Rupture of, 35 Tenesmus, Rectal, 471 , Vesical, 536 Teno-synovitis of wrist, 556 , Dry, 558 Tension, Fever of, 65 Testicle, Atrophy of, 506 , Cystic fibroma of, 515 , sarcoma of, 515 INDEX. Testicle, Cysts of, 516 , Enchondroma of, 515 , Imperfect development of, 506 , Irritable, 519 , Malignant tumour of, 514 , Neuralgia of, 519 , Position of, in hydrocele, 509 , Simple tumour of, 516 , Undescended, 503, 531 Tetanus, 72 Thigh, Injuries of, 216 , Length of, 205 Thoracic duct, Wound of, 138 Thrill in tumours, 265 Thrombosis, Arterial, 37 , , cause of gangrene, 347 , Cardiac, 59 of cranial sinuses, 86 of penis, 498 , Pulmonary, 59 , Venous, 37, 282 , , cause of gangrene, 349 Thrombus, Suppuration of, 282 - -, Venous, 243 Thrush of Tongue, 429 Tibia, Dislocation of, 219, 220 , Fissure of, 228 , Fracture of head of, 224 , of shaft of, 227 , Separation of lower epiphysis of, 234 Tibia and fibula, Fracture of, 227 , of back of, 235 , of lower end of, 233 Tissues around ulcers, 322, 331 Toe-nail, Ingrowing, 561V, Tongue, Abscess of, 424, 425 , Annulus migrans of, 429 , Chancre of, 428 , Diseases of, 423 , Dyspeptic ulcer of, 428 , Epithelionra of, 428 , Fibroma of, 424 , Gumma of, 424, 425 , Hydatid cyst of, 425 , Ichthyosis of, 429 , Local ulcer of, 427 , Mercurial ulceraMcn of, 427 , Mucous cyst of, 425 , patches of, 429 - , Nsevus of, 424 , Papilloma of, 424 , Sclerosis of, 429 , Syphilitic ulceration of, 427, 428 , The, in diagnosis, 54 -, Thrush of. 429 tie, 423 Tongue, Tumours of, 424 , Tubercular ulcers of, 428 , Ulcerated gumma of, 428 , Ulcers of, 425 , Wound of, 116 Tonsillitis, 419 Tonsils, Abscess of, 419 , Carcinoma of, 420 , Chancre of, 421 , Diseases of, 419 , Epithelioma of. 420 , Gumma of, 420 , Hypertrophy of, 420 , Sarcoma of, 420 , Ulcers of, 420 Torticollis, 436 Trachea, Foreign bodies in, 122 , Rupture of, 118 , Wound of, 116 Translucency of coverings of tumours, 262 of tumours, 261 Traumatic delirium, 71 gangrene, 349 meningitis, 97 swellings, 246 ulcer, 337 Traumatopncea, 134, 136 Treatment, Influence of, 17 Trismus, Acute spasmodic, 390 , Cicatricial, 391 , Eeflex, 391 Trochanter, great, To ascertain position of, 203 Trophic gangrene, 348 ulcer, 335 Tubercle bacillus, How to stain, 426 Tuberosity of hnmerus, Fracture of, 183 Tumour, age of patient, Influence of, in diagnosis of, 277 , Bruit in, 265 , Colour of skin over, 263 , Congenital, 239 , , of sacrum, 403 , Connections of, 251 , Consistence of, 254 , , Variations of, 250, 259 , contents of, Fluid, 274 , Diagnosis of general, 279 , Direction of enlargement of, 248 , Fatty, 286. (Se Lipoma.) , , Congenital, 285 , Fluid contents of, 274 , Foetal, of spine, 404 , Form of, 260 , Gas in, 250 582 SURGICAL DIAGNOSIS. Tnmour, General diagnosis of, 239 , growth of. Mode of, 249 , Hyperaemia over, 263 in childhood, 277 in heart, 267 in infancy, 277 , Influence of effort upon, 272 , Inguinal, 527 , Inguino-scrotal, 519 , Intrascrotal, 507 , Malignant, 288 , , of spermatic cord, 523 , , of testicle, 514 , , of tunica vaginalis, 515 , Microscopic examination of, 273 , Nsevoid skin over, 264 of bladder, 551, 553, 554 , Hipmuturia in, 43 of bone, Acute, 311 , Chronic, 313 , Diagnosis of, 303 , Examination of, 308 of breast, 446 of groin, 527 of lymphatic glands, 283 over aneurism, 307 over artery, 305 , Parotid, 408 , Pigmentation over, 264 Position of, 250 , Pressure effects of, 272 , previous history, Influence of, on diagnosis, 278 , Pulsating, 30 1 , Pulsation in, 264 , Pulse beyond, 267 , Puncture of, 273 , Eeducibility of, 269 , sex, Influence of, upon, 278 , Scrotal, 02 , , Puncture of, 517 , tapping, Effects of, 277 , Thrill in, 265 , Translucency of, 261 , Transparency of covering of, 262 , Ulceration of, 249 , Vesical, 551, 553, 554 Tunica vagiualis, Hxematoeele of, 509 , Hernia into, 465 , Hydrocele of, 508, 510 .Malignant disease of, 515 Tympanum, Fracture into, 84, Typhoid state, 62 Ulcer, Base of, 320 , Callous, 326 , Chronic, 326 , Condition of, 331 , Diagnosis of cause