. u\^3^^is:;^ {<{x^ ;3^ THE %^ 3 LIBRARIES V / > Of t**^ CLINICAL SURGICAL DIAGNOSIS FOR STUDENTS AND PRACTITIONERS. BY F. DE OUERVAIN Professor of Surgery and Director of the Surgical Clinic at the University of Basle WITH 510 ILLUSTRATIONS AND 4 PLATES Translated from the Fourth Edition by J. SNOWMAN, M.D. NEW YORK WILLIAM WOOD AND COMPANY MDCCCCXIII 55 3r ^ u- f I AUTHOR'S PREFACE TO THE ENGLISH EDITION. Thjs book, the English version of which affords me special pleasure, is the outcome of years of association with students, as I teacher, and with medical practitioners at consultations. ' It is ntended to serve as a guide to the former in the vast field of surgical iiagnosis which they are required to explore, and to recall to the after knowledge which has perhaps faded, while drawing their ittention to new developments in diagnosis. To this end I have employed the methods of investigation which are available for he general practitioner, or at any rate which can easily be :arried out for him. These methods comprise the bacteriological, serological, histological and radiographic researches, without which, lowadays, a reliable diagnosis cannot be obtained. I adhere throughout to the plan of starting with the symptoms A^hich caused the patient to seek medical advice, and not to the nethod of deducing symptoms from an already made diagnosis. If the appropriate questions have been correctly put, the problem vill in every case be narrowed down more and more, until, ultimately, he student arrives at a definite diagnosis, either as the result of Dositive symptoms or by a process of gradual exclusion. After ong training in this method, the student may be permitted to :liagnose a case as a whole, without first considering each symptom separately. One thing, however, must be borne in mind. Important IS it is to have an accurate diagnosis, our endeavours to obtain one iare not entail injury to the patient, nor involve the loss of the most Hvourable moment for a successful operation, while refinements of iiagnosis are being investigated. A diagnosis is not to be made iierely for its own sake, but as a means to a cure. This book represents, above all, the fruit of my own experience, md the illustrations are, with a few exceptions, derived from my )wn observations. The contents may, in consequence, be necessarily ncomplete in certain particulars, but I trust that this is compensated or by vividness of description. F. DE QUERVAIN. Basle, February, 19 13. Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/clinicalsurgicalOOquer CONTENTS. PART I. SURGICAL DISEASES OF THE HEAD. I.— FRACTURES OF THE SKULL I. — Direct Symptoms 2. — Indirect Symptoms IL— INJURIES OF THE BRAIN I. — Concussion' of the Brain 2. — Contusion of the Brain ... 3. — Cerebr.al Pressure following H.f:morrhage III.— ABSCESS OF BRAIN, HEMORRHAGIC PACHY- MENINGITIS, CYST OF BRAIN, TUMOUR OF BRAIN I. — Abscess of Br.ain 2. — Hemorrhagic Pachymeningitis 3. — Traumatic Cysts of the Br.ain 4- — New Growths .and Tumours of Granulation- Tissue PAGE I 2 4 7 8 10 17 18 20 21 OF SUP- IV.— THE CEREBRAL COMPLICATIONS PURATIVE OTITIS MEDIA v.— THE PROBLEM OF EPILEPSY VI. -SOME REMARKS ON CEREBRAL LOCALIZATION AND FOCAL DIAGNOSIS VII.— THE SURGERY OF EXOPHTHALMOS VIII. —ACUTE INFLAMMATORY PROCESSES ON THE SKULL IX.— SWELLINGS OF THE HEAD A. — Congenit.al Swellings of the Head B. — ACQUIRED Swellings of the Head I. — Innocent acquired Swellings 2. — Malignant Tumours of the Head and Chronic Inflammatory Swellings ... X.— ACUTE INFLAMMATORY DISEASES OF THE FACE XL— TUMOURS AND ULCERS OF THE FACE A. — Tumours with Overlying Skin unbroken B. — Ulcerative Processes XII.— INJURIES OF THE J.\W XIII.— LOCK-JAAV 25 34 38 49 51 56 59 62 62 64 7?> 75 Vlll. CONTEXTS PAGE XXX.— TUMOURS AND ALLIED GROWTHS AVITHIN THE THORAX iqq I. — Mediastinal Tumours 199 2. — Tumours of the Lung 207 XXXL— SWELLINGS AND TUMOURS OF THE THORAX 208 A. — Primary Disease within the Thorax 208 B. — Primary Disease of the Thoracic Wall ... ... 210 I. — Acute Diseases ... ... ... ... ... ... 210 2. — Chronic Diseases ... ... ... ... ... 211 a. — Chronic Inflammatory Processes ... ... 211 b. — Tumours ... ... ... ... ... ... 216 XXXIL— INFLAMMATORY DISEASES OF THE BREAST ... 219 I. — Acute Inflammations 219 2. — Chronic Inflamm.ations 221 XXXIIL— TUMOURS AND ALLIED STRUCTURES IN THE BREAST 223 A. — Multiple Tumours ... 224 B. — Single Tumours 224 I. — Small and Medium-sized Tumours ... ... 224 2. — Large Tumours ... ... ... ... ... 232 PART IV. SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA. XXXIV.— DISPLACEMENTS OF THE ABDOMINAL VISCERA 235 XXXV.— ABDOMINAL INJURIES '244 A. — Injuries without an Open Wound 244 -Gastro-intesnnal Canal ... ... ... ... 245 -The Spleen ... ... ... ... ... ... 247 -Liver and Bile Ducts ... ... ... ... 247 -The Kidneys ... ... ... ... ... ... 248 -The Bladder ... ... ... ... ... ... 250 B. — Injuries to the Abdomen with Open Wounds ... 251 I. — Gun-shot Wounds ... ... ... ... ... 252 2. — Stabs and Incised Wounds ... ... ... ... 253 XXXVI.— ACUTE INFLAMMATION WITHIN THE AB- DOMINAL CAVITY 254 A. — Abdominal Pain without Perceptible Changes ... 261 B. — Diffuse Peritonitis without Localization ... 263 C. — Localized Peritonitis 265 I. — Epigastrium ... ... ... ... ... ... 265 2. — Right Hypochondrium ... ... ... ... 265 3. --Left Hypochondrium ... ... ... ... ... 266 4. — Lumbar Regions ... ... ... ... ... 266 5. — Lower Abdominal Region 266 6. — True Pelvis ... ... ... ... ... ... 275 CONTENTS ix. PAGE XXXVII. ^SUB-PHRENIC ABSCESS 276 I. — Sub-phrenic Abscess without Pleural Effusion ... 277 2. — Sub-phrenic Abscess with Pleural Effusion ... 279 XXXVIII.— TUBERCULAR PERITONITIS 281 XXXIX.— DIAGNOSIS OF ABDOMINAL SWELLINGS IN GENERAL 287 XL.— SURGICAL DISEASES OF THE STOMACH ... 291 A. — Foreign Bodies in the Stomach 292 B. — Displacements of the Stomach 293 C. — Gastric Ulcer 294 I. — Uncomplicated Gastric Ulcer ... ... ... 294 2. — Haemorrhage ... ... ... ... ... ... 296 3.— Perforation ... ... ... ... ... ... 296 4. — Cicatricial Stenosis ... ... ... ... ... 299 D. — Cancer of the Stomach 305 I. — Cancer of the Body of the Stomach ... ... 310 2. — Cancer of the Pylorus ... ... ... ... 311 XLI.—SURGICAL DISEASES OF THE BILIARY PASSAGES 313 I. — G.all-stone Colic 314 2. — Acute Cholecystitis 316 3. — Gangrenous Cholecystitis 318 4. — Obstruction of the Common Bile-duct 321 5. — Hydrops of the Gall-Bladder, Chronic Empyema 323 6. — Acute Cholangitis 324 XLIL— TUMOURS OF THE LIVER 325 XLIIL— SURGERY OF THE PANCREAS 327 I. — Acute Pancreatitis and Pancreatic H/Emorrhage ... 328 2. — Chronic Pancreatitis, Cancer of the Head of the Pancreas, Pancreatic Calculus 329 3. — Pancre.^tic Tumours and Cysts 329 XLIV.— SURGERY OF THE SPLEEN 330 I. — Abscess of the Spleen 330 2. — Splenic Hypertrophy 330 3. — Tumours of the Spleen 331 XLV.— ACUTE APPENDICITIS 332 XLVL— COLITIS, SO-CALLED CHRONIC APPENDICITIS AND FUNCTIONAL DISTURBANCES OF THE LARGE INTESTINE 339 A. — Colitis with Definite Anatomical Changes ... 339 B. — Functional Derangements of the Large Intestine without Typical Anatomical Changes 342 XLVII.— INTESTINAL OBSTRUCTION 346 I. — Stenosis of Gradual Development (Chronic In- testinal Obstruction) 347 ^ — Symptoms ... ... ... ... ... ... 347 ^- — The Position of the Stenosis ... ... ... 350 c. — Form and Cause of the Stenosis ... ... ... 351 CONTEXTS PAGE 2. — Acute Intestinal Obstrixtiox 357 a. — Symptoms ... ... ... ... ... ... 357 h. — The Position of the Obstruction ... ... ... 358 c — The General Varieties of Acute Obstruction ... 360 d. — Causes of Acute Intestinal Obstruction ... ... 361 I. — Obstruction due to Bands and Kinks ... 361 2. — Obstruction by Gall-stones ... ... ... 362 3. — Intussusception ... ... ... ... ... 363 4. — Volvulus ... ... ... ... ... ... 364 5. — Strangulation of Internal Hernia ... ... 365 6. — Spastic Obstruction ... ... ... ... 367 XLVIIL— TUMOURS AND SWELLINGS IN THE ABDO- MINAL PARIETES 368 I. — The Upper Abdominal Region 368 2. — The Umbilical Region 371 3. — INGUIN.AL region 374 4. — The Lumbar Region 375 5. — Swellings an^d Tumours in Atypical Positions ... 376 XLIX.— ABDOMINAL SINUSES 377 L.— EXTERNAL INGUINAL HERNIA 379 I. — Diagnosis in the Absence of Hernial Swelling ... 380 2. — Diagnosis of Inguinal Hernial Swellings ... 382 3. — Diagnosis of Labial and Scrot.al Hernia 387 LL— INTERNAL OR DIRECT INGUINAL HERNIA ... 390 LIL— FEMORAL HERNIA 392 LIIL— TRAUMATIC HERNL^ 396 LIV.— STRANGULATED HERNIA 398 I. — Is the Case really on^e of Hernia? .... 398 2. — Is THE Hernia str.-^ngulated ? 401 3. — What does the Hernia contain? 402 4. — Where is the Str.4ngulation situated? 403 5. — What is the Condition of the Str.angulated Gut? 403 6. — The Questions w^hich may arise during Operation 404 7. — Questions which arise after Reduction by the Open or Bloodless Method ... 405 LV.— DIFFICULTIES OF DEF^EXATION 407 LVL— INJURIES OF THE RECTUM 412 LVIL— TUMOURS AND SWELLINGS OF THE SCROTUM 414 I. — Savellings of the Scrotum 414 a. — Acute Swelling's ... ... ... ... ... 414 h. — Chronic Swellings ... ... ... ... ... 415 2. — Swellings of the Scrot.al Contents 415 a. — Tumours of the Spermatic Cord ... ... ... 415 b. — Acute Swellings of the Testicle and Epididymis 416 c — Chronic Sv\-ellings of the Testicle and Epididymis 419 I. — Swellings of the Epididymis ... ... ... 419 2. — Swellings between the Testicle and Epididymis 420 3. — Swellings of the Testicle ... ... ... 420 LVIIL— FISTULA IN PERINEAL REGION 423 I. — Dermoid Fistul.^ 423 2. — Fistul/e in Con*nection with Bone 424 3. — fistul/e of the rectum and anus 424 4. — Urinary Fistul.^ 426 CONTENTS xi. PAGE 428 428 429 LIX.-GENERAL REMARKS ON THE SURGICAL DISEASES OF THE URINARY ORGANS ... 427 A.— DISTURBA^-CES OF MICTURITION I- — Painful Micturition 2. — Difficult Micturition ^:i^:^:^V>\\^^^ often operated for mas- toid disease know that there maybe severe sup- puration, and even se- questrum formation, in cases which have pre- sented but little tender- ness, and which have had neither swelling nor reddening of the mas- toid process. We must therefore take the other symptoms into con- sideration, principally the temperature and the subjective feelings of the patient. If the original symptoms of an acute otitis have sub- sided, and then there is another rise of tem- perature accompanied by pain behind the ear, or if these symptoms ap- pear during the course of a chronic otitis, we may infer the presence of mastoid disease, although the external visible sign may be indefinite. We may explain facial paralysis following aural suppuration in the same way. It should not be forgotten that, exceptionally, mastoid disease can occur without suppuration in the tympanic cavity. If cerebral complications have supervened, our third diagnostic task is to determine their character accurately. Two practical Fig. 5- — Diagram of inflammatory complications in sup- puration of the temporal bone area. Green = pus; red = inflamed menmges ; blue =: venous sinus; violet = throm- bosed sinus, a = mastoid antrum ; b = mastoid process cells ; c = thrombosed transverse sinus ; d subdural abscess; e ^= abscess in temporal lobe; /= cerebellar abscess ; g = abscess under the sterno-mastoid (Bezold's abscess). CEREBRAL COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA 29 questions are of urgent importance, viz., are the observed symptoms only sympathetic and reflex, or are they due to anatomical changes within the skull ? If the latter, do these represent an epidural abscess, a cerebral abscess, meningitis, or thrombophlebitis of the transverse sinus ? The correct interpretation of these questions is of decisive signifi- cance to the life of the patient. It is obvious that an acute suppurative process in close proximity to the brain has some effect thereon. Every enclosed focus of infection is surrounded by a zone of circulaiory disturbance, and in the case of a focus in the ear, the neighbouring area of brain and its sheaths may be involved. This explains the existence of a congested disc without any further changes within the skull. In addition to local circulatory disturbances, there are the pure rejiex processes, which are especially well marked in children, and the symptoms of a general intoxication. Delirium, convulsions, and even rigidity of the neck, when they occur in the first acute onset of an otitis, or in mastoiditis, must not forthwith be put dou^n to menin- gitis. We should be content with opening the local focus of suppura- tion in the tympanum or in the mastoid process, and carefully watching the course of events. Actual cerebral complications take a definite time to develop, usually a few days. They do not accompany the first aural symptoms, not even in rapidly acute cases ; but they follow them. But if such symptoms persist after the mastoid process has been properly drained, or if they occur afresh, then not only are we justified in diagnosing an intracranial complication, but we are compelled to do so and to act upon it. We have hitherto been deaUng with the matter from the point of view of an acute onset of otitis or mastoiditis. But this is not an invariable aspect. Discharge from the ear — chronic otitis — may have been present for years. Occasionally there is a temporary cessation of the discharge and the patient feels a dull pain deeply within the ear. The thermometer indicates a slight rise in temperature, but the patient, accustomed as he is to his malady, consults neither a ther- mometer nor a doctor. He knows that the discharge will soon start again, and he is content. But a fortnight or three weeks after this scarcely noticed incident, there supervene headache and giddiness, without anything remarkable occurring in the ear. Perhaps the patient may forget to tell the doctor that he has been suffering from an aural discharge. Such cases as these are really more serious than those which exhibit convulsions and delirium during an acute otitis. What is happening within the skull ? Are we dealing with an epidural abscess, a meningitis, a cerebral abscess, or a sinus thrombosis f 30 SURGICAL DISEASES OF THE HEAD The condition of least gravity is that of epidural abscess, i.e., a collection of pus between the roof of the petrous portion of the temporal bone and the dura mater, or more rarely posteriorly, between the petrous and the transverse sinus. These abscesses may be so free from symptoms that they are discovered quite accidentally when opening the antrum for mastoiditis. It is perhaps not correct to term their discovery '' accidental," because the experienced surgeon will inspect the roof of the antrimi in every case wherein he opens the mastoid process. If he has any suspicion of epidural abscess he will not hesitate to expose a limited area of dura, so as not to miss it. If the abscess is large, it will cause slight pressure symptoms : head- ache, somnolence, a somewhat slow pulse and a typical pus tempera- ture. Really severe brain symptoms do not usuallv occur. It IS very exceptional to find any svmptoms of local pressure, and then only in children. These concern the adjacent cortical areas and cause aphasia when the lesion is on the left side, and motor dis- turbances when the accumulation of pus is very extensive. If the symptoms do not unanimouslv point to a simple mastoiditis, our first thought should be of an " epidural abscess," although the condition of the patient mav not appear to us to be particularly disquieting. We may console ourselves and the relatives with this diagnosis, and yet we must confess that the pus may, after all, be on the other side of the dura. . So that anyone who explores for an epidural abscess must be prepared to extend his search, if necessary, beyond the dura into the brain substance. But are there no svmptoms which enable us to diagnose a cerebral abscess forthwith ? Let us first consider the fairlv common abscess of the temporal lobe, which damages the same cortical area as an epidural abscess, when in its usual position on the roof of the petrous bone. We shall discuss cerebral abscess later on. Theoretically, we may anticipate, from a temporal lobe abscess on the right side, a diminution of auditor}' perception in the left ear. But as the right ear is not available for comparison, apart from the fact that both ears are often affected in otitis, we must discard this test. An abscess in the left temporal lobe may cause sensoiy aphasia, but does not always do so. Although it is conceivable, as already stated, that an extensive epidural abscess may cause a certain measure of aphasia, owing to pressure upon the temporal lobe, nevertheless a definite sensory aphasia must be put down to the credit of a cerebral abscess. But in the absence of aphasia, or when the disease is on the right side, we must draw our conclusion from the intensity of the symptoms. If the headache, slow pulse and vomiting are very marked, or if uncon- sciousness be present, there is much greater probability of cerebral abscess than of a simple epidural abscess. The temperature can be CEREBRAL COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA 31 relied upon as a guide. On the whole, an epidural abscess is more likely to exhibit the regular curve of a pus temperature than a cerebral abscess, wherein the temperature is quite irregular. Days with normal temperature alternate with sudden and steep ascents in the chart. One must not neglect the " impression " conveyed by the patient. A patient with an epidural abscess does not convey the impression of a severe case. The general condition of a case of cerebral abscess does not give rise to great anxiety, except in the last stage. Never- theless a careful observer will detect "something" in the psychical state which, however, baffles definition. If the patient is a child the parents are quite sure that there is some "change," and a mother's observation is often more acute than that of the medical attendant. In diffuse purulent uieningitis the clinical picture is quite different. The existence of a severe illness is in striking evidence. As this impression gains in intensity from hour to hour, the diagnosis no longer remains in doubt, for there is a steady progress in meningitis, whereas in cerebral abscess the course is fluctuating. The following is a typical case of an abscess in the temporal lobe, following otitis : — A little girl had been suffering from a discharge from the left ear for several years. She began to complain of severe pain behind the left ear three weeks before admission to the hospital. The mother thought that there was a slight swelling, but the pain ceased on the application of domestic remedies, and the child returned to school, apparently in normal health. Then, severe headache and vomiting set in, and the doctor noted, at that time, a slight facial paralysis of the left side. There was a little tenderness behind the ear, but no swelling, though an offensive discharge issued from the meatus. There was neither aphasia nor congestion of the discs ; the pulse was not retarded, and there was only a little fever. The facial paralysis in- dicated a severe inflammatory process within the temporal bone, and the long duration of the disease, together with the offensive discharge, made the diagnosis of cholesteatoma very probable. The headache and vomiting made one think of abscess, but these symptoms may have been remote ones. The operation, which was undertaken immediately, revealed a cholesteatoma bathed in foetid pus. The facial nerve canal, seen on the floor of the large bony space, was eaten away into an open channel. There was improvement for two days after the operation ; then the headache recurred, with striking changes in the psychical condition and signs of aphasia. Congestion of the left disc was beginning, and therefore a diagnosis of abscess in the left temporal lobe was made. A second operation revealed an enormous abscess in this position, filled with foetid fermenting pus. The aphasia disappeared, the mental condition became normal, and in a few weeks the child left the hospital, completely cured except for a remaining facial pai"alysis. The diagnosis of cerebral abscess presents greater difficulties. Just 32 SURGICAL DISEASES OF^ THE HEAD as a temporal lobe abscess is the consequence of the spread of the inflammation upwards, so is cerebellar abscess the consequence of its spread backwards. The bone is not necessarily destroyed, but the transverse sinus, which runs in the direction of the cerebellum, is frequently involved. If, therefore, signs of a cerebral abscess follow those of a sinus thrombosis, our first thought will be of the cerebellum. The only other symptom which points to this diagnosis is giddiness, of the character of cerebellar ataxia. But it must not be forgotten that any intracranial disease can cause giddiness, and that if the giddiness be very severe it may depend upon the labyrinth being affected. To make the diagnosis of cerebellar abscess probable, the cardinal signs of a cerebral abscess must be preseiit, viz., headache, vomiting, and possibly slow pulse and congested disc, and in addition a giddiness which causes the patient to stagger, or even entirely prevents him from walking. If a sinus thrombosis is also present it supports the diagnosis, because it shows that the inflammatory process has extended backwards, but on the other hand this throm- bosis may itself cause symptoms similar to those of a cerebellar abscess. It is therefore prudent to give the first signs of a thrombosis the opportunity of disappearing before proceeding in search of a cerebellar abscess, The following is a classical case of cerebellar abscess : — A young man, the subject of an old chronic otitis, suffered from an abscess behind the left ear. His medical attendant opened it by means of Wilde's incision, and rapid healing followed ; but tiie patient began to complain of headache and giddiness a few weeks later. The pulse became slow and irregular, and definite signs of a cerebral abscess appeared. Giddiness was the only symptom af localizing value, and it was so intense that the patient, whose nervous system was otherwise healthy, could hardly walk. Operation, and unfor- tunately the subsequent autopsy, confirmed the presence of the expected abscess. How can we recognize sinus thrombosis? Its brain symptoms are of least significance. Of course, the blocking up and the infective inflammation of a large venous channel will produce a disturbance in the cerebral circulation which will manifest itself by certain signs, but these are so indefinite that no diagnosis can be based on them. There will be headache, vomiting and giddiness in cases of meningitis, just as there are in cases of abscess. But there are some special features which permit us to recognize disease of the sinus. These consist of changes in the veins connecting with the sinus. Frequently there is tenderness over the region of the emissary vein in the posterior portion of the mastoid process ; occasionally there may be oedematous swelhng due to the spread of the thrombus externally, through the emissary vein. CEREBRAL COMPLICATIONS OF SUPPURATIVE OTITIS MEDIA 33 Special attention must be paid to the condition of the internal jugular vein, which usually shares in the thrombophlebitis, at any rate in its upper section, which presents in its course some oedema, in the form of a cylindrical painful swelling. If these signs follow a previous aural discharge they suffice for a correct diagnosis. But this swelling behind the mastoid process must not be confused with the deep cervical abscesses, which are occasionally noticed after acute and chronic middle-ear suppuration, and which may spread thence over the entire side of the neck. I have seen an abscess of this kind — a fermenting phlegmon — reach clown to the gluteal region. This variety of abscess, first described by Bezolt, may follow a purulent sinus thrombosis, but this is not its only cause. If we suspect a sinus thrombosis in the absence of definite local signs, the diagnosis can be established in severe cases by the general symptoms of an infective thrombophlebitis. Repeated rigors followed by characteristic outburst of perspiration, sudden elevations of the temperature up to 104° — 6° F., a pulse-rate of 140 or more, and the sub- sequent onset of pulmonaiy embolism — all these form a clinicaf picture which once seen is never forgotten, and which even the inexperienced cannot fail to recognize. The only thing which now remains is meningitis. If the sym- ptoms do not fit in with any of the previously described conditions, we may diagnose it by a process of exclusion. The disease is ushered in by headache, stiffness of the neck, vomiting and fever. From the very beginning the aspect is grave, and the gravity increases from hour to hour. Sleeplessness alternates with delirium, and as the disease advances unconsciousness becomes more marked. Motor symptoms of irritation and paralysis may come on without any definite order, and in the most variable combinations, but, on the other hand, they may remain entirely absent. The fever persists, the slow pulse becomes rapid, the respiration interrupted, and death ensues in profound coma. If the diagnosis is doubtful, it may be cleared up by lumbar puncture. A negative result would justify us in searching for a cerebral abscess, but if the fluid is cloudy, operative interference is useless. The few cases of otitic meningitis which have recovered after trephining were of a circumscribed character. We must endeavour to operate m meningitis before the fluid has become cloudy as low down as the lumbar spine. 34 SURGICAL DISEASES OF THE HEAD CHAPTER V. THE PROBLEM OF EPILEPSY. The surgeon occasionally sees all three varieties of epileptics. He is most frequently concerned with those who suffer in consequence of previous injury, then with those whose epilepsy depends upon a non- traumatic anatomical lesion of the brain, and finally genuine epileptics find their way to him when medical treatment can offer no relief. As the surgeon has to pronounce the final verdict in regard to opera- tion in any given case, he must be able to decide to which class the patient belongs. The first thing to decide is, whether the patient is really epileptic, and here the difficulty begins. We will assume that no gross diagnostic blunder has been committed, and that neither uraemia nor eclampsia has been mistaken for epilepsy. It is important, however, to recog- nize accurately the so-called "epileptiform" attacks, and those ' of "petit-mal," and to distinguish the violent epileptic seizures in hysteri- cal conditions. The differential diagnosis of this last group of cases, which we cannot here discuss, is not always very easy, especially when the tongue is not bitten, when other self-inflicted injuries are absent, and when the moral perversity may be attributed to either one or the other. As just stated, the surgeon's most frequent opportunities for seeing epileptiform attacks are in post-traumatic cases. The following is an instance : — The patient was a young man of a low psychopathic type, afraid of work and prone to lying. He sustained a stab in the side with a knife ; the wound healed rapidly, but he developed epileptiform attacks, which kept many observers in doubt for weeks as to their epileptic or hysterical character. He was sent from one hospital to another ; he ran away at times and simulated, consciously or unconsciously, the most varied diseases. He wanted to be trephined, to have his thorax explored, to have a laparotomy performed, and he also indulged in attacks of mild self-injury, &c. It really matters little whether such an afflicted individual is diagnosed as an epileptic or a hysteric or as a combination of the two. His motor functions, like the rest of his nervous system, are in a state of intense irritability, and a prudent surgeon will leave him severely alone. But, assuming that the case is one of real epilepsy, we have to consider the clinical history, the course of the attack, and the objective condition during the intervals, before we can classify the patient correctly. The clinical liistory must be investigated for all tliose circumstances THE PROBLEM OF EPILEPSY 35 which can point to the non-surgical character of the epilepsy, viz., heredity, alcohol, absinthe and lead intoxications, and infections, especially syphilis. But if an alcoholic suffers from epilepsy, it must not be assumed that only the alcohol can be credited with it, for it may be due to some accidental injury to the skull. Hereditary pre- disposition, intoxications, and infections form the basis on which epilepsy develops, when some exciting factor comes into play. This factor may be so trifling that it baffles observation — then the case is, and remains medical. But this factor may be provided by the appre- ciable results of an injury, and then the case is surgical, in so far as these results can be removed by operation. If the question of congenital or inherited predisposition is disposed of, we must first ascertain whether the patient has ever sustained an injury to the head, more especially an injury involving both the skull and the brain. Our inquiries must be prosecuted even unto the patient's birth, because epilepsy may be the consequence of a poren- cephalitis due to injury by forceps. But, apart from forceps, childhood offers abundant opportunities for cranial injuries. If a child is not dropped by its nurse, sooner or later it will fall on its own account. The skull may be compressed without the attention of the parents being attracted thereto, and the brain may suffer severe damage beneath an apparently uninjured skull cap. This damage may, in its turn, produce softening, with consequent cyst formation or porencephalitis. If it is clear that the patient has sustained.an injury to the skull, we must ascertain whether the epilepsy is a direct or indirect result. This is especially important from the point of view of accident insurance. A patient may have been epileptic before his accident, but may wish to fasten the responsibility for his disease on the period following the injury. But even if it transpires that there has been a long interval between the injury and the first attack of epilepsy — years may have elapsed — we cannot conclude that the epilepsy is not traumatic. To cite one possibility, the injury may have caused a cerebral cyst, and this, many years subsequently may declare itself by means of epilepsy and other symptoms. But as a rule traumatic epilepsy appears within a few months of the accident. I once had a patient with a traumatic cyst in the frontal lobe. The lad began to masturbate eight years after the injury, and then epilepsy manifested itself in the form of "petit mal " at first. It was quite clear that the individual attacks were a consequence of this habit. So far we have confined ourselves to injuries of the head, or, rather, of the brain. But there is a form of epilepsy which may follow any peripheral irritation, apart from injury to the brain. This is called rc/lcx epilepsy. Any peripheral injury may set up this external irritation 3 -^6 SURGICAL DISEASES OF THE HEAD and painful scars over bones, or those involving nerve-trunks have long been credited with this evil. Even foreign bodies in the nose or ear may cause epilepsy. Demme reports a case wherein a rectal polypus acted in this way. When I was a student I saw a case of Kocher's, in which typical Jacksonian epilepsy appeared to start from a scar in the hand. The excision of the scar proved useless. It was then decided to trephine, but he escaped from this project by dying suddenly. The autopsy revealed a well-circumscribed tumour in the situation selected for the operation. Although too much has perhaps been attributed to reflex epilepsy, w^e must not neglect its consideration when examining the patient. Our conjecture will become a certainty if the patient experiences any abnormal sensations in the suspected scar before the attack, or if we are able to directly excite an attack by pressing on the scar. A boy, aged 3, who had never been epileptic, was brought into hospital with definite attacks, a few days after a fall on his forehead. Examination showed an abrasion of the forehead, from which ery- sipelas was spreading, and a subjacent abscess. This was opened ; there was no fracture of the skull. The fits ceased immediately, and the case, therefore, was either a toxic or reflex epilepsy. The actual observation of the fit is an important part of the clinical history. If it resembles an ordinary attack, beginning with general convulsions, and not regularly affecting any particular region of the body, either by a preceding aura or subsequent effects, we can draw no conclusion regarding its etiology. General convulsions usually signify so-called true epilepsy, i.e., epilepsy with an unknown anatomical basis, but they also occur in other forms of epilepsy, which are caused by certain gross anatomical changes. It is quite different when the aura, or the post-epileptic paralytic phenomena, either persistent or transitory, indicate a definite area of the cortex as the seat of origin of the attacks. Two varieties may be distinguished in this connection. In one, the convulsions are limited to a circumscribed motor area, and we are therefore confronted with typical Jacksonian cortical epilepsy. In the other, the attack similarly begins in one definite area, but it marches, in anatomical pro- cession, along into other areas, and thus the fit becomes generalized. Temporary paralysis in the area corresponding to the seat of origin, may follow the attack. The relatives can often furnish useful information on these points, but it is always advisable to personally confirm their statements, or to obtain their confirmation from a hospital trained attendant, because our treatment must frequently be dictated by this information. Finally, a careful investigation of the condition of the patient between the attacks must be undertaken. Scars on the scalp. THE PROBLEM OF EPILEPSY 37 irregularities on the surface of the skull, any trace of a previous injury which might be seen or felt, must be searched for to complete the clinical history. At the same time one must look for painful scars anywhere on the body, for the reason already given, and if the patient is a child suffering from recent unexplained epilepsy, the nose and ear must be examined for foreign bodies. A thorough investigation of the nervous system, with special reference to the motor areas of known function, must follow this external examination. If this reveals such symptoms as paresis of one extremity, unilateral paralysis of a cranial nerve, or hemianopia, the diagnosis of true epilepsy must be discarded, and the cause of the disease must be attributed to some gross anatomical change, viz., infantile cerebral paralysis, old apoplexy, cerebral tumour in its widest sense, or cerebral cyst. In children, the cause is most likely to be an intra-uterine encepha- litis, producing the so-called infantile cerebral paralysis. Tumours, tubercle, gummata, traumatic cerebral cysts may occur at any age, and old apoplectics may suffer from epileptic attacks. It is only when an epileptic emerges from such an exhaustive investigation without any flaw that he must be regarded as a case of *' genuine epilepsy," and as far as our present knowledge goes surgery can offer but little help. But, on the other hand, not every case of traumatic epilepsy can anticipate benefit from operation. Unfortunately, experience shows that the hopes based on operative measures have fallen far short of anticipation. This is, however, not the place to discuss this circum- stance. Nevertheless, interference is advisable in all cases of traumatic epilepsy, unless the long duration of the illness, or the great frequency of the fits, or the mental changes, indicate that the whole central nervous system is too deeply compromised. The prognosis in tubercle and in tumours depends upon the possibility of complete removal of the growth. Post-apoplectic epilepsy we must leave to the physician, and this also marks the limit of the assistance we can give in genuine epilepsy. SURGICAL DISEASES OF THE HEAD CHAPTER VI. SOME REMARKS ON CEREBRAL LOCALIZATION AND FOCAL DIAGNOSIS, We have already touched upon the subject of focal diagnosis — i.e., the detection of the situation of a brain lesion, based upon our modern knowledge of localization — but it is necessary to return to it by a more connected method. Our first work is to distinguish a peripheral from a central lesion of the nervous system ; but, as we have seen in the case of a fractured skull or of a cerebral tumour, this is not always easy, because the two lesions may be present at the same time. Let us begin with (i) disturbances of vision. A glance at the very simplified diagram in tig. 6 suggests the various possibilities which possess surgical interest. Blindness of one side indicates an interruption in the path between the retina and the chiasma (/), which may be caused by primary or secondary tumours of the orbit, or a fractured base. Bitemporal hemianopia is the classical sign of a tumour in the region of the chiasma (d), e.g., a pituitary tumour. Blindness of both sides depends upon the same cause {e), but it indicates a later stage or a more extensive lesion {e.g., gunshot with suicidal intent). It may also occur when there is severe congestion of the disc in cases of chronic cerebral pressure (tumours and cysts in any position, but more especially in the posterior cranial fossa). Finally, it may occur through a simultaneous lesion of both cortical visual areas — but this is rare (tumour of the Falx Cerebri), Homonymous hemianopia indicates a lesion in the optic tract (c), in the optic radiation (&), in the primary visual centres of the optic thalamus, lateral corpus genicu- latum and anterior corpus quadrigeminum (6^), or the cerebral cortex; {a), e.g., tumours, cysts, or trauma. From the surgical standpoint it is most important to distinguish between a lesion in the optic tract and in the cortex (see under Cerebral Tumour). A sign first described by Dufour may be of assistance. He states that if the visual path be interrupted at c or b, the vision is dimmed ; if the lesion be in the cortex the vision is totally absent. The hemiopic pupillary reaction must be tested to determine the mobility of the pupil. If no reaction is obtained, the lesion is at c, thus excluding lesions both at b and a. The cortical lesion is sometimes incomplete {e.g., in tumours). In such cases the hemianopia is also incomplete, there being merely a homonymous loss of one quarter of the visual field, which, however, CEREBRAL LOCALIZATIOX AXD FOCAL DL-\GXOSIS 39 must not be confused with a unilateral scotoma of peripheral origin There still remains another form of visual disturbance, which requires brief consideration, although it rarely possesses surgical interest, as it is bilateral — i.e., nnind blindness. Whereas the destruction of the cortical area marked {a) in the diagram prevents the perception of visual impressions, these impressions still arise if the cortex of the cuneus is unaffected, but they will not be appreciated by the mind, if the fields for visual memorv on both sides, or the association fibres leading to them, are destroved. This latter condition is termed "mind blindness," in contrast to " cortical blindness," due to destruction of the cortex of the cuneus on both sides. All these examinations demand normal intelligence and retained consciousness, but these patients frequently possess neither the one nor the other. We must then be content with the ability to dis- tinguish unilateral blindness, bitemporal and homonymous hemi- anopia. The examination can be carried out with approximate accuracv without a perimeter, although a correct visual chart is always desirable. W^e may infer from the pupil reflexes that they are served by their own special fibres. Their behaviour may be ascertained from the facts illustrated in fig. 6. Disturbances in the reflexes without simul- taneous visual disturbances always suggest an isolated lesion of the oculomotor nerve or its nucleus. (2) Derangements of the extrinsic ocular muscles can only be detected by causmg the patient to look in dehnite directions, other- wise thev may be confused with conjugate deviation. As soon as the patient is told to move his eyes, it will at once be seen whether he squints. If there is no movement of the eyes when directed to look sideways, there is probably conjugate deviation. Whereas advanced ocular paralysis can easily be detected, its slighter forms can be concealed by patients bringing the non-affected muscles into action. A very careful examination for double vision in all points of the visual field is therefore necessary. It has always been said, and it will subsequently be repeated, that ocular paralyses, except when they are of purely medical significance, indicate trauma, inflammatory diseases, tumours of the orbit or base of the skull, or affections of the base of the brain. Conjugate deviation on the other hand, is always a sign of disease above the nucleus (the patient looks towards the healthy side when there is irritation, and towards the lesion when there is paralysis). In this connection, tumours, cysts, abscesses in the cortex, or in the sub-cortical white substance, and also injuiies are especially of surgical interest. The nucleus of the sixth nerve forms an exception to what has just been said. According to the most recent researches, this nucleus 40 SURGICAL DISEASES OF THE HEAD represents a more deeply situated co-ordination centre. Injury thereof, which hardly possesses any surgical significance, leads to conjugate deviation towards the healthy (opposite) side. In addition to conjugate deviation, S'ystng^iiiis must also be a. Cortical lesion (cuneus, trauma, tumour, cyst, abscess). Homo- nymous crossed hemiatiopia (loss of opposite visual fields). Absence of vision com- plete. Reflexes normal. i. Lesion of optic radiation, or of primary visual centres(i5'). Causes as above. Sym- ptoms as in a, but vision dimmed. 39) ^"id then comes cancer, mostly in the form of rodent ulcer (tig. 34). If all the facts are not consistent with a dia- gnosis of cancer, one must also think of molluscum contagi- osum, just mentioned. In this connection the so-called telangiectatic granuloma should be re- ferred to. (5) Ulcers frequently form on the forehead and temple at the margin of the hair. These are usually sebor- rhoeic cancers of the skin. They occur, as a rule, in old syphilitics, whose skins show very definite signs of se- borrhoea and present other changes predisposing to cancerous induration, such as senile warts and even cutaneous horns. Such can- cers may be multiple. In young persons an ulcer at the' margin of the hair is very suggestive of an ulcer- ated syphilide. Fig. 37. — Lupus of the face. !l^ Fig. 38. — Lupus of the face. 72 SURGICAL DISEASES OF THE HEAD (6) Ulcers of the auricle are generally cancroids. If left alone, they lead to complete destruction of the auricle. Lupus in this position is more rare. In its hypertrophic, non- ulcerating form, it looks very much like a tumour (fig. 41.) Ulcers which have persisted for some time, not situated on the typical positions already referred to, may be suspected of another origin. For instance, if a patient, who is accustomed to patronize a barber, has recently acquired an ulcer on the chin or cheek, a primary chancre must be thought of, at any rate, so long as the asepsis of the barber has not reached the desired standard. A primary chancre on the con- junctiva may lead to mistakes. A workman allowed his companion to remove a foreign body from his conjunctiva. A little piece of wood had been used for this purpose, which, according to a very dniy custom (to put it mildly) had been previously sucked by several Fig. 39. — Lupus of the nose. Fig. 40. — Cancroid of the ear. Fig. 41. — Tuberculosis of lobe of ear (Lupus hypertrophicus). (From the Ear Clinic, Basle.) people. The foreign body was successfully removed, but at the same tiziie the spirochaete was inoculated. INJURIES OF THE JAW 73 CHAPTER XII. INJURIES OF THE JAW. Fractures of the lower jaw are so easily recognized that they hardly require any discussion. The most important question to ask is, whether the jaw has been completely fractured transversely, or whether merely the alveolar process has been broken off. The severe disturbance of function, the position of the teeth, and lateral pressure and counter-pressure in the neighbourhood of both angles of the jaw, will answer this question without any difficulty. A complete fracture may be overlooked when it is situated near the angle of the jaw or on the ascending ramus, that is to say, when it is outside the region of the teeth. But careful examination ought, as a rule, to detect it, because the loss of function and pain on local pressure are both very definite, even when there is no crepitus. The following case, however, gives an example to the contrary : — A dentist, in extracting a wisdom tooth, imconsciously broke the jaw, which, in that situation, was somewhat atrophic. No conclusion could be drawn from the position of the teeth, because the fracture was at the angle of the jaw, and because there was no displacement. The patient only complained of severe neuralgia in the mandibular nerve, and this diverted attention from the injury to the bone, no suspiciori being entertained that the neive might be nipped between the two fragments. It was not until a phlegmon started at the seat of fracture that attention was directed to the accident. Fractures of the upper jaw more frequently escape recognition. Not, of course, fractures of the alveolar process due to violent extrac- tion of teeth, or when the jaw is shattered by such an injury as a revolver shot for suicidal purposes. When all the bones of the face are torn asunder, the diagnosis of a fractured upper jaw presents neither difBculty nor interest. But on the other hand, it is important to recognize a fissured fracture when the soft parts are uninjured and the seat of fracture not exposed. This may occur when a force is applied flat to the face, both upper and lower jaw being fractured transversely. The most striking symptom which comes on after the blow is bleeding from the mouth and nose ; but this is not significant of fracture, because this may follow a simple wound of the nose. The presence of a rent in the mucous membrane, or at least a submucous haemorrhage of the alveolar process of the palate, is more important. Preternatural mobility, or displacement of one of the fragments, would be conclusive evidence. But this is likely to be missed in a superficial examination, because the displacement is much less than in the case of the lower jaw. If, however, the patient complains that some of his 74 SURGICAL DISEASES OE THE HEAD teeth have "become too long" we may assume tliat we have over- looked some abnormality in position, and that a fracture is present. This very signiticant statement permits of the diagnosis being made long after the accident. Pain is also an important sign. It is easy to demonstrate bv external pressure that there is pain on the anterior surface of tb.e upper jaw, unless a haemorrhage on the cheek prevents palpation. If such pain is limited to a definite position, we have every right to suppose that there is a fracture. Sometimes the pain can be traced straight across to the opposite jaw. This supposition will be confirmed if pressure on the teeth either in an upward or lateral direction elicits definite pain, whether accompanied by crepitus or not. If sen- sation is disturbed in the region of the infra-orbital nerve, especially if sensi- bility is diminished and neuralgia exists, this affords further confirmation of the diagnosis. The recognition of such fractures of the upper jaw, or even of less marked ones, has something more than a mere diagnostic interest, because the line of fracture may continue onwards to the base of the skull and involve other nerves, par- ticularly the optic nerve. Such fractures may even lead to meningitis. _ A woman was struck on the cheek by a drunken peasant. A few weeks later there still remained pain on pressure over the canine fossa, the feeling of long teeth, and a trigeminal neuralgia. Careful examination showed that the affected eye was blind, and the ophthalmoscope revealed optic atrophy, proving that the fracture had reached the area of the optic nerve. Partsch has even seen a case of bilateral blindness from this cause. Dislocation of the lower jaw need not detain us. The patient with his lower jaw pushed forward, with his mouth open, unable to open it any wider or close it, presents such a characteristic aspect that even the layman can diagnose it forthwith (fig. 42). ' Fig. 42. — Dislocation of lower jaw. (From the surgical clinic at Berne.) LOCK-JAW 75 CHAPTER XIII. LOCK-JAW. Whereas the inability to sJuit the mouth invariably points to dislocation, inability to open it "may be due to various causes. Let us begin with a rare case : — - A young girl was attacked suddenly, from time to time, with inexplicable seizures of lock-jaw, which disappeared when the patient was semi-anjesthetized. This was evidently a functional condition, a spasm, which Kocher compares to spastic torticollis, and which we must assign to the wide domain of neuroses. The rare cases of trismus, due to an apoplectic lesion in the lower frontal convolution, must also be classified as lockjaw of nerve origin. The lockjaw, due to tumours of the pons, is a peripheral irritative symptom. The following kind of case is much more frequent: The patient had taken a three hours' walk from the country into town to consult a doctor, because he had been unable to open his mouth for the last fortnight, owing to "a bad tooth." Besides his lockjaw, he had facial paralysis of the left side, and a small unirritating scar over his left eyebrow. The latter was due to an injury from an axe, sustained four weeks previously. All the reflexes were increased, the gait was somewhat stiff, and there was a grinning facial expression on the unparalysed side (fig. 43). This really constitutes the classical picture of head tetanus. The beginner, who thinks of the victim of tetanus as absolutely in- capacitated, would probably be misled by the history of the three hours' walk. But patients with tetanus often come, walking to the doctor, from a distance. Facial paralysis is not always present, but in its absence the '' risus sardonicus " is all the more expressive of the diagnosis, long before the patient has complained of his malady, especially of his bitten teeth. Fig. 44, a similar case to fig. 43, shows the facial paralysis better, there being complete absence of folds in the skin on the left side. If these somewhat infrequent causes do not account for the lock- jaw, it is necessary to determine some anatomical causation. We will proceed with the examination in the natural method. If the patient's cheek has recently become swollen, and if his expression is typical of toothache, we may suspect periostitis of the jaw. The mouth is opened as widely as possible, and the offending tooth, which will be near the angle of the jaw, is looked for. There may be nothing wrong to be detected with the tooth, but the fold of mucous mem- brane between the jaw and the cheek will be more or less obliterated. Instead of an even and regular swelling of the cheek, there may 6 76 SURGICAL DISEASES OF THE HEAD be a dense infiltration, with sundry sinuses, foci of granulation and fibrous contractures, reaching down as far as the neck (fig. 46). This will at once suggest actinomycosis. The pus expressed from the sinuses frequently contains the well-known yellowish little granules, of the size of millet seeds, which serve to confirm the clinical diag- nosis. We shall see later on that Actinomycosis or its allied Strepto- mycosis may also begin as a diffuse swelling. Tuberculosis of the jaw, which somewhat resembles the above, occurs but rarelv. The first glance should, however, dift'erentiate it, because the skin is less - - ' ' involved and because the glands are consider- ablv enlarged. If the lockjaw has set in acutelv, and a diffuse swelling occu- pies the whole of the lower jaw and the floor ofthe mouth, we should think of osteomyelitis of the jaw. A swelling more closelv confined to the cheeks, Avith tumid lips and a foetid, slightly sanious fluid issuing from the mouth, points to one of those rare cases of gangrenous stomatitis. Mcrcurinl s to 111 a i if is m av pro- duce a similar clinical picture. If the aspect of the patient does not suggest anv cause for the lock- jaw, we must examine the condition of the articulation of the jaw. A rapid and painful onset of the trismus will make us think of acute arthritis, which occurs in the most varied infective diseases, especially in scarlet fever, acute articular rheumatism and gonorrhoea. Tht region of the joint appears somewhat swollen, pressure in front of the ear, just under the zygomatic arch, is painful, and the patient complains of radiating pains ni the neighbourhood of the joint. Every attempt to open the jaws forciblv produces immediate con- traction of the muscles of mastication. If there are no acute inflani- FiG. 43. — Head tetanus. The patient is attempting to open his mouth. Contraction of right side ; facial palsy on the left. Scar over left lid. LOCK-JAW 77 matory signs and the lockjaw is of old standing, but has followed some acute disease, we must conclude that the articulation of the jaw has become ankylosed through some antecedent inflaniination. It must not be forgotten that ankylosis of the jaw can develop in the course of a chronic ankylosing polyarthritis. A very trifling derangement in this region may be mentioned here. It consists of some crepitation in the joint due to a slight looseness of the capsule of the articular cond^de (termed discitis, by Lanz). In other cases this crepi- tation points to arthritis deformans of the jaw, which ^ proceeds, if it is unilateral, to cause obliquity of the part, with corresponding obUquity of the lower teeth. Among the causes of ank^dosis of the jaAv are inflammatory processes in the neighbourhood, which attack the jaw secondarily. This occurs especially in snppnirition of the txnipanic cavity. Injuries also play their part, for they may lead to bony proliferation or to the deyelopment of osteomata. A striking smallness of the lower jaw — a bird face — accompanying the lock- jaw, will indicate that the disease dates from infancy. Disuse of bone leads to atrophy, and therefore the ankylosed lower jaw fails to grow adequately. If the exhaustive examination of the joint and its surroundings fails to discover the cause, we must inspect the pharynx. If the disease is recent, it may be due to a retro-tonsitlar abscess, if chronic, it ma}' be due to cicatricial bands in or under the mucous membrane, or to a malignant neoplasm near the tonsil. Fig. 44. — Head tetanus, with facial palsy. Small wound on the left eyebrow. 78 SURGICAL DlSIiASES OF THE HEAD CHAPTER XIV. INFLAMMATORY DISEASES OF THE JAW. In discussing the important symptom of lock-jaw in the preceding chapter, we have ahTady touched upon several inflammatory diseases of the jaw. We must now, however, deal with them again, more systematically. (i) Acute psriostitis of the jaw which is always the result of dental disease, presents such a familiar picture that its consideration need not detain us. It can only be necessary to distinguish it from primary osteomyelitis, which will be suggested by the great extent of the disease and inability to find any primary lesion in the teeth. The course of this disease resembles, in its severity, acute osteomyelitis of the extremities. (2) The chronic inflammations of the jaw are much more interest- ing. If we find a limited area of disease, for instance, a sinus m the gum or on the cheek, with more or less swelling on the corresponding section of the jaw, we may be sure that a tooth is responsible and that the condition is one of an ordinary dental fistula (tig. 45). The more contracted the neighbourhood of the fistula, the longer will its dura- ation have been. If there is no tooth in the affected situation, a piece of stump will probably be found on opening the alveolus, or in an extensive case, a scqiiesirimi may be forthcoming. If the removal of such causes does not cure the inflammation, some more serious disease underlies it, and we shall have to diagnose between actiuonycosis, tubercle, and phosphorus necrosis. The symptoms of actinouiycosis of the jaw have been briefly described in the previous chapter ; it only remains to add that the changes at the site of infection — a tooth or the gum — are so com- pletely overshadowed by the secondary appearances on the cheek and neck, that it frequently becomes impossible to define the spot where the infection entered. But it is interesting to trace the source of iiifec- iion. Usually we can find no clue in the case of the town dweller, and in country districts the bad habit of chewing stalks of grass is so widespread that the patient is most unlikely to remember any such incident. The clue is more definite, if one can ascertain that the patient has been tending cattle with actinomycosis, as once occurred to me in a case of abdominal actinomycosis. The diagnosis is based on the visible external changes (figs. 46 and 47), on the dense infiltration with brownish-red foci of softening on the somewhat contracted cicatricial areas, on the absence of glandu- INFLAMMATORY DISEASES OF THE JAW 79 lar enlargement, and finally on the demonstration of the yellowish little granules. The latter may be confused with the small particles of necrotic tissue which sometimes occur m tubercular abscesses. They may, however, be pretty clearly distinguished, even without the microscope, m the following manner : If a granule of the ray fungus is crushed between two glass slides, and examined, the periphery will be seen to be opaque from pus cells, while the centre will be comparatively transparent, being occupied by the interlacing hbres of the fungus. On the other hand, a pus coagulum, or a particle of necrotic tissue will be uniformly turbid. When all the described signs of actinomycosis are fully developed, a diagnosis can be made at first sight, even if the characteristic granules are not found. But on the other hand, actinomycosis must not be excluded if there is only a purely diffuse swelling present, without the skin changes (fig. 46). The pus should be examined for the rav fungus (actinomycosis or streptomycosis) in the case of every persistent chronic abscess of the jaw with hard edges. If the immediate exammation yields a doubtful result, culture tests should be undertaken. We have ali-eady referred to tuberculosis of the jaw among the causes of lockjaw. It may appear in the form of tubercular Fig. 45.-Sinus from tooth. iLlcers of the gum. These are dia- gnosed by their sharp margms, chronic course, the presence of enlarged soft glands in the neck, and the failure of antisyphilitic remedies. To expedite the diagnosis, it is necessary to scrape away a piece of the margui of the ulcer with a sharp spoon and it will generally be easy to detect tubercle in the frozen sections. In doubtful cases animal moculations will yield a decisive result. The early stages of tubercular disease of the boue itself are more difficult to recognize. The folio .ving is a characteristic case :— A woman, aged 38, gradually became affected with lockjaw. Already at the first examination severe swelling of the cheek and 8o SURGICAL DISEASES OF THE HEAD t Fig. 46. — Early stage of actinomycosis of jaw (before the bursting of abscess). temple were present. Some of the molars were absent, and the others did not appear to account for the clinical condition, more especially as the bone was thick- ened, especially about the angle of the jaw, and the ascending ramus. A little pus exuded from a small sinus behind the last molar, and the probe impinged upon bare bone. A bunch of movable soft and elastic en- larged glands was found in the neck temple fluctuated Four points in this case estab- lished the diagnosis forthwith: — (1) The insidious onset, which distinguished the disease from an ordinary dental periostitis. (2) The locahzation on the ascending ramus, which is not usual in dental periostitis. (3) The obviously tubercular glands in the neck. The swelling over the (4) The presence of a cold abscess over the temple. This abscess, which would be called a gravita- tion abscess if it were not making its way upwards, is quite distinctive of tubercle of the lower jaw. Owing to anatomical reasons the pus cannot find its way downwards ; it tracks along the line of least resistance, between the pterygoids and the bone, makes its way upwards and gets beneath the temporal muscle. The temporal bone and other bones of the skull may be attacked secondarily as a result of this abscess. Fig. 47. — Actinomycosis of jaw. (Advanced stage.) INFLAMMATORY DISEASES OF THE JAW 8 1 The subsequent progress of the above case was also very dis- tinctive. The abscess was opened from the mouth, a tubercular sequestrum was removed from the ascending ramus and the bony cavities were scraped out. But this only gave temporary relief. Before the disease was checked it was necessary to resect the whole of the ascending ramus, and subsequently a portion of the horizontal ramus. The tubercle afterwards invaded the upper jaw, and this had to be resected; and two years later the patient had ileo-sacral tuberculosis of both sides. Most cases of tubercle of the jaw, hitherto described, have run a similar course. Phosphorus necrosis presents a different picture altogether, the trouble also begins with msignificant symptoms of toothache, but the extraction of the painful teeth does no good. The pain persists, one acute abscess after another appears and they burst, either through the gum or externally, leaving permanent fistulse. The whole jaw becomes diffusely thickened through the formation of new bone from the periosteum, and finally a piece of the original jaw extrudes itself — the whole lower jaw may indeed become necrosed — and is easily removed by the patient himself or the medical attendant. In both phosphorus necrosis and osteomyelitis of the jaw exten- sive sequestra may form ; but in phosphorus necrosis this process does not develop from one sudden attack, but is the result of slow stages. Tubercle is similar to phosphorus necrosis in its chronicity, but the latter differs completely in the large extent of sequestrum formation. The only similarity between phosphorus necrosis and actinomycosis is also their chronicity. But the former always remains a bone disease despite abscesses in the soft tissues and despite fistulae ; in actinomycosis the affection of the bone assumes minor importance and the disease of the soft parts predominates. It is obvious that it must be shown that the patient has had long contact with phosphorus in order to confirm the diagnosis of phosphorus necrosis. But it must not be forgotten that the disease may arise many ^^ears after the patient has ceased to be imder the influence of phosphorus. Phosphorus necrosis might, happily, become merely a matter of history, if new spheres for the employment of yellow phosphorus in industry were not being opened up. 82 SURGICAL DISEASES OF THE HEAD CHAPTER X\^ TUMOURS OF THE UPPER JAW. Tumours of the upper jaw are imitated by harmless conditions, just as are so many malignant diseases, a circumstance responsible for delayed diagnosis. Periostitis of the jaiv and chronic inftmnniation of the maxillary sinus are the principal ones, A swelling in the upper jaw, coming on with toothache, sends the patient at first to the dentist, and a few teeth are extracted. If he is disturbed by unusual nasal _ discharge or by the obstruction of a nos- ] tril, he consults a nose ' specialist to get his antrum washed out. The patient is fortu- nate if it is recognized that his case does not belong to those speci- alities, but concerns the surgeon. This summary diagnosis is not difficult if one appreciates the maxim that any sivelling of the upper jaiv, lioivever small, accompanied by p e rs i stent neuralgic pains, must be sus- pected of a nialiguaucy. Other symptoms may be entirely absent, such as displacement of the nose, a sanio-purulent Fig. 48. — Carcinoma of upper jaw. discharge from the antrum, deviation of the eye (squint, double vision), ulceration into the oral cavity or vestibule of the mouth. Nevertheless, there can be no doubt of the diagnosis, if on comparing both sides it is found that the canine fossa is somewhat obliterated, the lower orbital margin spherical or irregular, the floor of the orbit perhaps already raised, and if the neuralgia is of infra-orbital character ; especially if one of the other symptoms just mentioned is also present. To confirm the diagnosis, some of the diseased tissue should be removed with a sharp spoon from the antrum, either through the nose, or by making a TUMOURS OF THE UPPER JAW 83 small incision and opening the antrum from the vestibule of the mouth. The piece removed must be submitted to histological ex- amination, which will at the same time reveal the intimate structure of the growth. Clinical diagnosis cannot go beyond declaring the presence of a iiialigiiaiit growth, it cannot define its histological details. Theoretically we should expect- that a tumour which at first is confined within the antrum and then gradually breaks through its wall is more likely to be a periosteal sarcoma — a growth which rapidly makes its way externally — than a squamous epithelioma. Experience, how- ever, shows that the very opposite may occur. Sometimes sarcomata are limited to the an- trum for months, and [ squamous epitheliomata may proliferate so rapidly towards the surface that warm poultices are ordered on the assump- tion that the swelling is due to periostitis. Palpa- tion aft'ords no conclu- sive evidence. In the case of tumours of the upper jaw it is not pos- sible to rely on the dis- tinction that firm nodular growths are generally cancerous, and that round, elastic growths are usually sarcomatous. Early en- largement of the glands is more important for the diagnosis of cancer, but this sign is often absent. But the practitioner is under no obligation to worry himself over the dift"erential diagnosis. He has done his duty if he has sent the case, in an early stage, to the surgeon as one of malignant growth. From the operative point of view it is immaterial whether it be sarcoma or carcinoma. There is, however, a great difference in the prognosis, as the ultimate results of operations on sarcomata of the upper jaw are much better than those on carcinomata. As we have already mentioned, difficulties of diagnosis may arise from empyema of the antrum, periostitis of the jaiv, tuberculosis of the jaiv, and deutal cysts. Each one of these diseases has its characteristic previous history. Fig. 49.