of, 327 , of condition of, 32 1 , Discharge of, 323 , Eczematons, 334 , Edge of, 321 , Epitheliomatous, 337 , Exuberant, 325 , Fuvgous, 325 , General diagnosis of, 319 , Gouty, 334 , Gummatous, of penis, 497 , Haemorrbagic, 327 , Healing, 325 , Indolent, 326 , Inflamed, 321 , Irritable, 326 , Luppns, 336 , Malignant, 334 , of groin, 523 , Neuralsrie, 326 , Number of, 328 , (Edeuiatous, 325 of anus, 477 of bladder, 553 , Origin of, 329 , Perforating, 335, 561 , Phagedesnic, 327 , position of, Diagnostic value of, 327 , Primary syphilitic, 336 , Rodent, 331, 403 , Scorbutic, 334 , Serpiginous, 327 , , of groin, 525 , Shape of, 329 ' , Sloughing, 327 , Spreading, 326 , Stationary, 326 , Strumous, 338 , Syphilitic, 337, 338 , Tissues around, 322 , Traumatic, 337 , Trophic, 335 , Varir ose, 338 Ulcers of face and lips, 405 of penis, 492 of rectum, 485 of scrotum, 504 Ulcerated sebaceous cyst, 384 Ulceration of sores on penis, 493 of tumours, 249 Ulna, Fracture of coronoid process of, 187 . of shaft of, 193 Umbilical hernia, 464 INDEX. Umbilicus, Diseases of, 454 , Polypus of, 451 Undescencled testicle, 506, 531 , Inflammation of, 531 Union of wounds, 46 Upper limb, Examination of, 170 , Injuries of, 169 , Measurements of, 174 Urachal fistula, 454 Urea, Test for, 161 Ureter, Eupture of, 157 Urethra, Abscess opening into, 544 , Foreign bodies in, 169 , Eupture of, 165 , Stricture of, 548 , Wound of, 165 Urethral calculus, 549 fever, 555 Urethritis, 491, 546 in female, 499 Urinary cyst, 157 fistula, 162, 538 in groiu, 526 Urine, The, 541 , Changes in, in spinal para- lysis, 104 , Cysts in, 545 , Dribbling of, 538 , Excretion of, 54 , Extravasation of, 166, 2 12, 502 , Faeces in, 545 , Hair in, 545 , Incontinence of, 102, 533 , , Nocturnal, 537 , Eesidual, 538, 539 , Retention of, 539 , Suppression of, 539 , Villi in, 546 Uterus, pregnant, Contusion of, 153 , , Wound of, 169 , , Eupture of, 153 Vagina, Foreign bodies in, 169 Vaginal hydrocele, 508 Vaginitis, 499 Value of evidence, 7, 8 Vuricocele, 508 Varicose aneurism, 302 ulcer, 338 Varix, 295 , Aneurismal, 302 , Hsemorrhoidal, 483 of saphena vein, 53C , Vesical, 5^3 Vascular papilloma of meatus urinarius, 500 Vas deferens, Eupture of, 166 Vegetations, Adenoid, 416 Vein, Dilatation of, 245 , Entrance of air into, 41, 59 , Eupture of, 37 , Thrombosis cf, 37 Venous engorgement, 268 pulsation, 267 thrombosis, 243, 232 Ventral hernia, 464 Ventricles of brain, Laceration into, 92 Vertebra, Injuries of, 10S Vesical pain, 534 tumour, 553 varix, 543 Vesico-vaginal fistula, 340 Virulent bubo, 524 Volvulus, 459 Vomiting, Causes of, 54 Vulva, Epithelioma of, 500 Vulvitis, 499 , Follicular, 500 Warts, 285 on penis, 492, 498 Water-bottle hydrocele, 522 Weak spine, 396 ulcer, 325 AVhite swelling, 361 Whitlow, 557 Wound of abdomen, 158 , with protrusion of vis- cera, 159 , with wound of viscera, 160 - of bladder, 160, 168 of bone, 42 of bur.su , 44 of chest, 133 of duct of gland, 45 of epiglottis, 116 of gall bladder, 161 of heart, 137 of intestine, 160 of joint, 44 of kidney, 160 of larynx, 116 of lung, 137 of muscle, 40 of neck, 115 , inflicted from within, 117 of nerves, 42 of esophagus, 116, 138 of parotid gland, 112 of pelvic viscera, 168 of pericardium, 137 of peritoneum, 168 of pharynx, 116 584 SURGICAL DIAGNOSIS. Wound of pleura, 136 of serous cavities, 44 of spinal cord, 111 of spine, 110 of Steno's duct, 112 of stomach, 160 of tendon, 40 of thoracic duct, 138 of tongue, 116 of trachea, 116 of urethra, 168 of uterus, 169 of vessels, 41 Wounds involving deep fascia, 40 Nature of, 39 Parts injured in, 40 Poisoned, 40 Punctured, 39 Wrist, Anchylosis of, 378 Examination of, 174 Fractures and dislocations of 193 Inflammation of, 556 . Teno-synovitis of, 556 Wry-neck, 436 CASSELL AND COMPANT, LIMITED, Bi-LLK SAUVAGE WOBKS, LONDON, B.C. Date Due PRINTED IN U.S.A. CAT. NO. 24 161 A 000511 099 WO G6"96e 1881* Gould, Alfred Pearce Elements of surgical diagnosis MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664