— Dental cyst on upper jaw. The right lateral incisor is absent below the cyst. 84 SURGICAL DISEASES OF THE HEAD In chronic empyema, the most striking incident is the periodical discharge of pus. As long as the discharge is free there is absolutely no pain, but when it is retained, there is a neuralgia of racking, beating, and sometimes of a boring character. There is also local pain on pressure in the stage of retention. Duiing the intermediate stage, the pain is dull and quite tolerable. But in the case of malignant growths the pain is severe and tormenting and allows of no respite, even when there is no external sign of irritation or anv marked pain on pressure. There is sometimes a purulent discharge in carcinoma, and this may lead to the mistaken diagnosis of oi'dinarv antrum disease. But the fact that there is so much pain in the presence of a free discharge must arouse the sus- picion of a malignant neoplasm. It is usually easy to detect the ofi'ending tooth in a case of peri- ostitis of the jaw. Malignant tumours produce toothache in teeth which are otherwise healthy. The pain also involves the cutaneous branches of the nerves (upper lip) and is fre- quently accompanied, by anaesthesia (anaesthesia dolorosa). In both peri- ostitis of the jaw and in empyema of the jaw, the pain is only present in the acute stage, or in acute exacer- bations, and it becomes relieved either spontaneously or after appropriate treatment. One special form of ostitis can give rise to very serious difticulties in diagnosis, namely, tuberculosis of the jaw. Its charac- teristics have been mentioned above. In cases of cysts of the jaw, there is a gradual enlargement of the bone, which eventually crumbles like parchment, but there is usually no pain as long as the contents of the cysts are not infected. In some cases they emptv themselves periodically through the nose and then fill up again. They may persist for years, a circumstance which differentiates them from malignant growths, for both in carcinoma and in sarcoma, the diagnosis can generally be firmly established within a few months of the onset of symptoms. If one tooth is missing from the set and is seen, on the skiagram, in the tumour, all doubt is dispelled {see figs. 49 and 50). If we meet with the symptoms of a malignant growth of the upper jaw in an adolescent male, we must also think of a nasopharyngeal Fig. 50. — Skiagram of fag. 49. X, Dental cyst with the missing incisor tooth, Z. TUMOURS OF THE LOWER JAW 85 fibroma. This growth springs from the base of the skull near the roof of the pharynx and penetrates into all accessible fissures, especially into the nose, the orbit, and circuitously, into the parotid region and the maxillary sinus. I have seen a case wherein the tumour penetrated thence into the mouth cavity and began to putrefy. This peculiar course at once suggested sarcoma. Histological examination and further progress, showed, however, that it was an ordinary nasopharyngeal fibroma. The patient made a good recovery, although the tumour was not completely extirpated from the base of the skull, it only being possible to burn it away with the thermocautery. Innocent tumours of the body of the upper jaw, apart from dental cysts, are so rare that they do not enter seriously into the question of differential diagnosis. They behave like the correspond- ing grow^ths of the lower jaw, the description of which should be referred to. On the other hand, innocent tumours, or gron'tlis only nialignant locally, play the most important part in connection with the alveolar process. These will be discussed, together with the growths of the oral cavity. CHAPTER XVI. TUMOURS OF THE LOWER JAW. Apart from neoplasms of the gums and alveolar process, which we shall discuss in connection with tumours of the oral cavity, new growths of the lower jaw present no difticulties of recognition. Care must be taken, however, not to confuse a swelling which appears to be a tumour, with what is really an inflammatory process. We must abandon the thought of a new growth, and conhne ourselves to one of the inflammatory conditions described in Chapter XIV, if the disease has started with toothache, caused by carious teeth which are in evidence ; if the thickening of the jaw has been preceded by an iicute inflammatory stage ; if the patient tells of repeated acute exacer- bations and shows the scar of an old dental fistula in testimony thereof ; or if wc find tubercular glands of the neck in a purely chronic disease. We are, how'ever, justified in diagnosing torthw'ith a new^ growth, if the swelling has come on gradually and painlessly ; if t(jothache, when present, is a late symptom, and healthy teeth 86 SURGICAL DISEASES OF THE HEAD become loose without any visible inflammatory changes in the gum. Palpation will sometimes elucidate the condition. An inflammatory swelling gradually merges with the healthy bone, whereas most tumours appear to be sharply separated therefrom. Central tumours form an exception to this rule, because these, at first, expand the bone in a spindle-shaped manner. In these cases, the exclusion of any antecedent dental disorder is decisive from the point of view of diagnosis. Having concluded that a growth is present, the first question concerns its innocence or malignancy. The history supplies the critical factor, because a slow growth always means innocence, and a rapid growth signifies f~ ^ malignancy. But this cri- terion must be cautiously applied, because even a sarcoma may last for many years. It is necessary, next, to consider the matter of painfulucss. Painless tumours, which remain painless for years, are inno- cent. If toothache comes on, a suspicion of malig- nancy arises, but only suspicion, for innocent growths may cause neu- ralgia by pressure on the inferior dental nerve. On the other hand, victims of sarcoma may remain free from pain for a consider- able time. It is only in extreme cases, therefore,, that the previous history permits of the formation of an immediate diagnosis. In intermediate cases every clinical aid will need to be enlisted, and often enough the microscope will be required to make the final decision. It must not be forgotten that a tumour which has been innocent for years may eventually become malignant. This change can generally be recognized by sudden rapidity of growth. We have purposely omitted one sign, viz., the absence or presence of metastases in the glands of the neck, because this is not a matter of significance in connection with tumours of the lower jaw. Malig- nant growths in this situation are sarconuita, which usually leave the glands unaffected. Enlarged glands should therefore not be regarded Fig. 51. — Odontoma of lower jaw. TUMOURS OF THE LOWER JAW 8/ as a mark of malignancy, but, as previously stated, rather an indication of tubercular disease. We now proceed to discuss the individual varieties : — (i) The first group of growths of the lower jaw embraces tumours connected in some manner with the developnieni of the teeth, or at any rate with the epithelial covering of the jaw. They are not indeed of frequent occurrence, but they are of great theoretical interest. Among these are dental cysts, which appear during the period of youth ; they push the jaw oiitivards, and they contain either a tooth which is missing from the series, or a supernumerary tooth. The expansion of the jaw which they cause is very gradual, so that finally the bone gives the crumbling sensation peculiar to parchment. If such a cyst has been incised in ignorance of its true nature, or if it has burst spontaneously, a fistula remains which is very prone to secondary infection, wherewith the whole aspect of the case is obliterated. Another group consists of odontoma and adamantinoma. These may be soft, or as hard as enamel, or of a mixed character. They arise in young people as an irregular proliferation of the various elements of a tooth, and they gradually, but painlessly, displace the enclosing bone, both ontward and imvards. Their favourite site is in the neighbour- hood of the posterior molars (fig. 51). Another tumour, less associated with tooth development, is the multilocular cystoma of jaw, in which the bone becomes gradually expanded by cystic proliferation of its epithelial covering, and finally becomes converted into a vesicular shapeless structure. This change eventually attacks the ascending ramus of the jaw, in contrast to what occurs in simple cysts of the jaw and odontomata. (2) Turning novv^ to connective tissne tnmonrs, we must mention the innocent groivths, fibroma, chondroma and osteoma, as of com- paratively rare occurrence. If they arise from the surface of the bone, they grow slowly, their structure is nodular, they feel firm or hard, and only become troublesome through secondary changes. But if they exist within the bone, their pressure on the inferior dental nerve may soon produce neuralgia. The bone is expanded, first in a spindle-shaped manner, and having reached the surface it appears as a nodular sharply defined structure. Sarcomata, malignant connective tissne tnmonrs, play the chief role among the tumours of the lower jaw. The initial symptoms and ■early discomfort depend upon whether their site is central or peri- pheral ; but their course is more rapid than that of the tumours -previously discussed, even if, exceptionally, the first signs date some years back. The following observation is very significant : — A female, aged 50, came to her medical attendant complaining of 88 SURGICAL DISEASES OF THE HEAD a gradual thickening of the riglit horizontal ramus of the lower jaw. It was regarded as a dental cyst and was opened from the mouth. The knife penetrated into a hollow space, from which a profuse stream of blood flowed. I saw the patient, two years later, with a diffuse expansion of the whole right half of the jaw. The diagnosis pointed to sarcoma, and the operation consisted of removing half of the jaw, which was expanded as far as the articular process into vesicular cavities, just like a multilocular cystoma of the jaw. The small amount of firm tissue present showed the structure of a round celled sarcoma. Two years subsequently I saw the patient again. Locally she was cured, but there were secondary deposits of similar structure in the skull and sternum. The diagnosis may be difficult in the early stages, as already intimated, but it cannot be missed if the tumour has proliferated into the oral cavity, has caused the teeth to fall out, has become adherent to the skin, or has finally ulcerated to one side or another. It should, however, not be allowed to reach such a degree ; every tumour of the jaw which does not remain quite stationary, ought to be suspected and removed. A careful examination will generally reveal the starting point of the tumour, notwithstanding many exceptions. The sensation of crinkling like parchment indicates a central site, as also does a bony resistance of the surface, detected by the acupuncture needle. If acupuncture is made in various places and bone is only struck at a great depth, the growth has arisen from the periosteum. But nowadays Rontgen-ray examination should replace acupuncture, because a skiagram gives a clearer conception of the distinction between bony and soft tumours, and also reveals the missing tooth in the case of dental cysts (figs. 49 and 50). We have said nothing about cancer of the lower jaiv, but this will be referred to in the next chapter, as it usually grows from the mucous membrane of the gums. Isolated masses of dental epithelium, deeply displaced, very rarely undergo cancerous degeneration. CHAPTER XVII. ACUTE INFLAMMATORY DISEASES OF THE ORAL CAVITY. We have already met with some of the acute inflammatory diseases of the interior of the mouth, and we shall come across them again when we discuss some of their main symptoms : lockjaw and difficulties in swallowing and breathing. We shall, therefore, here only collate a few points which have been treated disconnectedly, and supply^ sundry omissions. ACUTE INFLAMMATORY DISEASES OF THE ORAL CAVITY 89 An acute swelling of the lips nearly always depends upon the presence of a small furuncle, w^hich may have disappeared in the general oedema, assuming, of course, that the swelling is not a part of an extensive inflammation like erysipelas, or the result of a perios- titis of the jaw. We have already noted the possible dangers of a furuncle of the lip. Annciife ciicnmscrlbecl swelling of the ginn indicates either a diseased tooth or a root retained in the alveolus. The precise localization is shown by the position of the most intense redness of the mucous membrane, and the greatest obliteration of the fold between the cheek and jaw. If the offending tooth is still visible, it will readily respond to light percussion. Acute widespread swelling of the gum is a sign of some form of acute periostitis of the jaw {see lower jaw), or of a general stomatitis (see below). Acute swehing of the floor of the moiilli may be due to many causes. If the swelling is in the middle line, and more definite posteriorly than anteriorly, w^e should think of a secondarily sup- purating dermoid, which is common in children, or of an inflamed lymphangioma. In such a case an adult would observe that there had been something abnormal under the tongue before the onset of the acute inflammation. If the inflammation has proceeded externally towards the sub- mental region, the case is one of phlegmonous submental lympha- denitis, A sore on the lip, an acute pustule, a small infected abrasion of the skin, will have afforded the portal of entry of the infection. If the swelling on the floor of the mouth is rather unilateral, or if the patient can state on which side it began, acute inflammation of the salivary glands must be thought of. If the swelling is anterior, the sublingual gland is affected, if lateral, it is the submaxillary gland. In these cases the floor of the mouth, in the vicinity of the gland, may look like a translucent oedema and the swelling feel like a board. The cause of the swelling will be found in a salivary calculus, especially if the patient states that he has suffered from repeated attacks of such inflammation. If these exacerbations are of short duration, and terminate with a discharge of saliva, there is no doubt the swelling indicates salivary retention. If they are of longer duration — a day or more — and increasing infiltration of the tissue takes place, we must conclude that some bacterial inflammation of the salivary glands has become engrafted on the simple retention. If treatment is not undertaken, the swelling will proceed to its natural result — the forma- tion of an abscess. If the symptoms are distinctly inflammatory from the start and are better developed externally than towards the mouth cavity, the 90 SURGICAL DISEASES OF THE HEAD case is one of acute submaxillary lymphadenitis. Its cause will most probably be found on the gum, or the cheek, or nose if the portal of entry still remain demonstrable. If the infection is very severe, and tends to spread, especially towards the floor of the mouth, it is termed " Ludwig's angina," which is merely a clinical and not an etiological indication. The exciting causes, as usual about the mouth, are staphylococci, strepto- cocci and colon bacilli. The great severity of the infection strongly suggests that the infection arises from some deep focus — directly around the submaxillary gland. If the swelling involves the tongue from the start, and this organ quickly becomes converted into a dense immovable mass, with saliva trickhng from the open mouth of the patient, who can neither swallow nor speak, but can just breathe, the case is one of acute glossitis, which usually ends with the formation of a lingual abscess. This rare disease is of a metastatic character, and supervenes especially as a sequela of acute infectious diseases. If in the course of glossitis thei'e be dyspnoea with delayed respiration and stridor, it is obvious that the larynx has become oedematous, and that tracheotomy is urgently required. If, on the other hand, the dyspncea is accom- panied by cyanosis and hurried respiration, without stridor, we conclude that aspiration pneumonia has supervened, and our pro- gnosis will be correspondingly doubtful, if not bad. Sometimes the entire floor of the mouth is involved in a phleg- monous inflammation from the very beginning ; and the tongue, which is usually oedematous at the same time, is pressed against the palate. The clinical picture resembles that of Ludwig's angina, but is bilateral from the start. This constitutes a case of acute phlegmon of the floor of the mouth, and has three sources of danger — (i) suffocation, (2) aspiration pneumonia, and (3) extension of the inflammation to the connective tissue of the neck and mediastinum. If the original site of the swelling be the istJunus of the fauces, the first glance will suffice to distinguish between diffuse and ■uuilateral sore throat. If it be diffuse, we must think of catarrhal and lacunar sore throat, scarlet fever, diphtheria, and secondary syphilis. As far as these are of surgical importance, they will be discussed later on with the subject of diphtheria. The inexperienced often miss syphilitic soi-e throat when it appears in a mild catarrhal form, and is not accompanied by mucous patches on other parts of the mucous membrane. Those affected with "syphilis insontium " are of course unaware of its cause, and the others often enough refuse to know anything about it. But it is just in this stage that diagnosis is so important, both because of early treatment and the protection of the patient's surroundings. If the sore throat is unilateral, we should entertain the possibility TUMOURS AND ULCERS IN THE MOUTH, PHARYNX AND NOSE 91 of a tonsillar or retro-tonsillar abscess. If the swelling increases, we should not wait till it bursts spontaneously, but should search for pus in the classical situation before complications supervene. An acute swelling on the posterior or lateral wall of the pharynx must be regarded as an acute retropharyngeal abscess, which is generally due to a lymphadenitis, but in rare cases may depend upon osteomyelitis of the spine. If the abscess is not accessible externally we must evacuate it from the inside, using a puncture syringe so that the gush of pus should not inundate the larynx. Further, we must not forget that there are certain acute in- flammatory processes which lead to the growth of adenoids on the roof of iJie pharynx. The examination of this region is always im- portant when children suffer from unexplained pyrexia. If the lips and cheeks are infiltrated, and a diffuse swelling of the mucous membrane with severe turgidity of the gums is seen when the mouth is opened — as far as the lockjaw permits this — if there are already a few ulcers about, and foetid froth issues from the mouth, we are confronted by the rare disease gangrenous stomatitis, which may be fatal in a few days, but the cause of which is still obscure. This disease exhibits, in the most intense degree, the symptoms present in scurvy and mercurial stomatitis. If the inflammatory process is so severe that gangrene of the lips and cheeks ensues, it is impossible to miss the clinical picture of noma, which occasionally attacks children after debilitating infectious diseases. CHAPTER XVIII. TUMOURS AND ULCERS IN THE MOUTH, PHARYNX AND NOSE CAVITIES. Many new growths of mucous membrane appear as ulcers ; we must therefore discuss them in common, when dealing with the oral and pharyngeal cavities. We have previously stated that every obstinate nicer must be suspected of uialiguaucv, however little aspect of growth it may possess. If this maxim were adequately taken to heart we should not so often see carcinoma treated for weeks with lunar caustic, until the enlargement of the glands of the neck finally takes the con- firmed optimist by surprise, but renders the issue of an operation doubtful. 92 SURGICAL DISEASES OF THE HEAD /I.— NON-ULCERATING GROWTHS. We only include here among "ulcerating growths " those wherein ulceration is of the essence of the disease, such as cancer, tubercle or syphilis, but not those which have been exposed to accidental super- ficial erosion, e.g., an epulis wounded by an adjacent tooth. In cases of cancer it is often necessary to look for the ulcer. A cancer at the base of the tongue may start as a non-ulcerating growth, and only after a careful examination with a mirror or the palpating finger, will a deep, open excavation be discovered posteriori}^ We shall proceed topographically, because the various diseases have their own special sites of preference. (1) THE MUCOUS MEMBRANE OF THE LIPS AND CHEEKS. If a patient complains of a little tumour about the size of a hazel nut, situated in the mucous membrane of the lip or cheek — a tumour which disappears and reappears, and examination reveals a bluish translucent, semi-globular structure which is not dispelled by pressure, the diagnosis can only be a mucous cyst. But if the tumour in this situation is bluish-red, and is dispelled by pressure of the finger, the case can be nothing but one of cavernous angioma. It is noteworthy that the angiomata of the mucous membrane, in contrast to those of the skin, are distinctly encapsuled. A soft pedunculated growth, which cannot be dispelled by pressure, hanging from the mucous membrane of the cheek is a fibroma, in which the various components of the mucous membrane, viz., glands, blood-vessels and h'mphatics, are more or less extensively proliferated. (2) THE FLOOR OF THE MOUTH. The tumours in this region, covered by normal mucous membrane, are usually cystic structures, except for the very rare yellowish lobulated lipomata which are visible beneath the mucous membrane. The surgeon did not note the yellowish colour of the swelling, depicted in fig. 52, and he incised it, thinking it was a ranula. A bluish tumour, rather laterally situated, shining through the thinned mucous membrane, soft, elastic, or fluctuating in consistence, and raising the tongue, is a ranula. This diagnosis states nothing as to the origin of the structure concerning which embryologists and surgeons are at considerable variance. The view at present prevailing explains most cases on the assumption that they arise as cysts from segments of the sublingual gland, much in the same way as the mucous cysts of the lips or cheeks, varying in size from a pea to a hazel nut, which we have just mentioned. TUMOURS AND ULCERS IX THE MOUTH, PHARYXX AXD XOSE 93 It has been shown that besides the ordinary ranulae, cysts may arise in some cases from Bochdalek's ducts, which are Hned with cihated epithehum, Nuhn-Blandin's glands at the tip of the tongue have also produced cystic structures, but these have nothing in ■common with ranulae, because they are situated at the tip of the tongue and not under it. If careful attention is given to the various characteristics of ranulae it is difhcult to mistake them. Lxniphanglomaia, which have been observed in this vicinity, are much less sharply defined, and they frequently involve the tongue itself. They are composed of numer- ous small vesicles and do not constitute a single-spaced structure. Lipouiata are lobular and appear yellowish, as seen through the Fig. 52. — Lipoma of floor of moiilh. Fig. 53. — Sub-lingual dermoid. mucous membrane. Only a dermoid could lead to error of diagnosis because it is also a single-spaced structure. Dermoids which occur in this region nearly as frequently as ranul^e, are, however, centrally situated, whereas ranulae are rather laterally placed (ng. 53). Their walls are thicker than those of ranulae, and the cysts present rather a whitish-yellow than a bluish appearance from beneath the mucous membrane. Sometimes they are closely adherent to adjacent tissues, or are even attached to the bone, which is never the case with ranulae. They are also more liable to suppurate than the latter. If doubt arises, because a tumour apparentlv in the median line 94 SURGICAL DISEASES OF THE HEAD gleams through the mucous membrane with a bhush tint, e.g., a large ranula which has encroached on the middle line, or because a laterallv situated cvst — dermoids are in rare cases lateral — looks like a dermoid^ the diagnosis can be cleared up by a puncture, which is quite harmless. The treatment is similar m both conditions, so that an error in diagnosis has no serious consequences. (3) THE GUMS. A tumour projecting from the margin of the gum, varying in size from a pea to a walnut, may be summarily diagnosed as an epulis, I.e., tumour of the gum.' This is, of course, no histological Fig. 54. — Epulis growing from a space between teeih. Fig. 55. — Epulis (pure fibroma), with impressions of upper molars. diagnosis, it is merely a description of what is found. If the tumour is of the same colour as the healthv gum, and is firm, it may be regarded as a pure fibroiiia : if, with the same colour, it is softer, we must conclude that it is richer in cells and blood vessels, and there- fore approximates to a sarcouia. If the growth is darker, with a faint shade of brown, the case is one of giant-celled snrcouui, springing from the alveolar periosteum, the typical form of epulis. These growths have an abundance of vessels on the suiface almost like an angioma, all the rest of the tumour showing the structure or a giant-celled sai coma. Thev frequentlv contain a brown pigment TUMOURS AND ULCERS IX THE MOUTH, PHARYNX AXD XOSE 95 in addition. Their malignancy is limited to local occurrence ; the glands are not atiected nor do metastases occur. It is noteworthy that an epulis will often grow from a site which has been exposed to persistent irritation, e.g., in the spaces between teeth, in the neighbourliood of old stumps (fig. 54). Occasionally the epulis becomes somewhat ulcerated from friction on its surface, and it may even show the impression of the opposite teeth (fig. 55). They can be promptly distinguished from tumours of the jaw proper bv the narrow peduncle which connects them with their site of origin. At first sight they seem to be situated on a broad base, but if thev are well elevated it is astonishing to ^■:ee how slight their attachment really is. Granulations, which occur so frequentlv in connection with remains of stumps, and not infrequently in pulp cavi- ties, must be distinguished from epulides which are really <^enuine tumours. In neglected teeth, the whole row of miss- ing crowns may be occupied bv such granulations. <4) PALATE, TONSILLAR REGION, BASE OF TONGUE. A semi -globular swelling which has recently developed in the middle of the hard palate is usually a ginnina ; but if it embraces the margin of the palatal plate, or if it is close to a diseased tooth or an old stump, it is a dental abscess (fig. 56). If the growth arises from the soft palate or the tonsillar region, and is definitelv capsulated with the mucous membrane movable over it, we must think of one of those mixed tumours which more frequently (jccur in the parotid region. If the tumour has a wide attachment to the tonsillar region, and is only slightly or not at all movable, the case is certainlv one of sarcoma, and we must not wait for enlarged glands to confirm the malignancy. A striking swelling of the whole of the Ivmphatic system of the pharynx should suggest the possibility of leukaemia or pseudo-leukaemia. The fact that many tonsillar sarcomata have vanished after energetic treatment with arsenic, and also with X-ravs, has not only a therapeutic Fig. 56. — Abscess of palate arising from root of tooth. 96 SURGICAL DISEASES OF THE HEAD but also a diagnostic interest. These tumours must be classified with the still somewhat enigmatic group of lymphosarcomata. Pedunculated polypi are sometimes found on the palatine arch^ especially in the form of — purely innocent — papillomata. A soft, roundish well-defined tumour at the base of the tongue is most likely to be an aberrant goitre. This localization is explained by the circumstance that the central thyroid gland rudiment grows from the position which subsequently forms the base of the tongue. For this reason, accessory goitres may be met w^ith along the whole remaining track of this rudiment, between the foramen caecum and the processus pyramidalis of the thyroid gland, i.e., the thyro-glossal duct. Patients with lingual goitre feel as if they have a lump in the throat,. which cannot get down. If the growth is extensive the speech be- comes nasal, and ultimately respiration is obstructed. Sometimes severe haemorrhage occurs from the superficial vessels. (5) PHARYNX. If a tumour-like structure projects into the pharyngeal cavity, one must endeavour to ascertain its point of origin, by means of the eye, the probe and the finger. If it has a broad attachment to the anterior surface of the vertebral column it might be a sarcoma, but it is more likely to be a tubercular abscess due to spinal caries. The stiff manner in which the patient holds his head will already have suggested this diagnosis to the careful observer ; and the history will show that the tumour in the pharynx was long preceded by difficulty in moving the head. Palpation will also show at once whether we are dealing with an abscess or a solid tumour. If the tumour projects into the pharynx from above, it may be an ordinary mucous polypus arising from the nose. These are remark- ably soft to the touch, and they give the impression of receding out of the way of the palpating finger. If they are visible, directly or through the mirror, they are recognized by their w^ll-known bluish colour and their glassy translucent appearance. If the growth is of firmer consistence w^e may be undecided as between a fibroma spring- ing from the basilar fibrocartilage at the base of the skull in young people, and a sarcoma proper of the base. As the dift'erential diagnosis between these two is of extreme importance for prognosis and treat- ment, we must dwell upon it for a moment. A fibroma of the base of the skull, usually a nasopharyngeal fibroma or a nasopharyngeal polypus, can be excluded if the growth has occurred after the termination of adolescence, i.e., after the second decade. Naso-pharyngeal fibromata have the peculiarity of only TUMOURS AND ULCERS IX THE MOUTH, PHARYNX AND NOSE 97 developing before the termination of this period. But if the patient has not yet completed adolescence the growth might be of either variety. In doubtful cases, the sex as well as the age is of assistance, because in infancy nasopharyngeal fibromata are of equal incidence in both sexes, whereas at puberty, when they are most frequent, they only attack males. The previous history is also of great importance. If the growth has taken years to develop and has manifested itself by nasal obstruction and occasional severe haemorrhages, we can definitely exclude sarcoma. On the other hand, if the existence of the growth, the blocking up of the posterior nares, and possibly also haemorrhages have all taken place within a few months, we must regard the case as one of sarcoma. If the new growth emits processes into all the accessible cavities in the neighbourhood, processes which, if visible, display the same roundish form, and the same sharp definition as the tumour within the pharynx, the case is one of fibroma. On the other hand, a diffuse extension of the tumour, the early onset of neu- ralgic pains and brain symptoms are in favour of sarcoma. Teratoid growths of various kinds are to be found at the junction of the pharynx and oesophagus as well as in other positions in the pharynx. They may be teratomata proper formed from all the three layers of the embryo, with a tuft of hair on the surface, or they maybe simple I ipoinata or soit fibromata ; the latter may at times hang out of the mouth like a sausage (see fig. 57). At other times they only appear after some definite cause, such as vomiting, and then are again swallowed by the patient. Fig. 57. — Pharyngeal polypus, with a long pedicle arising from ihe palatopharyngeal arch. (6) THE NASAL CAVITY. Non-ulcerating new growths in this region, as in the pharynx, may be mucous polypi, fibrous nasopharyngeal polypi, or sar- comata. We have already discussed the first two, and would only add here there is usually some accessory sinus catarrh behind the mucous polypi. But for the formation of these polypi there is also 98 SURGICAL DISEASES OF THE HEAD required a special, and often a very obstinate predisposition, which tends to the constant development of new polypi. In fact, the shape of the nose may be so greatly deformed in some cases in the course of a few years, that a fibrous polypus or even a sarcoma would be diagnosed, if the previous history were unknown. Sometimes the appearance of a bluish mucous polypus at the nostril leads im- mediately to a correct diagnosis. Sarcomata of the nose usually start from the turbinated bones, and in the beginning are merely regarded as hypertrophied mem- brane. When they take on rapid growth, cause nasal obstruction and hjemorrhage, a small portion excised for histological exami- nation will make the diagnosis positive, or confirm it if already made. 5.— ULCERATION PROCESSES. Two points must be impressed upon the beginner in regard to the diagnosis of ulcers, viz., to closely examine the characteristics of the margin of the ulcer, and to investi- gate its base. This rule also applies to ulcers of the oral cavity, but it encounters many difficulties in this region owing to ana- tomical conditions and the occasional inaccessibility of the tumour. However, a superficial ulcer with a soft border and a soft greyish base is tubercle; an ulcer w^ith a fatty, yellowish base is a giiuiuia ; a hard undermined border with a hard segmented base, often covered with necrotic shreds, points to cancer; and an ulcer of firm consistence without undermined edges, but with a smooth, varnished-looking base suggests a primary chancre. But one must not conclude from this that a cancer must Fig. 58. — Mucous polypus of the nose. This figure represents a patient who regularly for fifteen years was relieved from time to time of whole bunches of mucous polypi from both nasal passages, before she made up her mind to undergo operative treatment for her bilateral accessory sinus catarrh. TUMOURS AND ULCERS IN THE MOUTH, PHARYNX AND NOSE 99 always have undermined edges and be segmented, and that a gumma necessarily must have a yellowish, fatty base in all its stages. Our diagnosis will always be most accurate when we bear in mind the most frequent morbid conditions which occur in the various portions of the oral cavity. (1) THE MUCOUS MEMBRANE OF THE LIPS AND CHEEKS. Cancer is the most frequent lesion in this part, although tubercle, gumma, and primary chancre are possibilities. We have already discussed cancer of the lip. Cancer of the mucous membrane of the lip is much rarer, but its prognosis is much worse. F The following case shows \ liow difficult the diagnosis may be, on the assumption that an ulcer of the lip," in an old man, must be cancerous. A man, over 70, an old sufferer I from bronchitis, had an ulcer on his left lower lip, and another one on the mucous membrane of his right cheek. They were both soft, superficial and very pain- ful. There were neither epithelial plugs nor tubercles visible. The history of syphilis was very in- definite, and the pain contra- indicated it. The only point in favour of cancer was the age, everything else was against it, and the pain suggested tubercle. The bronchitis appeared to be '" ordinary senile bronchitis. The diagnosis of tubercle could only only be made by a process of exclusion, but its accuracy was established by histological examination of a piece of the border excised for the purpose. It is hardly necessary to mention the small transitory ulcers on the mucous membrane of the cheek, which are so often produced by bites. (2) THE FLOOR OF THE MOUTH. Carcinoma is of frequent occurrence on the floor of the mouth ; tubercle and primary chancre are rare. In its early stages the cancer appears as a small, movable, roundish, definitely raised tumour, presenting as its centre a small superficial ulcer surrounded by an Fig. 59. — Sub-lingual cancer. Tongue drawn aside. lOO SURGICAL DISEASES OF THE HEAD encroaching border. This in itseh' suffices to justify the diagnosis. The practised observer will involuntarily feel for enlarged hard glands after examining the growth in question, in order to confirm the diag- nosis. The presence or absence of glands must, however, not be invested with too great a significance, at any rate their absence is not a conclusive argument against cancer. If the tumour has become adherent to the jaw and eventually also to the tongue, so that the latter gets fixed and movements of mastication and speech are inter- fered with, the diagnosis is easy enough. (3) THE GUMS. The careful examination of the gums is not only of importance to the dentist and the physician, but also to the surgeon. For in- stance, a persistent colic, which might be attributed to organic obstruction of the bowel, will be shown to be toxic in origin, by the discovery of the well-known blue line on the gums. In a case of obstinate suppuration between a tooth and the gum, and general loosening of the teeth, we should not treat the gum, but should examine the urine for sugar. If this examination does not reveal the cause of the alveolar pyorrhcva, some other general disease should be searched for. If called to arrest obstinate haemorrhage from a tooth, we must not be content with apphang a styptic, but must investigate the cause of the bleeding, which may be due to a hitherto overlooked Jweuio- pliilia, to a leulicvuiia, or to chronic jaundice. Alost clirouic iuliauiuiatorv diseases of the gums depend upon dental disease. If thev do not recover after extraction of the bad teeth, the removal of stumps or sequestra, we should suspect actino- mycosis, tubercle, or phosphorus necrosis. We have already discussed the diagnosis of these conditions. Ulcers which are surrounded by a definitely inflamed area must be diagnosed in the same way as those on any other part of the oral mucous membrane. It will be necessary to differentiate between cancer, tubercle, 3.nd gnniuia. Primary cliancre is very rare. The lead- ing points of differential diagnosis have already been adequately stated. Finally, swellings which bleed easily are due to scurvy, and in little children indicate Barlow's disease. It is noteworthv that in the latter condition the unmistakable bluish-red swelling of the gum only occurs where teeth have already erupted. The pain in the extremities completes the clinical picture and demands that we should not incise the swelling in the gum^ but should adopt immediately the only prompt and effective treatment, i.e., the abandonment of all artificial or artificial^ sterilized food. TUMOURS AXD ULCERS IN THE MOUTH, PHARYNX AND NOSE TO! (4) THE TONSILLAR REGION. Various forms of ulcer, cancer, primary chancre, tubercle and gumma have to be considered here, as well as the somewhat rare non-specific ulcer of the tonsil. The first lead in diagnosis is given by the presence or absence of glandiihir ciilargcnwnt. {a) If the glands are not enlarged we mav exclude chancre, unless it be quite recent; and we should think of cancer and gumma, possibly also of tubercle. The frequency of carcinoma renders its presence more likely than that of any other ulcer. If the patient is an alcoholic, this supports the diagnosis, because, in mv experience, tonsillar cancer, and especially cancer of the pharynx, have mainly occurred among heavy drinkers. The fact that only one ulcer is present is also in favour of cancer, apart from its hard base and border. Gummatous and tubercular ulcers are, on the other hand, frequentlv multiple. Pains radiating towards the ear and robbing the patient of sleep at once dispose of gumma and tubercle. Pain limited to swallowing is strong presumption against a gumma, but not against tubercle. The absence of pain is, however, no evidence against cancer, because pain may not come on until a stage wherein operative measures are useless. If the consistence and, perhaps, the multiplicitv of the ulcers show that it is either tubercle or gumma, the presence of separate little nodules on a reddened base around the ulcer points to tubercle, whereas the partial aggregation of areas which start as roundish nodules and their subsequent disintegration in the centre, point to gumma. These characteristics are sometimes difficult to detect, and it is therefore all the more important to pa}^ attention to the history of the patient and his general condition. There is generally some preceding pulmonary or intestinal tuberculosis in cases of pharyngeal tubercle, and although the most carefully taken history will not always reveal svphilis in cases of gummata, it very frequentlv will do so. In doubtful cases, we must resort to histological and bacteriological investigation, lest we overlook cancer. A small piece of the edge of the ulcer should be snipped off with forceps, or scissors, and a part thereof submitted for histological examination and a part used for animal inoculation. The micro- scope will settle the diagnosis with certainty in a few hours or within a day or two ; guinea-pig inoculations take at least four to six weeks ta supply definite information. Quite recently some experienced observers have cast doubt on the value of this kind of histological examina- tion. Personally I have emploved this method for many years in my own practice, and have had very reliable results when the little pieces are taken from the right place and the sections are cut in a 102 SURGICAL DISEASES OF THE HEAD proper direction. It would be best it the person who lias excised the specimen would himself examine it, but as this is usually im- practicable, he should inform the pathologist of the exact disposition of the piece submitted, so that sections should be cut perpendicularly to the margin of the ulcer. It would be useful to examine a piece from the margin and a piece from the base of the ulcer at the same time. If this investigation is negative and clinical signs are suspicious, we must not be content until another and larger piece has been removed, if it is impossible to establish the diagnosis in anv other wav. The result of a Wassermann test should always be taken into consideration, but it must not be forgotten that a syphilitic may become affected with tubercle or cancer. Diagnosis "ex juvantibus " still holds the field in syphilis. (6) Diagnosis is facilitated if enlarged glands arc present. If they have come on soon alter the appearance of the ulcer, and have reached a fair size in a short time, and are adherent to the adjacent tissues, we mav assume that the glands are in a state of early fibrosis. The minutest superticial injuries suffice for infective material derived from dirty drinking vessels to stick to the tonsils. One illustration, out of man}', may be given. A student drank out of a drinking horn directly after an old man, in token of mutual lovalty. The student acquired a tonsillar chancre, and it subsequently transpired that the old man had signs of secondary syphilis in his mouth — an instance, bv the way, of the neglect of elementary rules of hygiene, prevalent at the present day. If the glands have not enlarged until some considerable time has elapsed since the appearance of the ulcer, then the diagnosis lies between carcinoma and tubercle. In the former case thev are hard, in the latter rather softer. In both cases thev may become adherent, so that no conclusion can be drawn from this condition ; but enlarged glands which have existed for many months without contracting adhesions around are more likely to be tubercular than cancerous. The adhesions of cancerous glands are of a very firm kind, so that hai"d immovable masses are formed. After tubercular glands have contracted adhesions, suppuration generally takes place in the centre, so that it will be found that soft, elastic, and even fluctuating areas ■exist, surrounded by comparatively hard borders. Xo conclusions can be drawn from the condition of the ulcer, or of the glands existing at the time, if the attention of the patient or the medical attendant has first been directed to the presence of an ulcer bv the onset of glandular enlargement. It may be stated finally that Plaut-Vincent's angina {see infra) in the ulcerative stage may easily be mistaken for a syphilitic ulcer. The bacteriological findings and the rapid recovery are decisive. TUMOUKS AND ULCERS IX THE MOUTH, PHARYNX AND NOSE lOJ, (5) HARD AND SOFT PALATE. A solitary ulcer spreading from the tonsillar region towards the margin of the soft palate is usually a carcinoma. Carcinoma rarely begins on the soft palate, but we have seen it entirely eaten away by a primary cancer. A swelling in this region is much more likely to be a gumma, especially if it, or the ulcers, are near the linrd palate, or actually on it, or if they have already perforated it. Tubercle also occurs on the soft palate. It differs from gumma in its longer duration, in the appearance of the ulcer, and also by causing severe dysphagia, and by rarely failing to produce glandular enlargement. (6) PHARYNGEAL WALL. Ulcers on the mucous membrane of the pharynx are of rare occurrence, apart from those at the base of the tongue and the tonsillar region. Cancers are usually found at the entrance to the gullet, in the neighbourhood of the roof of the pharynx and in the vicinity of the posterior nares. As they arise in such concealed situations, enlargement of the glands is usually their first indication, and they require a careful rhinoscopic examination. Ulcers on the posterior wall of the pharynx are usually gummata. It is also necessary to mention the bedsore caused by the cricoid cartilage in very chronic diseases. (7) NASAL CAVITY. We leave the round ulcer of the septum to the rhinologist, so that cancer, svphilis and tubercle again come under consideration. A careful examination with a mirror is generally indispensable, but there are certain concomitant conditions of the diseases which are useful for differentiating one from the other. There are certain tumours and ulcers of the pharynx and nose, which would only be diagnosed if we are aware of the patient's occu- pation, or of his geographical relationships. These include the ulcers of glanders in the nose of people who attend to horses suffering from farcy, leprosy, and rhinoscleroma of certain districts, the latter usually from the Balkans. The diagnosis of leprosy will be made from the other appearances of the disease, and rhinoscleroma will be recognized by the "hardness of the infiltration, the absence of glandular enlargement, and the chronic course of the disease. A young man returned home from a sanatorium with his pul- monary condition improved, but he had an ulcer in the nose which gradually ate away the septum. In such a case, nothing hui tnherde would be thought of. An aged grandmother complained of '' a cold in the head," or,. I04 SURGICAL DISEASES OF THE HEAD rather, of a persistent and profuse nasal discharge. She produced a few shreds of bone, which, to her amazement, had escaped with the ■discharge. Her previous history told of one living child after a series ■of miscarriages. Iodide of potassium worked wonders. We shared her pleasure at this result, but we were careful not to tell her that this was a reminder of her late husband, whose portrait discreetly smiled on us from the wall. A middle-aged patient came with a bloody, offensive discharge from one nostril, which had lasted for some months. There had been hard glands at the angle of the jaw for the last few weeks. This could be nothing but cancer. CHAPTER XIX. CHRONIC DISEASES OF THE TONGUE. The custom of the old physicians — who invariably looked at the patient's tongue — was no idle habit, and the younger generation neglect this diagnostic aid too much, in favour of "exact" methods of diagnosis. The surgeon should find interest not onlv in the colour of, and the deposit on, the tongue, but particularly in its degree of moisture. Nothing affords us a more rapid conception of the patient's condition and of the prognosis in infective diseases, like peritonitis, than a glance at the tongue. A dry tongue of normal colour is worse than a moist tongue, however much coated it may be. We will not refer to the various superficial changes, such as the map-like tongue, the black, hairy tongue, the wrinkled tongue, &c., because they possess no surgical significance ; but leukoplakia must he noted, because it forms an excellent soil for the development of cancer. It is now generally recognized that the abuse of tobacco and syphilis are equally responsible for this latter condition. Fournier has asserted that in Paris cancer of the tongue is, so to say, a sequela of syphilis, with leukoplakia as an intermediate stage. This statement can only be applied to other countries with con- siderable reserve. As in the preceding chapter, we must separate here also the ulcerated from the non-ulcerated changes. (i) NOX-ULCERATED TUAIOURS AND SWELLINGS. We must first refer to macroglossia among the new growths of the tongue. It is a diffuse enlargement of the whole organ, which does CHRONIC DISEASES OF THE TONGUE I05 not concern so much the muscular structure, but consists of an increase of interstitial tissue and lymph spaces, so that it might, with more or less accuracy, be called a dijfusc lyuipJiangiouia. The muscular structures take comparatively little part in macroglossia. When this condition is fully developed it imparts an imbecile expression to the face, but we must not therefore conclude that all who are affected therewith are idiots. Nevertheless, macroglossia does occur most frequently among those whose mental development is defective. One of the signs of hypo- and athyroidism is a certain degree of diffuse enlargement of the tongue, which gradually decreases in size under the influence of specific treatment. Among the iriic tinnours of the tongue cavernous angioma is at once recognized by its colour and by easily emptying on pressure. Circumscribed lymphangiomata are not so easily diagnosed. They appear as fairly firm nodules in the soft tissue of the tongue, usually on the dorsum (tig. 60), but sometimes also on its under surface (fig. 61). As with other lymphangiomata their contents cannot be well expressed. Were it not for the long duration of the disease, one might be tempted to think of some chronic infiammatory process, of a tubercular nodule, or of actinomycosis. But if we carefully examine the tongue we shall note that the papillae around the tumour are prominent and enlarged and that some of them form little vesicles. This is decisive for the diagnosis of lymphangioma. If we feel soft lobulated growth within the substance of the tongue we may claim it as a lipoma, and thus add one more to the dozen cases which have hitherto been recorded. But much more important than the recognition of such rarities, is the accurate diagnosis of tubercle, guniiiia, actinomycosis, sarcoma and cancer. We mention cancer last, and then only with considerable reserve, because it never occurs in the tongue with an undamaged mucous membrane. Glandular cancer, which alone can come into considera- tion, is so rare that it is hardly necessary to reckon with it. But, on the other hand, inexperienced observers are liable to declare that a cancer is not ulcerated when they have failed to see it properly. Care- ful observation will often reveal a deep ulceration below the raised mass of new grow^th which may be covered by normal mucous membrane, and close inspection \vill often show that a nodule which can be easily seen and is apparently non-ulcerated, is covered by epithelium which even macroscopically is abnormal. A pednncnlated nodnle, soft as the tongue itself and situated thereon, must be regarded as a fibroma. It is rare, but occurs on the tongue, as it does on other parts of the oral mucous membrane. Its long duration \\\\\ serve to prevent its confusion with sarcoma. A nodule which has arisen within a few months and is iirmer than the tongue io6 SURGICAL DISEASES OF THE HEAD substance must, however, be looked upon as a sarcoma. There are also soft sarcomata ; but they do not possess the toughness of soft fibromata ; thev soon break down and form deep ulcers. If the nodule is iufiltraicd within the tissue of the tongue we must differentiate between tubercle, guuuna, actiiwuixcosis and siircoina. It must be regarded as a sarcoma if its size is greater than is com- patible with an inflammatory granulation tumour. A lump as large as a hen's egg will be neither a tubercle nor a gumma. In the case of smaller tumours the early onset of radiating pains points to malig- nancy. But, as a rule, we should only diagnose sarcoma of the tongue when there is no more plausible possibility, because it is a condition of great rarity. Fig. 6o. — Lymphangioma of the tongue. Fig. 6i. -Cystic lymphangioma of the tongue. The local circumstances often suffice to differentiate between gumma and tubercle. A nodule of a few weeks standing which has not yet broken down, is more likely to be tubercle than gumma. Other things being equal, the fact that a tumour is single, is in favour of tubercle. Tubercular nodules are also more painful than gummata; the latter may be sensitive on pressure but are only very slightly pain- ful in themselves. Soft swelling of the glands of the neck points to tubercle, as already stated in connection with ulcers of the pharynx. Gummata are not associated with glandular enlargement, if they are unbroken and therefore not secondarilv infected. The previous history and general condition of the patient are also of importance^ CHRONIC DISEASES OF THE TOXGUE IO7 Experience shows that tubercle of the tongue is very rarely a primary manifestation ; as a rule, it occurs only in patients who are suffering from pulmonary or abdominal tuberculosis. Similarly, in cases of gumma, the history or the general condition of the patient will provide evidence of old syphilis. Finally, as in all these cases, we have the serum reaction and the therapeutic test as ultimate resources. A deep-seated nodule of actinouixcosis, which occasionally occurs in the tongue, is distinguished from gumma by its hardness, and from tubercle by the absence of the characteristic glandular enlargement. If the disease has involved the surface, it consists of a board-like in- filtration of the tongue permeated by soft foci of granulation tissue, so distinctive of actinomycosis elsewhere. It is, therefore, only in the early stage that it presents any diagnostic difBculties in the tongue. If it has broken down, it is important to examine the pus repeatedly for the detection of the well-known granules. (2) ULCERATIVE DISEASES OF THE TOXGUE. In coming to any conclusion about an ulcer, it must not be for- gotten that all lesions within the oral cavity tend to ulcerate, especially as a consequence of friction against the teeth. The mucous membrane over a sarcoma may therefore become destroyed from secondary causes. But in such a case the growth itself is usually so prominent that the true state of affairs is perfectly evident. Advanced sarcomata, which have broken down extensively, are easily mistaken for cancer, in the absence of a microscopic examination. The reader is referred to the discussion on ulcers of the oral cavity, for the differentiation between tubercle, primarv sore, giunuia and cancer ; but a few special points may be mentioned here. When a deep-lying tubercular focus breaks dowMi, the lesion in the mucous membrane does not always assume the characters of a fully developed ulcer. A probe only penetrates through a small open- ing, more like a fistula than an ulcei", into a wide pocket corresponding to the original extent of the diseased focus. But when a gumma breaks down there forms immediately an extensive lesion of the con- nective tissue and mucous membrane. Gummata differ from cancer in being situated in the middle of the dorsum of the tongue or on its tip. Cancer nearly always starts on the edge of the tongue (fig. 62) and gradually invades the centre. Besides the well-defined gummata of the tongue there occurs occasionally a diffuse guuiuiafous infiltration of the organ, lout this is differentiated from cancer by its indefinite limitation and the fact that it does not break down. Finally, it should be noted that deep and often painful rliagades on the tongue are to be attributed to tertiary syphilis, although there ma}^ be no definite gummatous changes present. io8 SURGICAL DISEASES OF THE HEAD As far as the diagnosis of cancer is concerned the warning must again be given that it is neghgent to await the development of all possible symptoms and finally glandular enlargement, before inform- ing the patient of the nature and gravity of his disease. It is especially wrong to comfort him with the assumption that he is suffering from an ulcer caused by a tooth, until it becomes too late. Often enough it does happen that a sharp tooth or a jagged stump injures the edge of the tongue, causing a small superficial ulcer which fails to heal be- cause it is subject to constant friction. But the removal of the offending tooth or the filing of the sharp points, without doing any- thing at all to the ulcer, will result in its healing within a few days. If it does not heal, it signifies that the case is somewhat more serious, and careful palpation will no doubt reveal distinct hardness of the base and margin. To wait any longer in such a case, in order not to alarm the patient, is a delicacy of feeling which may cost the patient his life. But cancer does not always begin in this manner. Some- times it starts as a small hard nodule, with no loss of surface epithelium visible to the naked eye, but around w^hich slight contractures of the tongue tissue may be seen. Such a condition renders any further observation superfluous ; it demands immediate operation. In other cases we have to deal with patients who have been suffering from leukoplakia for years. Having been informed that this disorder predisposes to cancer they bestow the necessary, and more than necessary, notice on their oral mucous membrane, and obtain medical advice as soon as they discover any thickening of a leukoplakia patch. Often enough such a patient is obsessed with the fear of carcinoma, and fancies that there is some hardening present when in reality there is none. The practitioner must not be too ready with his reassurance ; the suspected spot must be most carefully palpated and compared with the other spots. If there is any hardening it must be treated as cancer, even. Fig. 62. — Cancer at the edge of the tongue. CHRONIC DISEASES OF THE TONGUE 109 though the unaided eye detects no loss of epithehum. At any rate the patch should be excised and submitted to microscopic examina- tion, with a view to a more extensive operation if the diagnosis is confirmed, Cancers which so frequently -start at the hinder edge of the tongue, opposite the tonsil, escape detection for a considerable time. When they are discovered, they are usually so far advanced that it is impossible to say whether they have started from the tongue and invaded the tonsil or vice versa. It is usually said that cancer of the tongue occurs in middle and in old age, and only in the male sex. But such a generalization should not be allowed to influence us too much in arriving at a decision. This is illustrated by the following case. A girl aged 22 consulted a doctor about an ulcer on the side of the tongue. The age and sex were such strong contra indica- tions of cancer that the treatment was limited for a long time to gargles and the application of lunar caustic. Eventually, the doctor became uncomfortable at the constant increase of the ulcer. Examin- ation then showed that a large portion of the left border of the tongue was occupied by a shallow ulcer with slightly projecting but somewhat undermined edges. The border and the base were hard, but only to a slight depth. There were a few hard glands in the neck. There were no points in favour of tubercle or syphilis. The clinical diagnosis of cancer was confirmed by a test excision. The operation, which was very extensive, did not succeed in preventing a recurrence. PART II. SURGICAL DISEASES OF THE NECK. CHAPTER XX. SURGICAL DISEASES OF THE RESPIRATORY TRACT. (LARYNX AND TRACHEA.) Diseases of the larynx have become so separate a department of practice that the general practitioner, in the stress of his daily work, does not scruple to declare himself unequal to them, at any rate he consoles himself for not making a careful examination by avowing that he is not a specialist. Although it is true that the diagnosis of these diseases at the present day demands complicated methods which are often out of the reach of the general practitioner, there still remain a number of maladies which he can and must correctly diagnose. It may then be necessary to refer the patient to a laryngologist for confirmation of the opinion or for treatment. It is not to be expected that the general practitioner should be familiar wdth such new requisi- tions as the tracheoscope and the bronchoscope, but we may anticipate that he is capable of rendering the larynx accessible by means of the laryngoscope and perhaps also with Kirstein's spatula. The symptomology of laryngeal diseases is very simple, comprising hoarseness, dyspnoea and difficulty in swallowing. This very simplicity explains the impossibility of making a diagnosis without the laryngo- scope, unless the history and extra-laryngeal signs declare the nature of the disease. The examination should invariably be concluded with the laryngoscope, but we should always ascertain as much as we can without it. We will take the cases as they occur in practice. DISEASES OF THE RESPIRATORY TRACT III ^.— ACUTE DISEASES. (1) INFLAMMATORY PROCESSES IN THE PHARYNX AND LARYNX. Our first question must be directed to the manner of onset of the laryngeal symptoms. If they have been preceded for a few days or even only for a few hours, by a general feeling of malaise, if they began with difficult}^ in swallowing and culminated in hoarseness and dyspnoea we shall at once suspect an acute infectious disease — a pharyngeal and laryngeal diphtheria. The younger the patient the stronger will our suspicion be. The inexperienced, however, sometimes forget that this disease also occurs among adults. The instances in which medical practitioners contract diphtheria as a sacrifice of their profession are well enough known. If the teuipcraiure is iionnal, we may be relieved as to the severity of the disease, but, despite this, we cannot exclude true diphtheria. Many a slight case, with a trifling rise in temperature, has rapidly developed huyngeal obstruction. Indeed, I would go further and say that mild fever with severe local symptoms distinctly indicate diphtheria, because, other things being equal, Loffler's bacilli do not raise the temperature as much as streptococci do. It should be noted incidentally that in the very severe cases, the temperature falls to the degree of collapse, after a preceding pyrexia. The gravity of the general condition will lead to a correct conclusion. It the temperature is raised, it is evident that there is some infec- tion. The examination of tlie pharynx will supply further information. If we find the familiar thick whitish deposit upon the tonsils, fauces and even on the posterior pharyngeal wall — a deposit which can be removed as shreds — we diagnose diphtheria — at least clinically. In the majority of cases we shall be correct, and bacteriological examination will reveal the presence of Loffler's bacilli. In a few cases the bacterio- logical report will be — streptococci, no diphtheria bacilli. A more careful examination of such cases would show that thei'e was no real membrane present, but merely a greasy deposit breaking up into shreds. But it is not always possible to make a very careful examina- tion of an excited and choking child. I have nevertheless seen deposits in streptococcal infection which could hardly be distinguished clinically from those of true diphtheria; but these cases are not frequent. They occur mostly in scarlet fever. If there be merely white specks on swollen red tonsils we must decide whether they are merely plugs of pus situated within the crypts of the tonsils — follicular tonsillitis, or whether they are 112 SURGICAL DISEASES OF THE XECK accumulations on the mucous membrane of the tonsils. Only the latter are or can be diphtheritic. I say " can be," because strepto- cocci may mislead us here also. It is not difficult to distinguish between plugs within the follicles and superficial fibrinous infiltrate and deposits, with careful inspection and a little experience. If we do not succeed in making the distinction, there is the prospect of the little specks coalescing into an undoubted membrane, while the bacteriological examination is being made. If the tonsils merely present a diffuse redness without any white specks at all, the case is most probably one of ordinary catarrhal tonsillitis, but diphtheria is by no means excluded. Every practitioner, relying upon this simple redness, has reassured the parents in many a case, only to find that in the course of a few hours, extreme dyspnoea has peremptorily demanded the performance of tracheotomy. This cannot be absolutely excluded even when nothing has been found in the throat. There is onlv one disease which occasions parents unneces- sary alarm — viz., false croup. A child who has been running about the whole clay in good health, becomes suddenly ill at night with a hacking cough and symptoms of dyspnoea, coming on in paroxysms. On examination, the temperature is normal or only slightly raised, the throat is somewhat reddened, and between the seizures the general condition seems to be good. A moist compress around the throat, the inhalation of steam and a mild sedative suffice to banish all the trouble by the morning. True diphtheria seldom sets in so rapidly, and never departs so quickly. Tlie foregoing leads to flie conclusion that every case of persistent dyspnoea, however mild., associated with general malaise, must he con- sidered as serious. If there are at the same time symptoms of faucial diphtheria, they will confirm our diagnosis of laryngeal diphtheria ; but their absence does not exclude this diagnosis. If the necessary apparatus is at our disposal and if we are sufficiently experienced therein, we should at once remove some of the tonsillar deposit with a small sterile swab and make a cover-glass preparation for the purpose of obtaining confirmation of our clinical diagnosis or justification for the prophylactic dose of serum so often administered when in doubt. In definite cases the bacilli are so abundant that no doubt can remain. But in all cases this immediate examination should be completed by making cultures in a bacterio- logical institute. This is most important if the diagnosis is not already rendered probable by the prevalence of an epidemic of diphtheria. We should certainly not await the result of a bacteriological examination as an indication for tracheotomy. If asphyxia threatens, the operation must be performed whether Loffler's bacilli or strepto- cocci are in question. DISEASES OF THE RESPIRATORY TRACT II3 There are a few secondary symptoms which have not vet been mentioned but which deserve consideration. The chief one of these is the enlargement of the glands of the neck. The absence of this enlargement is not evidence against diphtheria, but if it is present, the infection is a severe one and we cannot allow ourselves to be consoled with the idea of a false croup. The glands do not indicate the nature of the infection, although they enlarge more frequently in diphtheria than in streptococcal sore throat. The same remarks apply to splenic enlargement and to alhinninnria. It is obvious from the foregoing that to confuse diphtheria and streptococcal laryngitis is not only pardonable but is often unavoid- able. But there are mistakes which should be avoided. More than once has an incomplete history failed to elicit the presence of a foreign bodv, and a diagnosis of " diphtheria " has been made. In the absence of an epidemic every so-called case of "croup" which has come on suddenly without any prodroma, should remind one of the possibility of a foreign body and the historv should be com- pletely investigated from this point of view. Still more erroneous is its confusion with pneumonia. A little child was brought to the hospital in a state of severe dyspnoea. His temperature was high, and he was evidently very ill. A young assistant, who was much struck by the dyspnoea, forthwith reported the case as one of croup requiring tracheotomy. He did not notice that the child was breathing rapidly without any stridor. A more careful examination showed that the dyspnoea was due to extensive pneumonia. The beginner should note that obstruction of the upper respiratory tract s/tTit^s the breathing ; diminution of the respiratory surface as in pneumonia accelerates the breathing. The reason for this is very simple. In order to allow the same amount of air to pass through a diminished transverse area of the respiratory tract, a prolongation and a deepening of the respiratory movements are required, at first at the expense of the respiratory pause. As the difficulty increases, more work is thrown upon the respiratory muscles, and there is more necessity for intervals of rest. The breathing, which at first was only deepened, becomes slowed as it increases in urgency. An accelerated and therewith an unavoidably weakened respiration can only suffice when the respiratory surface is diminished, as in pneumonia, but it would not be able to overcome a mechanical obstruction. When the muscles are fatigued, that is to say, in a state of asphyxia, there may be a relative acceleration of the breath- ing, even if there is mechanical obstruction, but it does not resemble the hurried respiration of pneumonia. In addition to the frequency of respiration it is important to note the presence or absence of dra\ving-in of the soft parts of the thorax, the root of the neck, the supra-clavicular fossae, the lower thoracic segment, and of the epigastrium. But this must not be confused 114 SURGICAL DISEASES OF THE NECK with the so-called peri-pneumonic retraction of the lower border of the Inng in young children. It might appear to be quite superfluous to refer to these well- known matters ; but I once saw a doctor blamed bv parents for having submitted a child who was suffering from pneumonia to tracheotomy. Careful attention must therefore be paid to these signs in every doubtful case, and doubtful cases can occur in diphtheria. For instance, pneumonia may lead to dyspnoea in this disease, just as well as extension to the larynx may. It is therefore necessary to estimate, to which of the two factors the d3'spnoea is to be attributed. If it be due to pneumonia, vce must await the effect of the serum, if on the other hand, it be due to obstruction, we must operate despite the pneumonia. No sign is more conclusive than the type of the breathing. The association of ideas by which laryngeal obstruction in children at once suggests diphtheria may lead to mistakes. The cause of the respiratory difficulty need not be either in the larynx or trachea, but the glottis may be blocked by a retro-pharyngeal abscess. Such an abscess is often tubercular, and starts either in the vertebral column or retro - pharyngeal tubercular glands. Non - tubercular retro- pharyngeal abscesses are usually the sequelae of scarlet fever or measles, occasionally of erysipelas. If the pharynx is examined in every case of "croup'' before proceeding to tracheotomy, these abscesses will not be overlooked. The experienced observer will already have suspected a vertebral abscess from the stiff posture in which the child holds the head, and from his emaciated miserable appearance, so clearly described by Albert. Retro-pharyngeal abscesses, especially of the tubercular variety, obstruct the glottis by their own mass, but every acute inflammation in the neighbourhood of the larynx may produce a similar obstruc- tion by exciting an inflammatory oedema of the entrance to the larynx, a so-called oedema of the glottis, or to be more correct, laryngeal cedema. The loose submucous tissue may swell up so rapidly that the ary-epiglottic folds and the ventricular bands look like cushions, and a fatal result may ensue before assistance is forth- coming. Any infective process in the throat, acute abscesses, phlegmons or erysipelas may be responsible for this condition or it may originate in a small wound caused by a pointed foreign body. Not a year passes without accounts of persons being suft'ocated before help is available, through swallowing a bee or a wasp with fruit or juice, and being stung by the insect. OEdema of the larynx may also occur after operative procedures in the neighbourhood of the throat ; therefore patients who are threatened by this danger should be most carefully watched. This brings us to the so-called laryngeal perichondritis, whose DISEASES OF THE RESPIRATORY TRACT II5 chief danger is the development of acute laryngeal oedema. This is not a primary disease, it is always the consequence of a deep laryngeal ulcer of some kind, or it may be a uietaslalic process. Such ulcers occur in infiltrating injuries, typhoid fever, small pox, tubercle, syphilis, cancer, &c., and suppurating metastases are met with in the course of typhoid, small pox, scarlet fever, and pyaemic diseases from any source. If hoarseness and dyspnoea occur in any of these diseases, and there are at the same time external swelling and pain on pressure over the whole or part of the larynx, we must think of perichondritis. The laryngoscope will reveal the presence of ulcers, abscesses, and cedematous areas in very varied distribution. (2) PURE CIRCULATORY DISTURBANCES. ffidema of the larynx may exist, independently of any inflamma- tory disease, merely as a consequence of a pure circulatory disturbance. It may occur as a part of a general oedema due to circulatory disease, or nephritis, and as a result of new growths in the vicinity of the vessels of the neck, and finally as a variety of angio-neurotic cedema. This latter occurs in various parts of the body, either in the form of large urticarial wheals of the skin or mucous membrane, or as cedematous swelling of extensive skin areas. Sometimes the cause is not apparent, but sometimes it follows indulgence in certain food, just as in the case of urticaria. In a patient of mine it always followed the use of white wine. Occasionally a hereditary predis- position exists. Its localization in the larynx is not by any means a very rare event, but its danger is diminished by its usually short duration. In spite of this, however, it is quite conceivable that it would be fatal, if the obstruction of the glottis were complete. Indeed, death has resulted in such a case because medical assistance was not immediately available. But sometimes the oedema disappears as rapidly as it comes, even in the very presence of all the preparations made for tracheotomy. We must probably include in this category those cases of laryngeal oedema which have been observed in persons with an idiosyncrasy towards iodide of potassium. Asphyxia has even been observed in such cases. The diagnosis is not difficult in cases of angio-neurotic oedema, because the patients are usually aware of the nature of their malady and are able to provide their own diagnosis quite accurately. It is quite different in the cases of idiosyncrasy towards iodide of potas- sium. In every case of unexplained laryngeal oedema, enquiries should be directed towards the administration of some form of iodine, if we have not ourselves prescribed it. The diagnosis of laryngeal oedema is easy enough. It is quite Il6 SURGICAL DISEASES OF THE NECK possible to feel with the finger the two soft swellings which block up the entrance to the larynx, and a careful examination with the laryngoscope reveals an unmistakable picture. (3) INJURIES. Swellings of an inflammatory and circulatory character do not exhaust all the causes of acute dyspnoea. An external blow or stroke may lead to fracture of a cartilage, whether it be ossified or not, and the hematoma resulting therefrom is liable to obstruct the glottis in a very short time. The presence of unnatural movement on careful external palpation, surgical emphysema and the view of the hsematoma with the laryngoscope permit us to make the diagnosis. The most varied injuries of the respiratory tract may cause asphyxia by means of surgical eiiiphvsenin. (4) FOREIGN BODIES IN THE AIR PASSAGES. The practitioner often sees another cause for sudden dyspncea, in the inhalation of foreign bodies. We can realize the things which have been found in the air passages, if we think of what children put in their mouths and of what adults hold between their lips for con- venience. Beans, peas, glass beads, bits of bone are of the most frequent occurrence; nails, needles, and shirt buttons testify to the bad habit of using the lips as prehensile organs. Even pieces of dentures have found their way between the vocal cords, an incident which should always suggest unconscious inhalation in epileptic attacks. If the circumstances point to the possibility of a foreign body having been inhaled, we must first find out whether it is really in the air passages. If it is acknowledged that it was put into the mouth, and this was followed by a severe attack of coughing and the vomiting of blood-stained phlegm, the probability is that the foreign body was in the air-passages, but it may have been expelled by the coughing. The patient may still feel it there for a very long time, varying with his sensitiveness and the amount of injury inflicted on the mucous membrane — at any rate for a few hours. It there is no dyspnoea, there is ample time to use the laryngoscope. A negative finding, the disappearance of the cough without any artificial aid, and the absence of any lung symptoms suffice to reassure us. A foreign body situated more deeply, i.e., in the trachea, manifests itself by attacks of coughing which are incited either on the under surface of the vocal cords or at the bifurcation of the trachea. A foreign body in the bronchus will assert itself by pulmonary symptoms on the corresponding side. DISEASES OF THE RESPIRATORY TRACT 117 The accuracy of this last statement should be qualified. A foreign body may remain in bronchus for a day or two without causing any symptoms. Thus I saw a youth who confessed to having swallowed a lead-pencil case, but who distinctly denied having any respiratory inconvenience at the moment of swallowing it — this he did in order to put his fault in as favourable a light as possible. It turned out afterwards that, as a matter of fact, he had a severe attack of suffoca- tion. After the foreign body had entered the bronchus, there were no more subjective symptoms, but two days later the pneumonia which supervened, and the skiagram, showed that the metal case was in the left main bron- chus. It was suc- cessfully removed with the foreign body forceps, through a trache- otomy incision. If there is a persistent or par- oxysmal cough, without any sign in the larynx, we must listen for a fluttering sound in the trachea. If this should be heard, it signifies that the foreign body is being wafted between the larynx and the bifurcation, with each breath, and that the cough is being excited from both positions. Such a case will be further elucidated by tracheotomy, when the offending substance may fly out with the first cough. If this does not happen we must look for it with the laryngoscope introduced into the trachea. If the foreign body cannot be seen in the larynx, but is of such a nature as permits of its demonstration by X-rays, this measure must not be neglected (fig. 63). If this yields no result and the coughing still persists, we must either undertake a tracheotomy, with Left. Fig. 63. — Metal case in end of left main bronchus, extensively thickened (pneumonia). Right. Lung tissue Il8 SURGICAL DISEASES OF THE NECK some misgiving, or refer the case to an expert in tracheoscopy and bronchoscopy. The procedure must be quite different, if there is definite dyspncea from the start. All diagnostic speculations must be abandoned and the urgent demand of the moment must be satisfied. When the patient can again breathe and our diagnosis is still unformed, the Rontgen rays and bronchoscopy may be invoked. We have hitherto assumed that the dyspnoea is caused by the foreign body being situated in the air-passages ; but this is not always the case. I once had an epileptic on the operation table, who suffo- cated himself through swallowing his tooth-plate. It pressed from behind on the trachea, and I had to do tracheotomy before there was time to open the oesophagus to remove the plate. 5.— CHRONIC DISEASES. The problems are quite different if the laryngeal symptoms have come on gradually, in which circumstance the previous history is of the greatest importance. A remark of a non-surgical character is worth making here. If a young or middle-aged person, who is neither a drinker, a heavy smoker, nor a speaker, and is otherwise healthy, becomes persistently hoarse, the possibility of syphilis should be thought of, especially the catarrhal hoarseness of the secondary stage. If the trouble has begun with hoarseness, and there has developed, in the course of months, a persistent or paroxvsmal dyspnoea, with difficulty in swallowing, ^7 tumour or ulcer of tlie larvux must be suspected. We must, of course, be sure that we are not mistaking a tumour of the neck, such as a malignant growth of the thyroid or adjacent region, or a retropharyngeal tubercular abscess, for a laryngeal disease. A careful examination is necessary for this purpose. A small cancer of the thyroid may cause hoarseness by paralysing the recurrent laryngeal nerve and its pressure may cause both dyspnoea and difficulty in swallowing. This last diff'ers in character from the same symptoms as caused by laryngeal ulcers, because the difficulty of swallowing is due to a uwcliauical obstacle, whereas in laryngeal disease the paiu of tJie act of sivatlowiu^ is the real subject of complaint. The true nature of the disease can often be suspected before resort- ing to the laryngoscope. We need not liesitate about diagnosis if a typically tubercular looking patient states that he has been hoarse for years, brings up blood and suffers from night sweats. Of course a consumptive may have syphilis or cancel-, but the long duration of the symptoms excludes the latter, and the syphilitic factor can be cleared up by means of Wassermann's test and specific treatment. It takes a year or more for a tubercular ulcer to effect the damage DISEASES OF THE RESPIRATORY TRACT II9 which cancer can do in a few iiioiitlis, or a gummatous ulcer in a few weeks. The most significant point in the history of tubercle is the early onset of pain on swallowing, which is occasionally much more pronounced than difficulty in breathing. Too much deference must not be paid to the previous history, to the neglect of careful examination. The following case wdll convey this moral. A remarkably healthy young woman, hardly 30 years of age, sought advice about difficulty in swallowing, which had persisted for some months, but which had lately become worse. Her main symptoms were pain and a feeling of soreness. The laryngoscope showed an ulcer between the arytenoid cartilages, spreading towards the back of the larynx. Syphilis could be excluded and the case appeared to be clinically tubercle, but the microscopical examination of a small piece of the margin of the ulcer declared it to be carcinoma. Before the patient agreed to an operation she was suddenly attacked by aspiration pneumonia. In this case the position of the ulcer was certainly unusual for tubercle, and its situation in the inter-arytenoid region towards the back of the larynx might have suggested the possibility of carcinoma. Since then, I have seen a similar case, also m a young female patient. It should be added that Sendziak's statistics show that cancer in this particular situation is much more frequent in women than in men. If a healthy man of middle or advanced age begins to get hoarse, and if this hoarseness, after some months, is accompanied by some slight difficulty in breathing, we should think, instinctively, of cancer and examine the neck for hard, enlarged glands. The absence of such glands is no argument aoaiiisf, but their presence is a strong evidence for it, provided of course that this glandular enlargement is recent. A pronounced foetor ex ore is also in favour of cancer, because this symptom is very rare in other ulcers. Some support to the diagnosis is afforded by the knowledge that the patient is a lover of the bottle. Usually tobacco is blamed quite confidently ; people prefer to be knowm as inveterate smokers rather than as strong drinkers. Age plays so important a role in regard to cancer of the larynx, that chronic hoarseness coining on in a man over 50 ninsl be suspected to be due to cancer. But at the same time we must discard all preconceived ideas, as the following case shows. An old man was sent to the surgeon with the diagnosis of cancer, because he was suffering from hoarseness and difficulty in swallowing. The surgeon refused to operate, and for a good reason, because despite a late appearance, the patient had pronounced pulmonary tuberculosis, and his ulcer was not cancerous but tubercular. If the patient states at once that he has had syphilis, we must not forthwith conclude that he has a gummatous ulcer, but we should, 120 SURGICAL DISEASES OF THE NECK at any rate, institute specific treatment. The propriety of this course would be confirmed if the patient is neither tubercular, nor at the cancer age, if glandular enlargement is absent and if the subjective complaints are slight, and above all if other traces of tertiary syphilis can be detected. The history and the general condition having put us on the tracks we must next proceed to an examination with the laryngoscope. The situation of the lesion is full of suggestion. Tubercle prefers the vocal cords, the neighbourhood of the arytenoids, and less frequently the epiglottis. Svphilis rather prefers the latter situation,, but may occur anywhere in the larynx. Cancer is most frequently found on the vocal cords and then in decreasing frequency, on the ventricular bands, the epiglottis, and the posterior wall of the larynx. The greatest care is required in basing a diagnosis on the clinical features of the disease. All the three forms may start as nodules, and all three subsequently ulcerate. If there are a number of nodules^ present, we should think of tubercle or gumma rather than of cancer. A cauliflower-like shaggv appearance indicates cancer. That it is not easy for the inexperienced to decide from the appearance of the ulcer is obvious enough if we consider the difficulty which even the experienced find in diagnosing an ulcer of the oral mucous membrane, quite accessible to the eye. The rules we have already mentioned in connection with the latter ulcers also . apply in this instance. Ulcers and growths which extend beyond the boundaries of the larynx, encroaching upon neighbouring organs, are most likely can- cerous. In such cases, evidence of a hard margin and base, which can easily be obtained by palpation, is often of decisive significance. Often enough the laryngoscope does not permit us to get beyond the mere diagnosis of " ulcer." Three other methods may then be resorted to ; histological and bacteriological examination and thera- peutic experiment. The piece submitted to histological examination should not be too small. It maybe removed by the practitioner if he possesses sufficient dexterity, otherwise this procedure should be carried out by the laryngologist. It is most important that the piece should be snipped off the right place. An error in this respect may be disastrous in its consequences, as testified by a famous historical instance which it is unnecessary to recall. Thei'e is no difficulty in recognizing cancer under the microscope. The distinction between tubercle and syphilis may be rather difficult if there is no pronounced general tuberculosis present ; but here the gap will be supplied by bacteriological examination. It may be possible to detect tubercle bacilli by rubbing the surface of the ulcer with a laryngeal probe covered with cotton wool, and wiping the wool on a cover glass. Animal inoculation with a portion of test specimen DISEASES OF THE RESPIRATORY TRACT 121 1-emoved is, however, a much more certain method. The experiment of treatment with iodide of potassium must be regarded as an ultimate resort, if Wassermann's reaction is positive. It happens sometimes that although the symptoms have led us to suspect tubercle, syphilis, or cancer, the laryngoscope reveals a sharply circumscribed structure, situated on a vocal cord or on the anterior commissure, with absolutely no morbid change round about. This is in all probability an innocent growth, and if it is smooth on its surface like a pea, or somewhat rough, from being an aggregation of separate roundish little nodules, it may be regarded as a fibroma. If the growth looks like a cauliflower, or a condyloma with points, it is to be regarded as a papilloma. Such papillomata do not alwavs exist in the form of circumscribed tumours, they may extend superiiciallv just like papillomata of the bladder. Can these innocent tumours not be diagnosed clinically f In some cases, certainly they can ; in cases wherein the growth is pedunculated and gets caught occasionally between the cords. The history will show that the patient sometimes has a clear voice, and then suddenly gets attacked by hoarseness or even seized by suffoca. tion. If a child suffers from luiexplained persistent hoarseness, or from repeated attacks of unexplained suffocation, we should think of a papilloma, because this is not at all a rare condition in children, and is practically the sole laryngeal tumour which occurs among them. Errors in diagnosis in respect to innocent laryngeal tumours may be made in various directions. A circumscribed tubercular or gum- matous nodule may be mistaken for a fibroma, or vice versa, but the further course of the case would however clear this up. In other cases we may be doubtful whether a papillary structure which we have discoved is innocent or malignant. Age is of course of great significance here, for a papilloma in an old man is always suspicious of cancer, and if enlarged hard glands are present, the matter is con- clusive. One must never wait for enlarged glands to confirm the diagnosis before operating, because in cancer of the larynx the glands aie often very late in appearing. When in doubt the only course to pursue is to have an adequate portion excised for examination. There are some rare laryngeal tumours which cannot usually be diagnosed until after their removal. The practitioner cannot be expected to recognize these accurately. The same applies to tumours of the trachea. It may be mentioned as a curiosity that new growths ci'ith the strnctnre of the thyroid gland have been found in it, obviously arising from a misplaced thyroid rudiment. Sarcoma occurs more frcquentlv, and therefore has more practical importance. The dia- gnosis of a tumour of the trachea is made by a process of exclusion^ 122 SURGICAL DISEASES OF THE NECK if no other explanation for the difficulty in breathing is forthcoming. An expert in the use of the laryngoscope may be able to see the tumour even in this situation. If unsuccessful at first the patient must give several sittings in order to become gradually accustomed to the examination, as is so often necessary when laryngoscopy is not well tolerated. It must be mentioned that tumours, especially cancer, in the vicinity, may infiltrate the trachea, and grow in a fungiform manner. As a rule, by the time a primary cancer has manifested symptoms pointing to the trachea, it has already declared itself in other ways, so that the diagnosis is attended by no difficulty. CHAPTER XXI. DIFFICULTY IN SWALLOWING. In accordance with an old and useful rule, we must distinguish the difficulty in swallowing caused by some disturbance of the mechanism in the mouth or throat, from the difficulty caused by obstruction in the oesophagus. Obviously this difference implies the existence of very different conditions. .4.— DISTURBANCES OF THE MECHANISM OF SWALLOWING IN THE MOUTH AND THROAT. Deglutition may be deranged in various ways : (i) Paralysis of ilic muscles of Ihe palate. In order to swallow efficiently it is necessary that the upper portion of the pharynx should be shut off by the action of the soft palate. If the latter is paralysed it follow's that some of the food will gain access to the nose by escap- ing upwards. This upward flow will not affect the food alone, it will also affect the current of air during speech, and therefore the nasal intonation of the patient will suggest the cause of the difficulty in swallowing, before even we make an examination. Paralysis of the palate after diphtheria is a classical example of this condition. The paralytic symptoms in bulbar palsy are much more extensive, but in this disease the difficulty in deglutition is preceded by many other paralytic symptoms which will already have established the diagnosis. (2) Congenital or inherited defects in the development of the soft DIFFICULTY IN SWALLOWING 123 palate may interfere with the act of deghitition, just Hke paralysis The former condition is usually associated with a cleft of the hard palate, and the latter is the result of gnuiniatoiis destruction, but a patient with cleft palate is more or less able to compensate for his disability by raising his tongue to close the fissure. (3) Scats, especially after tertiary syphilis, more rarely after burns and corrosions, may interfere with the mobility of the palate and thus prevent the effectual shutting off of the pharyjix. (4) Pain is a frequent cause of difficulty in swallowing, for when severe it may completely inhibit deglutition by reflex action. Every layman recognizes the difficulty in swallowing in cases of sore throat ; but it is also a special complication of laryngeal tuberculosis, as also of laryngeal and pharyngeal cancer. In tubercle, the difficulty may be so great that feeding becomes almost impossible. The difficulty in swallowing when a foreign body is in the throat, especially in the pyriform fossa, is also due to the inhibition caused by the pain. (5) Apart from the inhibition caused by pain as just mentioned, acute inftaininatory processes interfere with the act of deglutition, and may even render it impossible. This is due to inflammatory infil- tration of the soft palate, to diffuse swelling of the entire throat, and to extreme bulging of the affected side, if an abscess has formed. The swelling in phlegmonous inflammation of the floor of the mouth and of the tongue causes a similar disturbance. (6) Swallowing may be mechanically prevented by pharyngeal tiunours of various kinds, such as naso-pharyngeal polypi, uaso-pharyn- geal pbromata, retro-pharvngeal tumours and uialigiiant growths in any part of the throat. A chronic retro-pharyngeal abscess, generally tubercular, acts in the same way. (7) The presence of a foreign body in the upper part of the pharynx also acts as a mechanical obstacle to deglutition. The circumstances attendant upon the case will put some limit on the above mentioned possibilities, even before we examine the patient's throat. A sudden onset of ditliculty in swallow^ing, in a healthy person,, indicates a foreign body, for which search must at once be made, either with the laryngoscope or the finger. If a foreign body is present, it is probably situated in the sinus pyriformis, or behind the larynx above the cricoid cartilage. I have seen a slice of raddish sticking there on one occasion, and on another, two pieces of tough unmasticated tongue. If the trouble has come on gradually, or at any rate has not come on within an hour or two, the age must be taken into consideration first of all. Palatal paralysis in a child will suggest a sequela of diphtheria ; in an adult it will point to bulbar palsy. If the difficulty 9 124 SURGICAL DISEASES OF THE NECK seems to be due to a tumour, a retro-pharyngeal abscess is the most likely cause in a child, in a young person a naso-pharyngeal fibroma is probably responsible, and after 50 the chances are in favour of a malignant neoplasm. The I'oicc is very characteristic. A nasal tone means that the palate does not close up the pharynx satisfactorily, owing either to paralysis or structural defect. If the voice is hoarse, we think instinctively of laryngeal tuberculosis in young people, and of carci- noma in those of a more advanced age. But first impressions must not be permitted to lead us astray, they are only of value as initial guides, as the two cases previously noted will exemplify (p. 119). Having made a provisional diagnosis from the history and the external circumstances, we next proceed to an exaniiuaiion of the mouth and tJiroat. Often enough, one glance into the open mouth suffices for a diagnosis. A lax, dependent soft palate, remaining so even on phonation, indicates paralysis. Sore throat and retro- tonsillar abscess are obvious at once. In retro-pharyngeal abscess the posterior wall of the throat bulges forward. If nothing abnormal is seen, we must palpate the post-nasal space, and finally bring the laryngoscope to our aid. If nothing still appears, we must con- clude that the trouble is not in the throat but in the region of the oesophagus. 5.— DISTURBANCES OF THE MECHANISM OF DEGLU- TITION IN THE REGION OF THE (ESOPHAGUS. We now come to the second and a most important of deglutition troubles, to those which depend upon diseases of the oesophagus ami its viciuify. (i) If the difficulty lias occunrd suddenly, we must first think of a foreign body in the throat. In a large number of cases it will be found that artificial teeth, pieces of bone or coins, have been swal- lowed. But clear as the history is in some cases, in others we can elicit nothing of value. An epileptic who misses his artificial plate after an attack will look for it everywhere except in his oesophagus, as long as he feels no discomfort. I have myself seen a case wherein an agricultural labourer swallowed a piece of a goat's skull with his soup, and at first paid no heed to the incident. A child who has swallowed a coin, even if able to speak, will only vouchsafe informa- tion about his misdeed when he finds himself in difficulties. So that even if there be no history available, the sudden onset of difficulty in swallowing should always arouse first, the suspicion of a foreign body. But how can the diagnosis be established ? If the epileptic just DIFFICULTY IN SWALLOWING 12$ referred to, consults us a couple of days after he has missed his plate, because he is quite unable to swallow, and some inflammation is already beginning, we are forthwith in a position to tell him the whereabouts of the lost object. But in the absence of such clear indications, we ask the patient to take a little drink carefully, and point out the site of any pain which may be present. But some caution is required in this matter, because the localization of pain is limited to the upper portion of the oesophagus, and even if pain is ascribed to some definite spot in the throat, this only suggests that some injury has occurred there, and not that the foreign body is to be found there. We next proceed to pass a sound, beginning with a soft india-rubber one for the sake of gentleness. If this should be held up in its passage downwards, it will afford approximate informa- tion as to the site of the obstruction. A very flexible whale-bone sound gives more reliable information. If it is conjectured that the foreign body has been swallowed a day or two previously, or even before that, the most extreme care will be required, lest inflammatory change has already supervened. In any case we should begin with a sponge sound, after assuring ourselves that the sponge has been carefully cleansed and fits in firmly. Accidents may happen even to the most expert in the passing of oesophageal bougies. Kocher had a case wherein he had to remove a piece of a whale-bone sound by gastrotomy. It was the first operation of the kind, deliberately carried out on a stomach not secured by adhesions. If we come to an obstruction on carefully pushing the sponge sound forwards, we must not proceed further, but withdraw it, and see whether there be any blood or pus on it. It will sometimes be necessary to wipe the sponge on a cover glass, and stain with methylene blue, in order to detect the pus. We may next use a firmer sound, which will permit us to estimate the distance of the obstruction from the upper teeth, better than is possible with a soft sound. If we know the nature of the foreign body, e.g., a coin, we may forthwith attempt to extract it with a Grafe's basket. Otherwise we should employ a whale-bone sound witli a metal or ivory top, as a third instrument, in order to determine the nature of the foreign body by the sensation experienced when the sound impinges upon it. But if the sound encounters no obstruction, we cannot exclude a foreign body, for even an artificial plate may be passed by the instrument without detecting it. But if the sound, especially the sponge sound, brings up blood when carefully passed, there is always a suspicion of a foreign body, and if pus is brought up it becomes very probable. In all cases, but especially in doubtful ones, Rontgen rays should 126 SURGICAL DISEASES OF THE NECK be employed, or a skiagram taken. Coins appear most distinctly (fig. 64), but in a successful picture, pieces of bone, teeth, and the metal portion of dentures may be visible. As a last resource, the expert may proceed to use the oesophagoscope, which will provide the truest solution. This instrument is naturally not one often used by general practitioners, and therefore must be entrusted to the expert. Matters are, however, not concluded with the diagnosis of a foreign body. Treatment and prognosis demand some information as to the presence of an injury to the oeso- phagus, or of a pres- sure ulcer with an incipient peri -oeso- phageal phlegmon. In these circum- stances the attempts at extraction must be most carefully con- ducted, the prognosis must be ^ guarded, and the patient must be attentively watched, even after the successful re- moval of the foreign body. In order that we should not be blamed for symptoms which already exist, we must take the temperature and pulse before the ex- traction ; and if the foreign body is in the upper portion of the oesophagus, we must note whether severe pain on pressure, swelling and oedema in the neck,, point to the existence of a peri-cesophageal phlegmon. It seems incredible that a foreign body may lodge in the oeso- phagus for quite a long time without causing severe symptoms. In the case illustrated in fig. 64, the copper coin had been in the oeso- phagus for three weeks, and there was such an absence of symptoms- that both the doctor and the mother doubted its presence before the skiagram was taken. Fig. 64. — Copper coin in ihe oesophagus (for three weeks) DIFFICULTY IX SWALLOWING 12'/ Besides foreign bodies, the causes for acute onset of difficulty in deglutition include corrosion by alkalis or acids, compression by an aciilc tJiyroiciitis, acntc goitrons infianiniation, or a phlegmon of flic neck or mediastiiinm. An accurate history is usually available in cases of corrosion, except in children, hysterical individuals, and pronounced mental patients. The very severe initial symptoms generally abate, but in the course of three or four weeks they are replaced by a gradually increasing stricture. In these cases great significance attaches to the persistent regurgitation or vomiting of blood-stained fluid. Inflammatory processes in the neck are at once recognized by appearance and by palpation, and a mediastinal phlegmon, inde- pendent of a foreign body or cancerous disease of the gullet or bronchi, is a very great rarity. If the difficul'y in swallowing has come on gradually, the cause may be a narrowing of the oesophagus, or external pressure thereon, or a functional disturbance. The first occurs in cancer and cicatricial stricture after ulcers — mostly due to corrosion or svphilis ; and external pressure results from tumours of the neck, changes in the shape of the spinal column, aneurisms, mediastinal tumours of any kind, cold abscesses, and diverticula of the oesophagus. Before we proceed to use the sound, there are others matters to note, because the instrument is not always safe, and because, not all patients are equally agreeable to its employment. We must, above all, be able to exclude aneurism. For this purpose, it is necessary to begin by the percussion and auscultation of the thoracic organs, and bv examining for other signs of aneurism. If they ai"e present, we should take care not to pass a sound. If examination reveals some malignant condition, the introduction of a sound can yield no fresh information. It is necessary to note the precise characteristics of the difftcnltv in sivalloiving, because they point sometimes to the nature and situation of the obstruction. If the patient complains, in the earlv stage of his disease, of a constant expectoration of saliva, we must conclude that the obstruction is situated high up, so that the gullet cannot dilate above it. We must come to the same conclusion, if a constant desire to swallow is the first symptom. But if the patient states that as soon as he takes a cup of tea or milk he forthwith vomits it, but that the vomit is not sour, that he frequently vomits insipid mucoid material l:)etween meals, we may suspect the case is not one of genuine vomiting, but merely of the evacuation of the spindle-shaped oeso- phageal dilatation which always forms above a deep-seated obstruc- tion. This profuse regurgitation shows that the obstruction is deeply situated and that it is of some considerable duration. These cases 128 SURGICAL DISEASES OF THE XECK have often been treated for months as gastric disorders. If we ascertain that the act of swallowing has gradual!}' become difficult, that at first, solid food well masticated and mixed with water went down, but that latterly only liquids can be taken ; if there is neither the constant desire to swallow, nor the profuse regurgitation of liquids just drunk, we should think of a gradually developing stenosis in the middle of the oesophagus. A glass of water will aflford the oppor- tunity of a test. If the patient begins to cough after the first or second draught, the obstruction is high up. But if he can quickly drink a half or the whole of the glass before it returns, the obstruction must be near the cardiac end ; the more water that can be swallowed the lower it is. The neck of the patient must be inspected during this procedure. If hard glands exist above the clavicle, and the patient complains of pains in the shoulder and back of the neck, there can be no doubt about the diagnosis of cancer. If one side of the neck fills up somewhat during the swallowing, we should think of a direiiicnlmn. Having proceeded thus far with our examination we mav now^ resort to the sound, provided that we have excluded an aneurism. By means of the sound we can distinguish between a true stricture and a stenosis produced by compression, just as we can distinguish a stricture of the urethra from hypertrophy of the prostrate. If, despite difficultv in swallowing, a medium sized or larger sound immediately passes into the stomach at each attempt, the case is one of a tumour compressing the gullet from without. If the sound is at one time arrested at a short distance, whereas at another time it passes easily, there can be no question about the diagnosis of a diverticulum, provided that the instrument has not been held up by a fungating projecting carcinoma which has not yet led to stricture. The presence of this last condition w^ould be recognized by slight bleeding. If the neck becomes inflated on swallowing and this swollen part can be emptied on pressure, the diagnosis of diverticulum is conBrmed, and it is superfluous to render the stricture visible by filling with bismuth and applying the Rontgen-rays. The question whether a case is to be grouped under prcssnrc or traction divert icnia is easily settled. The former alone, when full, cause blocking of the uppej- part of the gullet, and produce clinical symptoms. They are usually situated in the cervical portion of the oesophagus and only exceptionally in the thoracic portion. The latter, when they are large enough, cause the usual symptoms of diverticula, even swelling up to the neck. Absolute accuracy of diagnosis can only be assured by Rontgen-rays. Traction diverticula are usually discovered post-mortem, and the sound has no special tendency to catch in them. They hardly enter at all into clinical consideration. Traction diverticula seldom dilate through pressure. Spindle-shaped dilatation of the oesophagus, previously noted. DIFFICULTY IN SWALLOWING I29 and dependent upon some functional disturbance must not be confused with a diverticulum. It is certain that this condition may sometimes be caused by spasm of the cardiac end of stomach ; but the possibility of it being caused in consequence of paralysis of the oesophageal muscle cannot be excluded. Solid food may remain in the oesophagus for days at a time. The sound can be moved about in the oesophagus remarkably easily, and it occasionally catches in its wall, so that a diverticulum would suggest itself, if it were not so deeply situated. The emaciation is often very pronounced, but even after many years' duration, it does not reach the extreme degree which is usually present after one year's suffering from cancer of the oesophagus. As in the case of a diver- ticulum, the presence of this dilatation can be demonstrated by the Rontgen-rays after a bismuth meal. If the oesophagus is not permeable to a soft sound of medium thickness (10 mm.), we should endeavour to pass an olivary sound, beginning with one of a somewhat smaller calibre, but not the smallest, because this is much more liable to penetrate a putrefying growth than a thicker one. Having overcome the first difficulty, the cricoid cartilage at a distance of 15 cm. (6 inches) from the upper incisors, the sound passes along easily until the stenosis is encountered. If delay arises here, the sound is withdrawn somewhat and then pushed on again, in case it may have caught against some projection of the new growth. But if this manoeuvre does not succeed in passing the sound further on, without violence, we must try smaller sounds until we hit upon the one which just goes through. The sound is pushed right on into the stomach to see whether there is only one obstruction, and in with- drawing the instrument we note the exact spot where it is grasped so as to determine the lower limit of the obstruction. This point is sometimes of practical importance, because carcino- mata, whose lower limit is not more than 20 cm. (8 m.) from the incisors, can be removed through the neck. It is obvious that a physiological obstruction must not be mistaken for a pathological one ; the cricoid cartilage, situated 15 cm. from the upper incisors has already been mentioned. A little resilience is also felt at the level of the bifurcation of the trachea (26-27 cm.), and this is a little more pronounced when the sound passes through the oesophageal opening in the diaphragm (38 cm.) We must not be deceived by spastic constriction which occurs now and again in nervous individuals, and which may prevent the passage of tiie sound, analogous to the case of urethral spasm. We should conclude that this kind of difficulty is present if the condition varies from time to time while genuine signs of diverticula are absent. If we have found a stricture, we must next decide whether it is cancerous or cicatricial. A patient never forgets having drunk a 130 SURGICAL DISEASES OF THE NECK corrosive acid or alkali, and therefore the evidence for a stricture from corrosion is at once available ; so that in practice the diagnostic distinction usually concerns cancerous and syphilitic stricture. A recently developed hard gland in the supraclavicular region points to cancer. There is no connection between the size and age of the cancer and the extent of the grandular enlargement. I have seen a bunch of glands as large as a tist, when there was clinically nothing at all definite, the autopsy only revealing a growth of 2 cm., which had not formed a ring, but allowed even the largest sound to pass. On the other hand it is often impossible to feel any enlargement of the supra- clavicular glands, although the cancer be of great extent. Age, addiction to tobacco or alcohol only afford approximate in- dications. But a history of old syphilis, and especially the presence of other tertiary signs, is of great significance, when enlarged glands are absent. The course of the disease is conclusive from the clinical stand- point. A syphilitic stricture may develop more quickly than cancer, but once having formed, it does not increase continuously like a cancerous stricture. Neither is syphilitic stricture attended by the spontaneous pain which is seldom absent in advancing cancer. The diagnosis may be confirmed by oesophagoscopy, by aid of which a piece of the tissue in question can be removed for examina- tion. But cancerous stricture is so much more frequent than syphilitic stricture, that we may well dispense with this method. A man of advancing years, suffering from a gradnallv increasing stricture of tlie oesophagus is in all frobabilitv a victim of carcinoma. In addition to syphilis and the action of corrosives, certain other rare causes of stricture have been noted, viz., non-traumatic ulcers, peptic ulcers of the lower part of the oesophagus and peri-oesophageal abscesses. Sarcoma of the oesophagus is very rare, and can only be diagnosed with the microscooe. CHAPTER XXII. ABSCESSES OF THE NECK. The questions involved in acute abscesses and acute phlegmons of the neck are so different from those which present themselves in chronic abscesses, that we separate the two classes, although inter- mediate forms do occur. ABSCESSES OF THE NECK T3I ,4.— ACUTE INFLAMMATORY PROCESSES. In cases of phlegmon or abscess of the neck, our first concern is to ascertam the position of the inflammation. If the latter corresponds to the known situation of glands, we shall not be wrong in assuming that there is suppuration of the glands. This diagnosis is confirmed by daily experience, but our task is not completed therewith. Glands do not suppurate of themselves ; there must be some antecedent in- fection from without, and the suppuration represents the attempt of the glands to prevent the micro-organisms gaining further access into the system. We must, therefore, search for the portal of entry. If the sub-mental or sub-maxillary glands, or those along the large vessels are involved, there may be some easily visible skin infection such as a furuncle, but the origin is more probably in the mouth or pharynx, especially in connection with the gums, teeth, or tonsils. This kind of cervical abscess is most prevalent after scarlet fever and diphtheria. Sometimes the inflammation at the portal of entry is so slight that the most careful examination is required to detect it. If the glands at the back of the neck are suppurating, a condition to which children are prone, the experienced practitioner will at once look for an eczema of the scalp, and he will rarely be disappointed. We will now discuss the various regions of the neck. (1) THE SUB-MENTAL REGION. Sub-mental abscesses are easy to recognize, for they almost always arise from the Ivinphatlc glands and not merely from the jaw. The portal of entry for the infection is usually situated on the under lip or chin. A persistent abscess in this neighbourhood, which fails to heal after incision, must be regarded as a snppnrating dermoid of the floor of the mouth, although these usually grow towards the mouth. The sub- lingual gland very rarely comes into question, and it is so situated that if it does inflame the swelling is inwards. In acute glossitis and in cellulitis of the floor of the mouth there is also oedematous swelling of the sub-mental region. (2) THE SUB-MAXILLARY REGION. Acute inflammatory swellings of the sub-maxillary region may be due to one of the following causes : — ■ {a) Periostitis op the jaiv after caries of the teeth. Examination of the teeth and gums, palpation of the jaw will indicate the existence and situation of the inflammation. (6) Osteo-niyelitis of the jaw. This dift'ers from periostitis by its 132 SURGICAL DISEASES OF THE NECK great extent (usually bi-lateral) and the greater severity of the general symptoms. (c) Acute inffamuiatioii of the sub-maxitlary gland (salivary), through obstruction of Wharton's duct (salivary calculus), infection from the mouth, or as part of an epidemic parotitis. The gland can be more or less easily felt, both in the mouth and externally. Sometimes pus exudes from Wharton's duct when pressure is made on the tumour. The occurrence of repeated attacks suggests calculus, which can occasionally be felt within the mouth, especially after its exact position has been ascertained by a skiagram. If the parotitis is predominant, there is no difficulty about the diagnosis. (d) Inflammation of the lymphatic gland tissue enclosed in the capsule of the salivary glands, so called angina liidovici. Here also, the swelling projects mainly into the mouth, but the general symptoms of infection are much more severe than in inflammation of the salivary glands, and there is in addition a very widespread oedema. (f) Inflammation of the superficial lymphatic glands superjacent to the salivary glands. This is the most frequent form of sub-maxillary phlegmon, and chiefly spreads outwards. It causes fluctuation much more quickly than intra-capsular suppuration, and is less dangerous. The infection may start from the nose, eye, cheek, or gums. A laryngeal perichondritis may open externally in this direction, and suppurative periostitis of tJie hvoid bone may be mentioned as a curiosity. (3) THE SIDE OF THE NECK. Practically the only condition which presents itself at the side of the neck, in the sterno-mastoid region, is glandnlar abscess. If no focus of infection is found on the skin or mucous membrane, we must assume that the original disease, eczema of the head, rhagades on the nose, and inflammation of the gums, &c., had already recovered when the abscess came on. Injury to the mucous membrane of the pharynx or gullet by a fish-bone or similar pointed foreign body is a rarer cause of cervical abscess. Abscesses tracking from the cesophagns always appear first in the neighbourhood of the sterno- mastoid, and are recognized by the fact that they cause pain on swallowing from the very beginning. The patient will also, as a rule, be able to recall the severe sudden pain caused by the foreign body responsible for the mischief. Pain on deep pressure can usually be elicited before any inflammatory change appears on the skin ; and the abscess does not reach the surface in the form of a circumscribed swelling but as a diffuse phlegmon. ABSCESSES OF THE NECK I33 (4) SUPRA-CLAVICULAR REGION. Abscesses and phlegmons in the supra-clavicular fossa are less frequent. The glands in this position very rarely suppurate, because the infective organisms are usually arrested by glands higher up. The abscesses which do occur in this region are usually due to extension of suppuration from above. If a phlegmon does arise primarily in the supra-clavicular fossa, we must think of osfeo-iuyclitls of the clavicle'. (5) ANTERIOR TRIANGLE OF THE NECK. We now proceed to the somewhat rare abscesses of the anterior triangle of the neck. They usually originate in the thyroid gland, whether the change therein is only goitrous or not. If the patient is seen in an early stage when the inflammatory process is limited to the thyroid gland or to a goitre, there is no difficulty in the diagnosis. But if the patient is not seen until a state of diffuse phlegmon has supervened, it may be necessary to consider the possibility of myositis of the stenio-inastoid. Osteo-inyelitis of the mannbriinn sterni with the pus tracking upwards, might also be mistaken for inflammation of the thyroid gland ; but the pain on pressure over the sternum should guide us to a correct diagnosis. Finally, there are phlegmons of the anterior mediastinum wdiich appears in the neck. I have seen two cases which ended fatally, despite early incision. (6) POSTERIOR CERVICAL REGION. Abscesses in the posterior cervical region and its neighbourhood are more frequent. If the abscess is situated posteriorly, beloiv the mastoid process, and has been preceded by middle-ear symptoms, we cannot fail to diagnose a Bezold's abscess, i.e., an abscess of the mastoid process which has burst into the neck. How can this latter variety of abscess be distinguished from one of the ordinary superficial glandular abscesses of this region ? An abscess starting from the petrous bone, or mastoid process is at first deeply situated and covered by the insertion of the sterno-mastoid. The patient therefore complains of pain and holds his head stiff, before any swelling or redness of the skin appears. But on the other hand, glandular abscesses are from the first quite close to the skin ; the subjective disturbances, therefore, go hand in hand with the visible and palpable development of the abscess. A carbuncle at the back of the neck presents a very distinctive picture. The simple posterior cervical furuncle demands no dia- gnostic skill ; and it is not easy to mistake a cai-buncle formed by the 134 SURGICAL DISEASES OF THE NECK agglomeration of a group of contiguous furuncles — sometimes called anthrax, after its French designation. Both terms occasionally mislead the beginner into thinking of true anthrax. Before the advent of bacteriology the differential diagnosis was often difficult. As a matter of fact the typical carbuncle at the back of the neck has nothing to do with anthrax. It is a staphylo- mycosis which finds a favourite soil for growth in the aged or diabetic. The inflammatory process is not always limited to the diseased hair follicles and their immediate vicinity. The entire integument of the back of the neck, from ear to ear, may become indurated and of a bluish red colour. The persistence of fever after the evacua- tion of cores of pus shows that some deep inflammation exists. A phlegmon may develop over a muscle, beneath superficial skin which is perforated like a sieve, but the cutaneous infiltration renders the detection of fluctuation very difficult. Nevertheless, it is important to open such a phlegmon as quickly as possible, in order to anticipate the deep extension of the pus. If there is no furuncle to explain the condition, disease of the bone must be thought of, i.e., osieo-inyelitis of the occipital bone, which is more likely to be metastatic than primary. Suppuration of a tuuiour at tlie tjack of tJie iiecli is rarer still. While acting as assistant, I saw a girl with a large fistulous abscess at the back of the neck constantly discharging fcetid pus. It was a case of a dennoid, containing a large bunch of hair. Lipoumta may also suppurate, exceptionally. /i.— CHRONIC ABSCESSES. A slowly developing, painless and circumscribed swelling at the back of the neck should suggest a new growth, and this diagnosis should only be abandoned in favour of a tubercular or cold abscess if all the cnxamstances are not in accord with it. The possibility of cold abscess has occasionally been forgotten, and immediate operation has been undertaken in the expectation of finding a tumour or a cyst. This error is easily avoided if the glands are suppurating, because the multiplicity of the swellings will indicate, even to the beginner, that glandular disease is present. But it is quite otherwise when a deep- lying abscess starts from a tubercular vertebra. If it has not vet reached the surface, the presence of fluctuation cannot always be detected, and the original specific disease may not have manifested itself in any striking manner. There is, however, even in this early stage, a sym- ptom very significant of tubercular abscess, and that is, the situation of the swelling beliiud the thyroid and beliiud the carotid, to which further reference will be made in discussing tumours of the neck. A swelling which pushes the carotid artery forward must be a tumour ABSCESSES OF THE NECK 135 of the vertebral column, or of the deep cervical muscles, or a cold abscess. If the pus has tracked to the surface bv one route between the muscles, the deep origin of the abscess may be obscured. It is there- fore always necessary to examine the inside of the throat, because the origin of the abscess may be easier to detect from there than from the surface of the neck. A careful examination of the spine will generally reveal signs of tubercular disease before the patient is conscious of any. trouble. The experienced eye will also note the stiffness of the neck, - and will be struck by the fact that the patient never turns his head without turning his back at the same time. A full cvsopluigeal divcrticu- liini projecting into the side of the neck may feel like a chronic abscess. But its long duration, extending over years, and its objective condition of expressibility render the dia- gnosis quite easy. Not all chronic abscesses of the neck are tubercular. These are always distinguished by their softness, but there are some clironic abscesses in the neck which are, on the contrary, remarkably hard. Reclus applied to them the term " phlegmon ligneux," and in German the expression " holzphlegmone " (board- like phlegmon) has been adopted. Actinomycosis, which we have already discussed, is one example of the cases which must be ascribed to this group. The occurrence of small soft areas in the midst of the board-like induration allows us to recognize actino- mycosis before the characteristic granules have been discovered. Cases of hard chronic inflammation, which are not to be attributed to the ray-fungus, have been found to be due to various schizomycetes. The patients are always in a feeble state of general health and of an advanced age. The board-like nature of a phelgmon does not, there- fore, represent any specific disease ; it is merely the distinctive reaction _ Fig. 65. — Tubercular abscess from spinal disease. Upper half of sterno-mastoid bulged forward. 136 SURGICAL DISEASES OF THE NECK evinced by old cachectic individuals towards the presence of any kind of suppuration. Instead of the abscess breaking, it becomes surrounded by an induration of connective tissue, which renders it all the more difficult either to get absorbed or to burst through. Thus it is that the whole process is so protracted. Finally, it should be noted that these " board-like phlegmons " must not be confused with Ludwig's angina, a mistake which has occurred, owing to their hardness on palpation. Notwithstanding the term " phlegmons," these cases are of a definitely chronic character, whereas Ludwig's angina is characterized by its acuteness. These cases have also often been mistaken for malignant growths, a matter to which we will refer subsequently. CHAPTER XXIII. SINUSES IN THE NECK. SixuSES which result from iii/itries offer no diagnostic difficulties. The memory of the injury abides with the patient, and the direction of the sinus can be inferred by noting whether air bubbles through it, whether food issues from it or pure saliva flows therefrom. All other sinuses arise either from inflammatory processes (tubercle, syphilis, actinomycosis), or from congenital anomalies. A correct diagnosis can usually be made from the mode of origin, conrse, and external appearance. Gummatous inflammation does not lead to sinus formation, unless there be extensive destruction round about, and such a sinus does not persist very long, if no deeply situated organ has been perforated. The sinuses which are present in actinomycosis are situated, as previously mentioned, in hard board-like tissue ; they are not drawn in, but are found on the summits of small dark-red pro- jections of soft skin. Their duration is short, unless the disease has affected deeper organs, such as the spinal column and the base of tiie skull, when the sinuses may last for months, and become contracted while the characteristic changes of actinomycosis round about may become obliterated. In such cases there is always some secondary infection at work. Tubercular sinuses- arise either from glands or from tnhercnlar foci in tnine, generally in the vertebral column. In the former case their duration is a matter of weeks, or at most SIXUSES I\ THE XECK 137 months, and there will usually be present, among old scars, some remaining tubercular glands in various stages of suppurative softening. But sinuses arising from bone, such as in spinal caries, mav persist for years. Here, however, signs of tubercular disease in the spinal column will alwavs be present. The points already mentioned will usually enable us to distinguish between a sinus due to infiainination and one due to coiigeiiittril causes. The history will, as a rule, inform us whether the sinus dates from birth ; but we must not exclude its congenital origin, because the sinus first appeared in later years. It frequentlv happens that a branchial-cleft cvst persists in the deeper parts for years after birth, and then gradu- ally makes its way to the surface, finally penetrating the skin and forming a sinus. Neither must we at once assume that a sinus has an inflammatory origin, because signs of inflammation appear round about, for these bran- chial-cleft cysts are often the seat of inflammatory processes. Inflammation of a cyst alternates with the breaking out of the sinus, so that the patient complains of an " abscess in the neck," which empties itself from time to time, and which, after a longer or shorter existence, again develops a sinus. The inflammatory changes in cases of congen- ital sinus are of small extent, and abate as soon as the sinus develops. It appears as a small punctiform opening, surrounded by a somewhat in-drawn area of skin, either normal or slightly irritated by secretion. A sinus of many years' duration, with these characters, is almost certainly of congenital origin. The secretion from a sinus aft'ords us an additional diagnostic aid. Pm-e pus escapes from an inflammatory sinus ; but in the case of actinomycosis it is occasionallv mixed with the characteristic granules. Congenital sinuses discharge a purely mucoid or muco-purulent fluid, in which epithelial cells can be demonstrated as well as pus cells. Fig. 66. — Corgenital sinus of neck, originating in the middle but opening at the side. 138 SURGICAL DISEASES OF THE XECK The position of the sinus also yields useful indications. Con- genital sinuses are situated in the middle line, or in the region of the sterno-mastoid, whereas the sinuses of spinal disease, with which they may easily be confused, are generally located much more posteriorly. But if all this does not suffice, we may test the connec- tion between the sinus and the oral or pharyngeal cavit}^ by injecting some harmless colouring matter or a bitter fluid. Finally, we may scrape some tissue off the wall of the sinus with a fine, sharp spoon. If, on examination, this is shown to be pure granulation tissue, with probably some tubercles, we are dealing with an inflammatory fistula ; if epithelial cells are found, the case is one of congenital sinus. Assuming that the diagnosis of congenital sinus is established, there still remain two questions to be answered. (i) Is the case one of a hrandiial-clcft sinus, or is it one of so-called median sinus, arising from the thyreo-glossal duct ? (2) Is the sinus complete or incomplete, i.e., is it connected with the throat or not? The first question is answered by the position of the sinus. If it opens in the middle line, and it runs along the course of the middle line towards the hyoid bone, its origin in the thyreo-glossal duct is quite certain. If it opens at the side, it is usually a branchial-cleft sinus, aribing from the first (very rarelv the ear region), the second, or possibly from the third, branchial-cleft. Confusion may arise if a sinus from the thyreo-glossal opens duct laterally (fig. 66), and one from a branchial-cleft runs centrally, as sometimes happens. We must, therefore, note the course of the sinus as well as the point of its exit. The beginner may be inclined to use a probe in order to ascertain the direction of the sinus, but this is as dangerous as it is unreliable. It is very easy to penetrate the wall of the sinus with the end of a fine probe, and thus infect the surrounding tissue without ascertaining the direction of the sinus. This must be determined mainly by palpation, for the track of the sinus feel like a firm cord. As the course of the sinus which originates in the thyreo-glossal duct is a comparatively superficial one, we may be able to follow the whole tract as far as the body of the hyoid bone. If a sinus opens in the centre, and it is not possible to follow its course in this way, we must assume that the passage runs deeply, and to the side, that is to say, that it is the sinus of a branchial- cleft. If one has the opportunity for an X-ray examination, some bismuth emulsion should be injected into the sinus, and its course followed either on the screen or in the skiagram. There are some cases wherein the microscope affords the first definite differentiation. Sinuses originating in the thyreo-glossal duct TUMOURS AND ALLIED SWELLINGS OF THE NECK 139 are generally surrounded by minute lobules of thyroid gland tissue, a feature which is, of course, absent in the cases of sinuses from genuine branchial clefts. To determine whether the sinus is complete, and reaches as far as the throat, we must adopt the method of injection, as already observed. In the case of a sinus of the thyreo-glossal duct the coloured fluid will appear at the foramen caecum, in front of the epiglottis ; in the case of a branchial-cleft sinus it will appear at the lateral pharyngeal wall. Finally, there remains one special form of sinus, with its orifice at the front or side of the neck. It is usually situated in the scar of an incision, and thus shows its artificial origin. When the patient swallows, it rises upwards and forwards with the thyroid gland, and if a probe is carefully introduced, it loses itself in a swelling which can be identified as a goitre. The case is therefore one of a sinus from a goitre, originating after incision of a goitrous abscess. Such sinuses may persist for years, if the inflammation has developed in a cystic goitre with calcified walls. The sinus can only be radically cured either by removing the whole cyst or by extirpating all the tissue which is incapable of cicatrizing. Sometimes towards the end, cancers of the month, larynx, or throat break through to the surface, but this condition .can hardly be termed a sinus. The diagnosis is easily made by the appearance of the opening on the skin and by the symptoms connected with the original diseases. CHAPTER XXIV. TUMOURS AND ALLIED SWELLINGS OF THE NECK. As the neck contains a variety of organs, it offers examples of tumours of every kind. In discussing these, we purposely include certain congenital cystic structures as tumours, and at the same tmie embrace chronic inflammation of the lymphatic glands in this section. Before we ascertain the nature and point of origin of a new growth, we must be quite sure that we are really dealing with a tumour, even in the somewhat extended application of the term as just indicated. There are morbid conditions in the neck, producing pseudo-tumours which may mislead even the experienced. 10 140 SURGICAL DISEASES OF THE NECK Tubercular abscesses should be especially mentioned in this connection. These start from the vertebral column, gradually track towards the surface, and have, as previously stated, often been mistaken for tumours (p. 134). If we find a hard, slightly movable tumour in the submaxillary region, or even posteriorly thereto, we must think of the hoard-like fihlegjjion, of varied origin. The absence of fever and pain on pressure, its sharp limitation and sometimes a certain mobility of the skin over it, appear to point to a new growth. Even if the skin has become extensively adherent, the limitation of the structure is so sharp that it is difficult to discard the idea of a malignant growth. The careful consideration of all possible sources of infection will, however, lead to the recognition of the true nature of the disease. But sometimes an exploratory puncture only will give the first clue. This occurred to me in the case of an aged female who had a phlegmon at the side of the neck which looked like the terminal stage of an inoperable carcinoma. Its explanation was found in a periostitis of the root of a molar, which had run its course almost unnoticed. On another occasion I had a case which seemed to be a sarcoma of the side of the neck, and which had become adherent to the skin. It had been preceded by symptoms arising from the cranial nerves. A trial puncture showed that the case was probably one of actinomycosis starting in the sphenoidal sinus, and this was subse- quently confirmed by autopsy. Tubercular or guniuiatous deposits in muscles, especially in the sterno-mastoid, may be mistaken for tumour. The same applies to cesopJiageal diverticula. We shall refer to the diagnostic difficulties presented by inflam- mation of the salivary glands and the thyroid gland in their appro- priate place. We shall also subsequently discuss the not infrequent errors of diagnosis to which aneurysms and cervical ribs give rise. In order to facilitate the survey we will discuss the conditions topographically. A.— THE ANTERIOR TRIANGLE. This triangle and its lateral vicinity consist of the space between the external borders of the sterno-mastoids and a horizontal line drawn through the upper border of the thyroid cartilage. It is so dominated by the thyroid gland that our first question in regard to any tumour in this space must be to ask whether it originates in this gland or not. Oiie classical sign will seldom fail us, i.e., the ascent of the tumour with the larynx and trachea on swallowing. This sign only becomes indefinite or entirely absent if the diseased TUMOURS AND ALLIED SWELLINGS OF THE NECK 141 gland is so firmly adherent to the adjacent structures that it actually prevents the ascent of the trachea. Further evidence is afforded by palpation, because this demon- strates with more or less certainty the connection of the tumour with the thyroid gland. The relation of these tumours to the sterno-mastoids is not at all constant. They may project forwards between them, or glide under them towards the sides of the anterior triangle, or the muscles may be spread out flat over them. The most common disease of the thyroid gland, a tumour in the wide significance of the term, is goitre. The connection be- tween goitre and the thyroid gland appears to us to-day to be obvious. But up to the middle of the nineteenth century the terms bronchocele and air - goitre (Luft- kropf) prevailed in German literature, thus showing the predomi- nance of imagination over observation. At the end of the eigh- teenth century the theory was maintained that a goitre was a hernia of the air-pass- age, and the term bron- chocele still persists in ■ English as a vestige of this error. In the Middle Ages and up to within the last hundred years there was a general confusion between goitre and lymphatic gland enlargement. A vestige of this error still remains in the use of the term "struma" for "tubercle," which was formerly common in France and still is in vogue in England. 1 have called a goitre a tumour in the "widest sense of the term," because most goitres are not tumours in the pathological sense, but are processes of hypertrophy, hyperplasia and degeneration, often associated in striking confusion with changes which possess certain characteristics of tumour formation. The external appearances of the goitre afford some indications of all this. However, to ascertain ivliich variety of goitre we are dealing with is not a mere whim, but is a matter of therapeutic significance. Fig. 67. -Simple hyperplasia of the thyroid gland (" full neck ") in a chlorotic girl. 1-12 SURGICAL DISEASES OF THE XECK (1) THE EXTERNAL APPEARANCES OF GOITRE. We have in the first place to distinguish between (a) the dijfnse^ and {b) the circiiniscribed or nodular goitre. / (a) Diffuse Goitre. The diffuse goitre (fig. 68) imitates in considerable measure the horse-shoe shape of the normal thyroid gland, and is of fairly uniform consistence throughout. If it feels soft, like a normal thyroid gland, and there are no accompanying vascular symptoms, the case is one of simple hyperplasia, without any other histological changes, except^ perhaps, a slight enlarge- ■^ ment of the vesicles, Such a goitre hardly grows beyond three times the size of the normal thy- roid gland. It usually occurs in young, and especially chlorotic, girls in the period of adoles- cence. If the goitre is rather firm, and feels some what nodular, the case is one of diffuse colloid goitre, in which the vesicles are greatly dilated, the colloid material increased, and under pressure. If the tumour is softly elastic,, compressible, and has an expansile pulsation, and if on auscultation all kinds of blowing mur- murs, appreciated by the hand as thrills, are heard over the large thyroid vessels as well as over the goitre, the case is one of vascular goitre. It may be noted here that the superior thyroid artery can easily be felt on the external surface of the thyroid cartilage, whereas the inferior thyroid artery retires from the finger, owing to its deep situation. In examining for pulsation, one must be careful not to mistake the beating of the carotid artery for expansile pulsation, and, of course, care must be taken not to look upon a burrowing abscess beneath a forwardly displaced carotid artery as a pulsating goitre — as has actually occurred. Fig. 58. — Diffuse colloid goitre. TUMOURS AND ALLIED SWELLIXGS OF THE XECK 143 ^ If we are confronted by a vascular goitre, we should instinctively look for the other symptoms which go to make up " Graves's disease." If the whole svmptom-complex is well pronounced — a pulsating goitre, exophthalmos, tremor, and tachycardia— even the most in- experienced can have no doubt about the diagnosis. The exoph- thalmos, more than anything else, would indicate the diagnosis to him. If there be leisure for fur- ther diagnostic exercises, a search may be made for the rarer symptoms. As far as the eyes are con- cerned, some of these are due to mechanical •causes, and others to mus- cular weakness — for instance, the width of the palpebral tissure, the fixitv of the lids (Stell- wag), deficient movement of the upper lid on looking up- Avards and down- wards (Grafe), insufficiencv of convergence {Mobius). Gen- uine ocular paralyses, which are occasionallv met with, must not be confused with these svmptoms. Is there anything in the form of the goitre in favour of, or against, 'Graves's disease ? This evidence is onlv circumstantial. In Graves's disease the goitre is diffuse and vascular (tigs. 69 and 70). Histologically a diminution of colloid substance can be demonstrated, and a prolifera- tion of epithelium. But any variety of goitre may become ''Graves's disease " secondarily. We must therefore not conclude that a case is not Graves's disease because the patient has a nodular goitre. Easy as the diagnosis is, when the classical triad of symptoms is present, it may be extremely difficult when the disease runs an Fig. 69. — Early stage of Graves's disease. 144 SURGICAL DISEASES OF THE NECK irregular course. The clinical picture presented by the disease is^ however, more frequently atypical than t3'pical, and a large number of subordinate varieties have been described — to the great confusion of students, and even of experts. If we rigidly cling to the view that hyper-thyroidism is the cause of most of the symptoms of Graves's disease, it is not always easy to distinguish between the normal and pathological, because transitory anomalies of function are con- ceivable in the thyroid, as in other glands. We should therefore limit the designation of Graves's disease to s3'mptoms of hyper- thyroidism \\' h i c h remain permanent. The clinical picture remains incomplete in many cases for months^ and even for years. The patient complains of emaciation, increasing m u s c u 1 a r d e b i 1 i t y ,. tremors, slight perspir- ations, unexplained diarrhoea, long before any exophthalmos in- dicates the diagnosis to the practitioner. If such a patient, when completely at repose^. presents strong pulsa- tion of the carotids, it is as definite an evi- dence in favour of Graves's disease as a normal amplitude of the carotid pulse would be against that diagnosis. The instability of the psychical equilib- rium of the patient is frequently so predominant that the case may be treated for years as one of neurasthenia or hysteria, until a careful examination reveals the cause of the nervous disturbances. In other cases, the cardiac symptoms are the most predominant, and the goitre itself attracts little attention, as long as no other symptoms of Graves's disease have appeared. Whether these cases should be regarded as thyro-toxic goitrous hearts, or as examples of the " forme fruste " of Graves's disease is merely a matter of terminology. Fig. 70. — Pronounced Graves's disease. TUMOURS AND ALLIED SWELLL\GS OF THE NECK 145 It is obvious that ^ve must not confuse circulator}^ disturb- ances, which are caused b}' the mechanical effect of the goitre, with cardiac disturbances, which are of toxic origin. I admit that the distinction is not always easy. Finally, one must not conclude that every case of prom- inent eyes is one of Graves's disease. Prom- inence of the eyeballs may be a family pecu- liarity. In order to establish the diagnosis of Graves's disease, it is necessary to show that the previous position of the eyes was normal, for which purpose we can derive assistance from earlier photo- graphs of the patient. The examination of the blood is of interest for the diagnosis of Graves's disease, al- though this is rather a matter for the laboratory than for the consult- ing room. According to Kocher and others, Graves's disease is characterized by a de- crease in polynuclear leucocytes, an increase of lymphocytes, large mononuclears, and eosi- nophiles, and bv a de- crease in coaguiabilitv. -blG. 71. — Colloid goitre, mainly of right side, consisting of separate lobules. Pendulous goitre. 146 SURGICAL DISEASES OF THE XECK Similar changes occur in ordinary goitre, and even in hyper- tliyroidism ; but in the latter the coagulability is often increased. The interpretation of the blood-picture therefore requires great care. Our own experience seems to show that more importance attaches to a pronounced increase in the antitryptic content of the blood, but the demonstration of this cannot be expected from the general practitioner. Nevertheless, the employment of this test is desirable in doubtful cases, because of the prevailing fashion of diagnosing " Graves's disease " on insufhcient evidence. Not every goitrous individual who trembles occasionally is the subject of Graves's disease. Recent researches have shown that certain relations exist between Graves's disease and changes in the thymus ; but no useful assistance from the point of view of diagnosis has hitherto followed there- from. Still less has this fol- lowed from the more or less hypothetical relations which have been stated to exist between the thyroid and other glands, with internal and external secretions. If an elderly person is suffering from symptoms of Graves's disease, we should always inquire whether iodine has been taken. The rapid disappearance of goi- \' trous tissue after iodine treat- ^s ment leads to a flooding of - ^-^ ' the system with thyroid gland Fig. 73.— Cystic goitre. products, which manifest themselves, especially in old people, by symptoms of Graves's disease, persisting for months. (bj Circumscribed Goitre. In the circumscribed goitrous degeneration of the thyroid gland, nodular goitre, the entire parenchyma is more or less damaged — at any rate histologically — but the appreciable changes are limited to a few places which grow into nodules. These nodules are at hrst composed partially of tissue rich in colloid material, and partially of hyperplastic and adenomatous-like proliferation ; they may secondarily liquefy and become cysts. TUMOURS AND ALLIED SWELLINGS OF THE XECK 147 Fig. 74. — Sunken goitre with relaxed sterno-mastoids. Fig. 75. — Sunken goitre pressed deep down by contraction of sterno-mastoid. 148 SURGICAL DISEASES OF THE NECK The cysts which arise from dilatation of individual vesicles (giant vesicles) have no clinical significance. Frequently there is only one nodule — when it is of an extensive size. In other cases, especially in elderly people, there is a whole bunch of goitrous nodules in the thyroid gland, one exceeding another in circumference. If a nodule is regular in form, smooth on its surface, softly or tensely elastic in consistence, it may be a hyperplastic (follicular) nodule, a colloid nodule, or a c\st. Purely hyperplastic nodules are usually small, and their clinical significance is slight. Pure colloid nodules rarely reach the size of a fist. The differentiation of a cyst of smaller size than this is often impossible clinically, because they do not show fluctuation, but are softly elastic, just like colloid nodules. A sudden increase in size and the onset of tension points to haemorrhage within a cavity, and justifies the diagnosis of a cyst. The distinction, however, between nodules and cysts is not of great therapeutic importance, because nobody treats cysts now by pimcturing them or by opening them in the old-fashioned way, like an abscess, and allowing them to shrivel up gradually. Firm or hard portions indicate fibrous degeneration or calcification^ as can be easily demonstrated by Rontgen rays. This change may occur both in colloid nodules and in cysts, especially in old people. There is an intermediate form between the diffuse and nodular goitre, in which the whole thyroid gland has become converted into a conglomeration of small colloid nodules. (2) POSITION OF THE GOITRE. The point of origin and the position of the goitrous nodule have their significance. It usually arises from one of the lateral lobes, and but seldom from the isthmus, even when it appears to be just in the middle of the throat. The sterno-mastoids cause it to follow this route. If it goes on growing in this position, it will finally become a pendulous goitre, a variety which is exceedingly rare in these da^^s of operations for goitre. Less frequently the nodule glides right under the sterno-mastoid and appears in the inferior lateral triangle of the neck. But more dangerous than the goitres which make their way outwards are those which remain hidden under the sterno-mastoid, or make their way towards the aperture of the thorax instead of externally. If a goitre is drawn into the thorax on deep breathing, or is displaced therein by contraction of the sterno-mastoids, it is spoken of as a wandering goitre, a sunken goitre, goitre plongeant (figs. 74 and 75). It is quite easy to make TUMOURS AND ALLIED SWELLINGS OF THE NECK 149 such a goitre evident by swallowing, or making the patient droop his head so as to relax the sterno-mastoids. A goitre which is visible and palpable in the neck, but whose lower extremit)^ is so far within the thorax that it cannot be reached except by means of the manoeuvre just mentioned, is called a deep goitre. A goitre situated mainly or entirely in the thorax is called an infra-tlioracic retro-sternal goitre. We shall discuss this in connection with media- stinal tumours. The extent of a deep or intra-thoracic goitre within the thorax can be fairly well estimated by percussion, and quite accurately determined by a skiagram (fig. iii). Diffuse goitres some- times penetrate behind the trachea {retro-tracJieal goitre) or behind the oeso- phagus and pharynx (retro- %'isceral goitre) and cause the posterior pharyngeal wall to bulge like a retro- pharyngeal abscess. We should especially think of these varieties if the diffi- culties of breathing and swallowing are not clearly explicable by the palpable part of the goitre. If both sides are af- fected, it is important for the purpose of operation to know definitely from which side the trouble mainly arises. As a rule it is not the side which is blamed by the patient, and frequently by the beginner also ; in other words, not the side which is the more projecting. Alternate pressure on both sides of the goitre, and especially the raising of the one lobule and the other from tlie trachea where this is feasible, will very often show whence the difficulty comes. A laryngoscopic examination, of course, yields more definite information. It not only shows the lateral displacement, the twisting and bending of the larynx, but also the convexity of one tracheal wall or the flattening of both walls. A skiagram demonstrates the entire condition of the trachea even more clearly, and one should be taken in every case which is Fig. 76. — Skiagram of goitre (posterior view). S = calcified cyst. T-T, skiagram of trachea. Slight concavity on right. :iSo SURGICAL DISEASES OF THE XECK not quite clear. It may then be possible to tell the patient before the operation that it is not the externally visible goitre which is to be removed, but a much more dangerous one, which is concealed. In discussing the ano- malous positions which goitres may occupy we have hitherto assumed that the abnormallv placed goitre is directly con- nected with the thyroid. As a matter of fact, this is generally the case ; but the goitre may have de- veloped in an accessory thyroid gland. These are termed secondaiy goitres, as suggested by Wolfler. They are called genuine if they have no anatomical connection with the main gland, and false if they are connected with it by means of a bridge of tissue. Lingual and tracheal goitres are always secon- darv goitres, sometimes also the intra-thoracic variety, but the other forms, Fig. 77.-Skiagram of goitre ^^^^^ ^^ retro-visceral, are Severe compression of trachea on left, b = calcined . . i , colloid nodule on right. laten SO. (3) COMPLICATIONS OF GOITRE. HAEMORRHAGE, IXFLAMMATIOX AXD MALIGXAXT DEGEXERATIOX. The conipliccitions of goitre possess diagnostic interest as well as the condition itself. These complications consist of hcrinorrJiage, inflaninnition and malignant degeneration. (a) Haemorrhage. A patient suffering from a colloid or cystic goitre may suddenly, or sometimes overnight, be seized with rapidly increasing dyspnoea^ combined with a feeling of tension in the goitre and visible enlarge- ment thereof, with moderately severe pains radiating towards the jaw, hack of the neck, ear and shoulder. These symptoms may come TUMOURS AND ALLIED SWELLINGS OF THE NECK I5r without any external cause, or after an injury, or congestion of the- circulatory system through coughing or vomiting. They reach their maximum in a short time, then they remain at a standstill, and subsequently decrease gradually. This assemblage of symptoms points to heemorrhage. The goitrous nodule is found to be tensely stretched, even hard, somewhat painful on pressure and, if not of great circumference, quite movable. This mobility enables us to exclude forthwith any inflammatory process or malignant goitre with similar symptoms. A colleague of mine watched his own goitre in a mirror enlarging until severe dyspnoea set in. He made the diagnosis and drove off at once to the surgeon. Meanwhile the haemorrhage had attained its maximum and no interference was required. I once operated on a young girl whose goitre increased during a pleasant evening's walk from unnoticeable dimensions to that of a medium-sized apple. A little morphia calmed the dyspnoea, and the operation which was done immediately showed that the nodule was tensely filled with blood. On another occasion I was consulted about a young girl with- malignant goitre. The diagnosis had been based by an experienced practitioner on its hard consistence, radiating pains and recent increase in growth. The nodule was, however, too movable to attribute the radiating pains to malignant goitre, and further the pains and enlargement had come in attacks within the last two months. The case was therefore one of cystic goitre with haemor- rhage, a diagnosis confirmed by the operation. (b) Inflammation. If the swelling and difficulty in breathing and swallowing do not reach their maximum in the course of minutes or hours, but only after a day or two, and if there exist also severe pain on pressure, sharp local and radiating pains, adhesion to the skin and the deeper organs, and more or less high fever from the beginning, . the case is not one of haemorrhage into the goitre, but of inflammation thereof — an inflamed goitre. If the skin is oedematous and red, and fluctuation is present, or if pus bursts through eventually — rarely into the trachea or pharynx — the state of affairs is obvious. Timely intervention by operation nowadays renders it impossible for a suppurating goitre to burst into the trachea ; but even without operation this is a rare contingency. But on the other hand the pressure of the goitre on the trachea, or the inflammatory oedema of the laryngeal mucous membrane, may lead to dangerous dyspnoea or even to suffocation. Peter Frank, who wrote on this subject a century ago, describes the case of a 7-year-old lad who was nearly suffocated by a suppurating. 152 SURGICAL DISEASES OF THE XECK goitre. The village quack said that a nerve in the vicinity of the ]ar3'nx was torn and that a fatal result was unavoidable. The mother made a more correct diagnosis, and she implored the local barber to open the abscess between the swollen veins. The desired result followed. A practitioner of the middle of the last century describes how he allowed a young man to die from gradual suffocation of an inflamed goitre, bemoaning his sad fate, but without the energy to venture on the life-saving incision. An inflamed goitre is always of a metastatic nature, and comes on especiallv after scarlet fever, typhoid, or puerperal fever, but also after trifling derangements of the trachea and oesophagus — sore throat or intestinal catarrh, &c. This fact may be important in differentiat- ing between this condition and haemorrhage. The bacteriological examination of the pus has made it possible to establish the diagnosis of a recent attack of typhoid. If the swelling has arisen in the course of a catarrhal affection of the respiratory tract, there may be some doubt about the diagnosis. The infection would point to an inflamed goitre ; the increased pressure through coughing would suggest haemorrhage. Xo import- ance is to be attached to a slight rise in temperature, because this may occur in haemorrhage, quite apart from the catarrh. The differentiation depends upon the whole course of the symptoms and upon the local findings. If the tumour is immovable and there is considerable local heat and pain on pressure, the case is one of inflamed goitre, notwithstanding that the other symptoms may be in accord with the diagnosis of haemorrhage. The noruial thyroid gland may inflame just as a goitre. This usually occurs after infectious diseases, especially typhoid, malaria, influenza and articular rheumatism, but may occur as a clinically primary disease. This is not an inflamed goitre, but a thyroiditis — a condition insufficiently recognized. Just as in the case of an inflamed goitre, this does not always lead to suppuration, but may resolve in the course of a few days. This is the form which follows acute rheumatism, malaria and influenza, and is also the clinically primary form. It is best termed, as Mygind suggested, simple tliyroiditis. It is not always easy to decide whether there is any suppuration, and if spontaneous resolution occur it does not by any means signify that there was no pus. In a case reported by Breuer as one which ran its course apparentlv without suppuration, I found at the autopsy, seven months afterwards, a small abscess with inspissated staphylococcal pus. Suppuration can as a rule be diagnosed by attention to the temperature chart and to the increasing adhesion of the gland to the adjacent organs, which circumstances show the necessity for early surgical mtervention. TUMOURS AND ALLIED SWELLLVGS OF THE XECK 153 Sometimes the inflammation travels over the whole gland in the course of a few weeks, and finally attacks the pyramidal lobe, when the inflammation of the lateral lobes has gone down. Recurrences, with intervals of months or years, take place but rarelv. There is one important dift'erential sign, in the initial stage, between an inflamed goitre and thyroiditis, apart from the historv of the goitre. This depends upon the fact that the swelling in an inflamed goitre is usually limited to one individual lobule, but nevertheless may attain a considerable circumference, whereas in thyroiditis a whole lobe, if not the whole gland, is affected, and still the swelling does not exceed the size of a goose's egg. The extension of the inflammation over the whole of the thyroid gland indicates thyroiditis. (c) Malignant Degeneration. Inflamed goitre and malignant goitre are occasionally mistaken for one another, and errors of diagnosis are made in both directions. 1 have seen cases of indefinitely outlined swellings of the thyroid, with redness of the skin and pyrexia, and with rapid growth, declare themselves as sarcomata at the operation. On the other hand a chronic inflammation in an old hard goitrous lobule mav present all the clinical signs of malignant growth, including even metastases and a fatal result. It is quite impossible to distinguish between those rare conditions syphilis and tubercle of the thyroid on the basis of the clinical symptoms. If the clinical course, the history, and a posi- tive Wassermann reaction suggest syphilis, and if the symptoms are not urgent, a trial of specific treatment is indicated. Otherwise, any suspicion of malignancy demands operation without delay. Hitherto, tubercle has been first discovered at the .operation, or more correctlv speaking has been recognized on histological examination, there having been no clinical symptoms. A malignant goitre can usually be confidently diagnosed from the following signs: — (a) An unexplained steady growth of a goitrous nodule in a patient over 30 years of age. (6) The onset of hoarseness not accounted for by the size of the tumour (paralysis of the recurrent laryngeal). (c) Radiating pains towards the jaw, ear, back of neck and shoulder without any acute inflammatory symptoms or signs of haemorrhage. (d) Diminution of mobility, irregularity and unevenness in form, and hard consistence of the goitre. As long as the malignant degeneration is limited to the interior of the goitrous lobule, the unexplained growth is its only striking 154 SURGICAL DISEASES OF THE NECK feature. There is neither hoarseness nor radiating pain. Nothing short of the microscope can yield a positive diagnosis. I once removed a malignant goitre in such a case, thinking it was an innocent growth. Unfortunately no microscopic examination was made, but a recurrence of the cancer first notified me of the error and enforced the lesson that every goitre removed should be examined for malignancy. On the other hand, a contracting cancer and even a sarcoma, in consequence of early adhesions with adjacent structures, may cause hoarseness, radiating pains, possibly also narrowing of the pupils and other signs of sympathetic paralysis, while the growth itself has not yet attracted the attention of the patient and may really require looking for. Operation must never be delayed until all the signs of inalignancy are present, because the aim is not dia- gnosis but cure. The pro- gnosis in nu'dignant goitre is only favourable as long as the growth is within the capsule of the goitre, and therefore must be suspected rather than diagnosed. The distinction between sarcoma and carcinoma need not detain us, because even the interpretation of the histological appear- ances is not always easy. The differentiation between the various forms of car- cinoma appears to be of even less practical importance so far. But it should be observed that the adenomatous variety (the "proliferating goitre" of Langhans) runs a remarkably slow course, despite the presence of all the signs of malignancy. On one occasion I declined a further operation on a female patient suffering from paralysis of the recurrent laryngeal, with extensive adhesions and thrombosis of the veins of the neck, and informed the friends that the course of the disease would be rapid. The patient, however, lived for nearly ten years in great suffering. Fig. 78. — Malignant Goitre (from the Surgical Clinique at Berne). TUMOURS AXD ALLIED SWELLIXGS OF THE NECK 155 The uiefastafic ^roivtJis from thyroid gland tumours have certain special characteristics which are also of diagnostic interest. Colloid goitres, which are clinically and histologically apparently innocent, sometimes give rise to metastases, especially in the bones, with a structure partly composed of normal thyroid tissue, partly of colloid goitre and partly of cancer. Sometimes the metastases of definite thyroid gland cancers consist of normal thyroid tissue by way of atavism. All forms of cancer of the thyroid have a predilection for metastases in the osseous svstem. Growths independent of the thyroid gland which occur in the anterior triangle of the neck are rapidly disposed of. They are branchial cleft cysts, or, when situated in the median line in front of the thyroid cartilage, they are cysts of the iliyro-glossal duct. We shall discuss these in connection with the other cysts of the neck. Z^.— TCMOURS OF THE SIDE OF THE XECIv AND ITS VICINITY. The tumours which are found at the side of the neck differ widely in character, and in order to avoid repetition we shall include among them new growths under the sterno-mastoid and those which occur in the submaxillary and parotid regions. (1) ENLARGEMENT OF THE LYMPHATIC GLANDS. In the first place we must be quite sure whether we are not dealing with enlargement of the lymphatic glands. These always declare themselves by their number and their arrangement in groups. If a tumour, which is apparently single, is really made up of separate lumps or nodules, we must think of a mass of adherent glands. Appreciable swelling of one individual gland may occur, both in tubercle and in secondary malignant degeneration, but is not common in either. If we recognize the tumour to be of glandular origin, it may be due either to inflammation, or to new growth, or to the intermediate condition of malignant lymphoma. I am not treating now of acute inflammation of the cervical glands. Their behaviour is similar to that of the abscesses to which they give rise, to the description of which the reader is referred. If a child suffering from eczema or a chronic mucous membrane •catarrh has enlarged glands in the area drained by the corresponding lymphatics, the diagnosis is simple lymphadenitis. We must assume that the glands have been affected by the constant introduction of mildly virulent organisms or by their toxins. Foi-meiiy, simple and tubercular lymphadenitis were included II 156 SURGICAL DISEASES OF THE XECK under the one term ^'scrofula." To-day this term has no meaning, unless we reserve it to express that general state of lowered resistance which is due to hereditar}' causes (alcohol and syphilis), and to unfavourable hygienic surroundings, and which prepares the soil for various micro-organisms. If the tubercle bacillus be among these — a very frequent circumstance — then scrofula becomes tuberculosis. Adolf Czernv and his school apply the term " exudative diathesis " to anv condition wherein there is hyper-sensitiveness to infective organisms, and they only speak of "scrofula "' if a tubercular infection is super-added to this diathesis. Even the beginner knows that a chain of nodules which are partly elastic and movable, partly hard and infiltrated or even fluctuating, are tubercular. Scattered scars indicate to hmi that the disease is not recent, and that there is no reason to entertain the idea of malignancy (fig. 79). If there be but little pain, and the mobility is free, and the consistence is elastic with no sign of involve- ment of the skin despite their long existence, we know that the glands are of the non-caseating, or of the very slowlv caseating va- riety. If there be definite pain on pressure, with only slight mobility, and the superjacent skin can only be picked up with diffi- culty, it shows that casea- tion is proceeding and that peri-adenitis has begun. If the skin has become red, and the glands are fixed and their firmness is replaced by a softlv elastic or fluctuating consistence, there can be no further doubt about their suppuration. If a patient wdio has hitherto been free from glands, acquires a bunch of them on one side, within a short time, one must think of the possibility of a syphilitic infection, and a primary sore must be looked for in the area drained by the corresponding lymphatics, especially in the mouth or nose. Sometimes it is difficult to distinguish between tubercular glands and the large glands which occur in the course of such lymphatic " 1 m 1' Nv'- \ Fig. 79. — Tubercular lymphoma. TUMOURS AND ALLIED SWELLINGS OF THE NECK 157 diseases as leukaemia and lymphadenoma. Leukaemic changes are very easy to recognize because the glandular enlargement is over- shadowed by the signs of leukaemia — pallor, debility and the hemor- rhagic diathesis — and the examination of the blood sets aside any doubt. Pseudo-leukaemic glandular h3'perplasia, i.e., malignant lymphoma (lymphadenoma or Hodgkin's disease) is equally easy to recognize if all the glandular situations are affected, if the liver and spleen are enlarged and the patient has a cachectic appearance, with blood not tvpical of leukaemia. We adhere here to the usual view that pseudo- leukaemia is a clinical unity, despite the fact that it has been shown that it gradu- ates into true leukaemia on the one hand, and sarco- matous processes on the other. The histological differentiation of one type wherein the glands are con- verted into a kind of granu- lation tissue (Sternberg's variety) and of another type wherein there is hyperplasia of the lymphadenoid tissue (Cohnheim's variety) is, so far, of no diagnostic interest clinically, because it is not possible to distinguish the two, with any certainty, and because their course is the same. Finally, there are some rare cases wherein every- thing points to Hodgkin's disease, but the bacteriological examina- tion declares for tubercle. Further, pseudo-leukaemia may occur in tubercular subjects, and tubercle may become engrafted on pseudo- leukaemia. Observations such as these have given rise to the suggestion that pseudo-leukaemia is fundamentally a tubercular disease. The pro- bability is that it is a chronic infection, siii generis, the organism of which (antiformin-fast bacillus of Fraenkel-Much) is morphologicallv similar to the tubercle bacillus, but is clinically more malignant. The view that Hodgkin's disease, at any rate Sternberg's type, is caused by an attenuated form of the tubercle bacillus is refuted by its clinical course. Fig. 80.— Lymphadenoma (pseudo-leukaemia) Early stage. 158 SURGICAL DISEASES OF THE XECK Tubercular glands are rarely met with, equally developed in all glandular situations, as is the case in lymphadenoma. They generally show some points of tubercular softening if the trouble is widespread. In the initial stage when the neck alone is affected, and therefore the extension of the glandular enlargement offers no points of dif- ferentiation, the diagnosis may be indeed difficult. Our opinion must be based on the size and condition of the glands and their relation to the surrounding parts. If they are of medium size, soft and immovable, it is, unfortunately, impossible to dogmatize about the diagnosis, because a non-suppurating form of tubercular lymphoma cannot at this stage be distinguished from the soft variety of malignant lymphoma. In such cases the latter is always first recognized by its gener- alization, or by excising a portion for examination. It is quite different if numerous movable, but hard, glands are present. Such a condition indi- cates the hard form, or rather the hard stage of Hodgkin's disease. Tubercular glands only exhibit the pronounced hardness, which the latter disease occasion- ally manifests, after a recent inflammation. But in such cases signs of peri-adenitis, and especially of adhesions with the surrounding tissues, are present. It must not be supposed that the glands cannot become pretty fairly adherent in lymphadenoma. Indeed, adhesions do occur, but they are not accompanied by as much peri-adenitic infiltration of the tissues as occurs with caseating tubercular glands. i\lthough the glands may be very hard in lymphadenoma their outlines can be distinctly felt, and this serves to differentiate it from tubercle. The glands are also more prominent, so that the whole aspect resembles a caricature of tubercular adenitis. These considerations suggested a diagnosis of malignant lymphoma in fig. 80, although the upper Fig. 81. -More advanced case of lymphadenoma, but still confined to the neck. TUMOURS AND ALLIED SWELLINGS OF THE NECK 1 59 glands only were affected. A small portion excised for examination confirmed this diagnosis. I have even seen diffuse necrosis — not caseation — in cases of Cohnheim's type, as in some of the glands depicted in fig. 81, in which case tubercle was excluded by micro- scopic examination and annual inoculation. Blood examination affords but little information. It merely reveals the signs of an ordinary moderately severe anaemia, possibly also a relative increase in the lymphocytes. There is one rather rare symptom which is in favour of lymphadenoma (and leukaemia), and against tubercle, as showing that the bone marrow participates in the disease, and that is, severe pain on percussion over the sternum. The stress laid upon the differential diagnosis from tubercle is justified by the great difference in the prognosis of the two diseases. Malignant enlargement of glands is especially indicated, when they are hard, contract early adhesions to surrounding parts, and cause radiating pain. It is often verv difficult to demonstrate the primary tumour, because it frequently bears no relation in size to the extent of the glandular enlargement and may, therefore, lie in a very concealed situation. I once found a small carcinoma at the hinder end of the middle turbinate bone (fig. 82), as the primary growth in a case of consider- able enlargement of the glands at the side of the neck. In another case the primary growth was at the posterior border of the septum nasi. A growth in the neck can only be regarded as primary, if a careful search has excluded cancer from the various sites of the internal mucous membrane which are usually attacked. If the cancerous infiltration has gone beyond the glands, and has penetrated the skin and become secondarily infected, it is very liable to be mistaken for a chronic inflammatory process (fig. 83). On the other hand, there are certain very rare cases wherein can- cerous glands have an elastic consistence and are very late in contracting adhesions. Sometimes it is quite impossible, even at the operation, to distinguish these from hyperplastic tubercular lymph oraata. (2) TUMOURS WITH LIQUID CONTENTS. If we have excluded disease of the lymphatic glands, and at the same time recognize that the growth is a tumour in the widest sense of the term, further deductions nuist be based primarily on its consistence. If a tumour at the side of the neck is soft or elastic in consistence, or if it fluctuates, we must conclude that its contents are fluid. We can only be misled by a lipoma, which also has a soft or elastic con- sistence, but subcutaneous lipomata may be recognized by theu^ lobular structure and the deep subfascial lipomata are too rare to merit early consideration. i6o SURGICAL DISEASES OF THE NECK The liquid contents of the tumour may consist of lymph, blood or the product of an epithelial secretion. The Hquid is either in numerous small vesicles or within one large cavity, or both conditions may be combined. This already gives rise to a large number of varieties, which are increased bv the circumstance that the blood within these tumours may be either arterial or venous. The variety is, however, not so great, if we leave a few rarities out of account and limit ourselves to a small number of typical conditions, whose diagnosis is not difficult. {a) If the growth is so near the surface that its contents gleam through, but not with dark blue colour indicative of blood, the case is one of lymph tumour - {i.e., lymph cyst) if the growth is smooth and round, but is a cavernous lymphangioma if it appears to be multilocular or spongy in consistence. These tumours look red- dish in transmitted light and light blue in direct light, if the skin-covering is thinned out sufticienlly. In addition, lymph- containing tumours react much less to changes in ^j^-^- - \ -wm^w -^ - states of pressure (posture j^H^ , of body, squeezing) than ^*^ --' do blood-cysts, and their contents are much less displaceable. If a growth of the neck resembles a blood tuuKjur in coloui-, but has all the other characters of a lymph cyst, we must first ascertain whether it has been punctured. A puncture may sometimes cause the contents of a lymph cyst to remain permanentlv bloody. We have just drawn a distinction between one-chambered lymph cysts and cavernous lymphangiomata, but there is really no sharp differentiation between the two. The most pronounced hmiph cysts permeate deeply among muscles by means of cavernous strands, and manv cavernous Ivmphangiomata contain large cystic cavities between spongy portions. The diagnosis of cystic lymph tumours is facilitated by the cir- cumstance that thev occur in two well-defined forms, viz., cystic Fig. 82, — Cancerous glands, with small primary growth on the middle turbinated bone. (From the Surgical Clinique at Berne). TUMOL'RS A\D ALLIED SWELLINGS OF THE XECK l6l lyinplidiigioiiia of infants (congenital cystic hygroma of the neck), and the lateral lymphatic cyst of adults. The former is present at birth, and is situated in the upper part of the anterior triangle of the neck, below the parotid region. It spreads thence, rapidlv increasing in size, to all sides, and if bilateral it encircles the neck like a collar. As it approaches nearer and nearer to the skin, the latter becomes thinned out in places to a line membrane, and at the same time the cyst penetrates deeply between the muscles and interferes with the structures in the neck, through its increasing extent. Sometimes it is possible to feel hard fibrous portions situated within the soft elastic cysts, and the whole tu- mour shakes like jelly on being moved. The lymphangiomata of adults are mostly situ- ated in the supra-clavicu- lar fossa, and occur gen- erally in women. They consist either of large single cysts or of a con- glomeration of smaller cysts. The growth illustrated in fig. 84 consisted of one large cavity, and of a pedicle made up of di- lated lymph spaces, which ran down deeply among the cervical muscles. The purely cystic forms are liable to be confused with branchial cleft cvsts, which will be discussed subsequently. In adults the lymph does not gleam through the skin as clearly as it does in children. Both growths are essentially congenital in origin, but thev do not develop till later years. If the cyst is situated very much to the side, this is the only sign really valuable for the diagnosis of lymphatic c^^st: positive accuracy can only be obtained by puncturing the cyst and microscopic examination of a portion of its wall. (/)) If the contents of the tumour look dark blue through the thin skin, the case is one of a blood-tumour. If the surface is Fig. 83. — Diffuse carcinoma of neck. Primary growth on tonsil. (Resembles actinomycosis, or board- like phlegmon). l62 SURGICAL DISEASES OF THE NECK irregular and rough, it is called a cnvenioiis angioma, and if it is round and regular it is known as a blood-cyst. In both varieties the contents of the cysts are definitely expressible, thus contrasting with, lymphangiomata; but as soon as the pressure is relaxed the cyst immediately fills up. A deeply situated venous blood-tumour is not recognizable by its colour, but it becomes inflated when the intra- thoracic pressure is raised by coughing, crying or squeezing, or by- keeping the head low. This sign distinguishes it from a deep lipoma of lymphangioma. As we have mentioned the matter of expressibility, we must again refer to divert icuhnn of the cesophagus. Its contents i can also be expressed,. but it does not fill up forthwith when the pres- sure is relaxed. The dia- gnosis is readily made from the history and the fact that there is difficulty in swallowing when the diverticulum .fills up, owing to pressure on the gullet. {c) The tuinours con- taining venous blood just referred to, proclaim the nature of their contents by their colour and ex- pressibility ; but struc- tures filled with arterial blood, aneurisms, pos- sess another characteristic symptom, viz., pulsation. This feeling of pulsa- tion may be appreciated under three different cir- cumstances : — (i) The tumour itself may pulsate— expansile pulsation. (2) The tumour may be rhythmically raised by the pulsation of the carotid artery — a communicated pulse. (3) The carotid artery itself may be pushed forward by a tumour lying beneath it. In order to differentiate between these conditions, one must endeavour to grasp the tumour between two fingers. If these are stretched apart from each other, in all situations and in all directions, the pulse is then an expansile one. If the fingers are hfted with each pulsation, but ai'e not stretched apart, the tumour is merely Fig. 84. — Lymphatic cyst at the side of the neck. TUMOURS AND ALLIED SWELLINGS OF THE NECK 163 raised by the carotid — it belongs to the second variety. If only a pulsating strand is felt over the tumour, while the rest shows no pulsation, the tumour lies under the carotid. If an expansile pulse really exists, the beginner is apt to think at once of an aneurism ; but very vascular sarcomata may also yield an expansile pulse and be accompanied by loud haemic murmurs. Although a vascular goitre may have a pronounced expansile pulse, it could only be mistaken for an aneurism after a very in- different examination. A vascular goitre usually affects the whole thyroid, and is, therefore, bilateral. The fact that it follows the movements of deglutition ought to remove any doubt. The carotid artery sometimes undergoes dilatation in old syphilitic subjects at the point of bifurcation, and this may lead the beginner to think that an aneurism is developing. If he overlooks the pulsation and neglects to examine the other side, he may regard the swelling as an enlarged gland, especially if the presence of a cancer of the lip causes him to look for one. A communicated pulse may be observed in enlarged glands lying on the carotid artery, goitrous nodules and other tumours, especially deep-lying branchial cleft cysts. The mistakes which occur, owing to the carotid pulsating /// front of a pathological structure, mainly concern hnrrowing abscesses and deep sarcomata of the uecli. Similarly a subclavian artery, pushed forward by a cervical rib, has often been diagnosed as an aneurism. The etiology is always an important factor in the diagnosis of aneurism. Arterial dilatation is always preceded by some morbid condition of the vessel wall, produced by arteriosclerosis or syphilis, or is the result of some trauma. If, after considering all these points, we arrive at the diagnosis of aneurism, we must determine the artery whence it arises. If the tumour is behind the sterno-raastoid we should think of the carotid, and if it seems to start low down its origin will probably be at the root of this artery. The delay of the pulse in the temporal artery is an important corroborative sign, but its absence is not an uncon- ditional proof against aneurism. If the tumour is situated high up and it displaces the tonsillar region inwards, it can be nothing but an aneurism of the external or internal carotid. If the temporal pulse is weakened and delayed, we must conclude that it is an aneurism of the external carotid — the more frequent variety. If an aneurismal swelling is found in the supra-clavicular fossa, there is no difficulty in diagnosing an aneurism of the subclavian artery. Weakening and delay of the pulse in the corresponding radial, pressure signs referable to the brachial plexus, are the classical symptoms. 164 SURGICAL DISEASES OF THE NECK It is necessary to mention a very rare condition, which, however, the experience of recent wars with modern firearms shows to be getting more frequent. In this condition the region of the common carotid presents a scar resulting from a gunshot wound, stab or cut, beneath which there is a pulsating tumour, varying in size from a walnut to a hen's egg, with haemic murmurs audible over it. The patient complains of symptoms pointing to disturbance of the cerebral circulation, and the superficial veins of the corresponding side of the head and neck are dilated. This condition is one of arterio-venous aneurism, and is caused by a simultaneous injury to the common carotid artery and internal jugular vein. Exceptionally a similar condition may occur in connection with other arteries of the neck, viz., the external carotid and subclavian. There is a difference between an artcrio-vcnous aneurism proper, wherein the blood exists in a space between the artery and vein, and an niieitrisinal varix, wherein the blood flows directly from the artery into the vein. The former is somewhat irregular in outline, jSji^^^ fhe latter is more circular in shape. -JbP^W' (i - Fk;. 86. — Sebaceous cyst, in exact posi- patient probably mforms us that a ^-^^ ^f ^^^-^^^ ^yst of neck, but more whitish fluid exudes from it occa- superficial. sionally, whereupon the "gland" vanishes, only to reappear again in a short time. Sometimes this evacuation is preceded by an inflammatory attack, and then the exudation is more or less purulent. The picture is complete if we find a small scar in the vicinitv of the sinus. We must not be misled into diagnosing tubercular glands, because we find the condition on both sides. Branchial cleft cysts and sinuses may occur on both sides, symmetrically arranged. Sebaceous cysts situated /// the skin, in favourite situations of the neck, must not be mistaken for branchial cleft cvsts. l66 SURGICAL DISEASES OF THE NECK (3) SOLID TUMOURS OF THE NECK. We now proceed to deal with the solid tumours of the neck. As we have already mentioned, a lipoma is on the borderland between the fluid and solid tumours, and we sliould think of it when palpation leaves us in doubt as to which variety is in question. We shall not here refer to the easily recognizable superficial lipoma, which we shall discuss in connection with tumours at the back of the neck — the usual site of this tumour. The deep suh-fascial lipoma occurs, but rarely, to add to diagnostic difficulties ; and although it is well defined^ its processes permeate between the various organs in the neck. The questions which centre around most solid tumours of the neck are quite of a different character. These tumours are usually distinctly firm in consistence, if not hard, and we have, therefore, to decide between fibroma, sarcoma, and carcinoma. Having recognized that the tumour is primary, the question of its innocence or malignancy arises. If the growth has taken years to develop, and still remains movable, it must be regarded clinically as innocent, though it should not be forgotten that a fibroma of the neck may be on the borderland between innocence and malignancy^ and that it may spontaneously become malignant after many years^ existence. It is only in a very few definite situations that any question of dift'erential diagnosis can arise as between a fibroma and some other innocent tumour. It may, however, occur in the neighbourhood of the submaxillary or parotid gland, including the region behind the ear. For the purpose of making a general survey, we propose to discuss separately the various sections of the side of the neck. (a) Submaxillary Region, Chronic inflammatory processes are occasionally observed in the siibiiiaxillarv gland, leading to its enlargement through increase of the connective tissue, while the glandular tissue itself diminishes. The diagnosis generally points to new growth, and the comparatively rapid growth usually suggests malignancy. It is quite easy to demonstrate by palpation that the growth is connected with the submaxillary gland. As it is not always possible to distinguish this condition accurately from a real tumour without the microscope, and as the loss of one submaxillary gland is not a very serious matter, the course will usually be adopted of removing the structure. This chronic inflammation of a single submaxillary gland must not be confused with the symmetrical chronic inflammation of all TUMOURS AND ALLIED SWELLINGS OF THE NECK 167 the salivary and lachrymal glands, known as Mikulicz's disense. In some cases this enlargement is merely one manifestation of leukaemia or lymphadenoma. Tuberculosis of the submaxillary gland is so rare, that it can only be recognized by the microscope, unless the diagnosis is suggested by a chronic abscess. Omitting rarities, the only innocent tumour among those which are genuine growths, which we need consider, is the so-called mixed tumour. A movable hard tumour which has slowly grown in the submaxillary region is a fibroma of the neck, if we can feel the salivary gland quite separate from it, on making bi-manual palpation, externally and in the mouth. If the gland cannot be demonstrated as distinct from the tumour, and if it has a smooth surface, it is suspicious of chronic fibroid inflammation of the salivary gland. If the new growth is perfectly movable, but has a strikinglv nodulated surface and has existed for years, we should regard it as a so-called mixed tumour. If we learn that the tumour has been noticed for many years, but that the rate of gipwth has increased rapidly within the last few months, we must assimie that it is a mixed tumour which has become secondarily nialigiianf, a not infrequent event- In these cases the growth soon loses its mobility, and at the operation it cannot be shelled out as easily as an innocent mixed tumour. Primary malignant tumours of the gland are very rare, and we will discuss them in common with those of the parotid. On examining these mixed tumours a little more closelv, we shall see on section that they are partly fibrous, partly gelatinous and partly like soft cartilage. Histologically they consist of a richly cellular tissue in which there are regularly arranged strands of cells, called by some observers epithelial cells, and by others, with equal confidence, endothelial cells. In addition there are numerous islets of cartilage, and areas which have undergone mucoid degeneration. (b) Parotid Region. The considerations referring to the submaxillary region hold good for the parotid region, but here the differential diagnosis is more limited in one respect, although more extensive in another. Fibroma does not occur and chronic inflammatory processes which look like growths have not been observed in the parotid, with the exception of the diffuse swellings,, which have been described in syphilis. But, on the other hand, there is the possibility of confusing tubercular glands with a new gi-owth. It is easy to avoid this confusion in the submaxillary region, because the tubercular glands are multiple and can be felt separately. In the parotid region, however, there are small lymphatic glands within the capsule of the salivary gland, and when these become tubercular, they gradually lift up the capsule, still being i68 SURGICAL DISEASES OF THE NECK confined within its limits. It may, therefore, be quite impossible to feel the individual glands as separate structures, because they con- stitute as it were a common growth within the capsule. The presence of other glands in other situations of the neck might of course lead us to think of tubercle. A female of healthy antecedents, aged 30, consulted her family doctor because of a swelling, elastic in consistence, which was gradually making its appearance in the parotid region. Lower down in the neck there were a few soft glands, apparently deeply situated, but not adherent to their surroundings. The facial nerve was un- affected and there was no pain. Everything pointed to tubercular glands rather than to a _ growth. But the shape of [ the tumour, which corre- sponded to that of the parotid gland, including even its posterior process, behind the lobule of the ear, looked startling and made one think of a new growth. Nevertheless the operation showed that the case was one of tubercular glands ; they were as if moulded within the parotid capsule, and the parotid tissue itself was entirely dis- placed irito the deeper parts. Tuberculosis of the glan- dular substance itself, which is a rare condition, must be distinguished from ; tubercle of the lymphatic j glands over the parotid. If I the patient is not tubercular and there is no chronic abscess present to give a clue, it is hardly possible to make the diagnosis. At any rate, we are not able to differentiate it clinically from tubercle of the lymphatic glands over the parotid. If we have excluded tubercular disease, the innocent tumours which remain are the mixed tumour, described in connection with submaxillary gland, and pure enchondromata, which are rare. The mixed tumours of the parotid are so typical of new growths, that no mistake can be made in their diagnosis, even if they do not present those grotesque shapes which used formerly to be seen. Every m(jvable irregular nodular tumour of the parotid region must. L. Fig. 87. — Mixed tumour of the parotid. TUMOURS AXD ALLIED SWELLINGS OF THE XECK 169 at first, be assumed to be a mixed tumour, but the question at once arises, whether it is still innocent. The absence of facial paralvsis and of radiating pains in addition to its fiee mobility should be conclusive in this respect. Pure enchondromata, apart from the pre-auricular skin appendages which contain cartilage, are of much rarer occurrence. We now come to the primary mahgnant tumours of the sub- maxillary and parotid region, whose chief symptoms — adhesion to the surrounding parts, especially to nerves — we have already noted. We conclude that a case is one oi primary sarcoma, or carcinoma of the affected salivary gland, from the absence of anv stage of long duration which is characteristic of an innocent tiunour, and wliich could hardly be overlooked bv the patient. Can we go bevo nd this and distinguish between carci- noma and sarcoma ? xAs a rule we cannot, because even the histo- logical picture of salivarv gland tumours is variously interpreted. Experience, however, teacher us that cancer is more frequent in the salivary glands than is sarcoma. It should be added that cancer does notalways exist in the form of a ''tumour." The parotid is some- times affected by a scirrJioiis cancer, just as the breast, in which con- dition the skin is puckered rather than swollen. Such new growths manifest themselves early bv means (jf radiating pains, especially to- wards the head, and also bv par- alysis, or paresis of some of the facial twigs, if not of the whole nerve. If such symptoms are present we must not neglect making a thorough examination of the parotid region, although there may be no tumour apparent. Fig. 88. — Cancer of the parotid. The lobule of the ear is pushed forwards by the posterior process of ihe gland. (c) Side of the Neck. We now come to the side of the neck in the more limited sense. As mentioned above, the innoccni tumours in this region are mostly fibromata, or ncnro-Jibromata ; the primary malignant tumours are, with two exceptions, sarcomata. Cancer of the oesophagus and trachea are not included here, because they are fatal before thev give rise to any growth externally. IJO SURGICAL DISEASES OF THE NECK Cancer of the cervical portion of the gullet may at times be palpable from the outside, but the difficulty in swallowing is so prominent a feature that the site of the disease is always perfectly clear. Fibromata and neuro-fibromata occur as slowly growing, firm^ movable, spindle-shaped, or oval tumours, over which the skin is freely movable. If their origin is deep — from the sympathetic, from the pre-vertebral connective tissue, or from the vertebral column itself — their position is more or less retro-pharyngeal and they cause correspondingly early symptoms of dysphagia and even of dyspnoea. These tumours are frequently confused with fibromata growing from the base of the skull and with retro-pharyngeal abscess. The same applies to fibro-sarcomata, except that these grow more rapidly and are less movable. Even with the microscope their distinction from fibromata on the one hand and sarcomata on the other is very difficult. Xeuro-fibromata have a special tendency to become sarcomatous. Often they are only one indication of a general fibromatosis known as "Recklinghausen's disease." Congenital psychical abnormalities are often associated with this disease, viz., imbecility, infantilism, psycho-neuroses. The fibromatosis may encroach on the central organs and give rise to the most varied nerve symptoms. Sarcoma of the neck may originate in any of the connective tissue structures of th:s region, e.g., fascia, periosteum, muscular connective tissue, nerves, &c. Its favourite seat is, hov\-ever, in the lymphatic glands, even leaving out of consideration their enlargement in malignant lymphoma. In connection with lymphatic gland sarcoma it is necessar}" to distinguish between " lympho-sarcomata " and "sarcomata of the lymphatic glands." The former are sarcomatous proliferations of the Ivmphatic tissue; the latter are sarcomata of the supporting tissue. The former are, therefore, round small-celled sarcomata, sometimes with an interlacing reticulum; the latter are mainly spindle-celled sarcomata. The difference is interesting from the standpoint of pathological anatomy, but it would be too much to expect that the difference should be detected from clinical signs. If the tumour is definitely soft and the growth is infiltrating, we should suspect " lympho-sarcoma " ; if it is definitely iiard it should be regarded as a " sarcoma of the lymphatic glands." "Malignant lymphoma," referred to above, must not be confused with these sarcomata. The former is a constitutional disease, whereas lympho-sarcoma and sarcoma of the lymphatic glands are tumours of individual glands. Intermediate forms have been described, but these are either very malignant forms of "malignant lymphoma" — with rapid growth and surrounding infiltration — or " sarcomata of the lymphatic glands" with secondary metastases. The whole subject is, however, still in some obscurity, especially in regard to so-called lympho- sarcomata. TUMOURS AND ALLIED SWELLINGS OF THE NECK 171 Vasciihiy sheath sarcoma formerly constituted a separate variety. It is undoubted that sarcomata may grow from the sheaths of large vessels, but most of the cases thus described were really sarcomata of the lymphatic glands. We must be reconciled to the difficulty of determining clinically their point of origin, especially as it is usually impossible to do so, even at the operation. In every case of primary malignant growth of the neck the question, whether it is one of the rare primary forms of carcinoma, eventuallv arises. Tumours have often been found in the upper part of the side of the neck, which have been demonstrated by histological examination to be cancers, with stratified pavement epithelium and for which no primary growth could be found. Their origin must therefore be ascribed, as Volkmann suggests, to congeni- tally displaced epithelium of a branchial cleft, or to some persistent epithelium of this rudiment. If, in the position indicated, and in a man of middle age, there be a tumour with the signs of a malignant growth, especially if there are severe pains radiating towards the head and back of the neck, the case is in all probabiHty a branchiogenous carcinoma. Hitherto these cases have only been noted in males. In some few cases it has been possible actually to demonstrate the transition of a congenital cyst, situated at the side of the neck, into a carcinoma. ^Malignant growths of the parathyroids may also be regarded as branchiogenous carcinomata in the widest sense of the term, as also the much rarer growths which arise from the post-branchial bodies, the so-called lateral thyroid gland rudiments. On the other hand, cancer of the accessory thyroids are not related to the branchial apparatus but to the thyreo-glossal duct. An accurate diagnosis of this growth is impossible without the microscope. There is yet another tumour, worth bearing in mind, which occurs in the same situation as the usual branchiogenous squamous 12 Fig. Branchiogenous carcinoma. 172 SURGICAL DISEASES OF THE NECK epithelial cancer. It is neither a carcinoma nor a sarcoma, but a structure, siii geiiei-is, just like a hypernephroma. It is a new growth arising from the carotid body, found in both sexes and at very various ages. It is definitely encapsuled, and its growth extends over many years, thus exhibiting a comparatively innocent character. In this way, it shows a clinical differentiation from a branchial cancer. Vessel walls are constantly observed to grow through, and local recurrence frequently occurs. It is usually soft or elastic in con- sistence, and its close connection with the carotid artery imparts to it a pulsatile movement. ^Microscopically this tumour is similar to a normal carotid body. It is composed of a tissue made up of polvgonal epithelioid cells, like the main structure, and is traversed by blood spaces invested by endothelium, after the manner of a sponge. fd) Supra-clavicular Region. The genuinely primary tumours of this region are the rare deep lipomata as well as fibromata and sarcomata. Cervical ribs often give rise to errors of diagnosis, and we shall therefore now proceed to discuss them. A cervical rib is a small hard structure which can be felt in the s u p r a-c 1 a V i c u lar fossa. Its exists ence may give rise to no subjective symptoms, but on the other hand it may cause neural- gia or paresis of the nerves of the arm, and excep- tionally it ma}' pro- duce circulatory disturbances in the subclavian artery. Sometimes these symptoms of pres- sure on the nerve plexus or on the ar- tery only supervene after some definite cause. Thus I have seen, in a soldier with a cervical rib, complete obliteration of the radial pulse from the effect of the leather strap of his knapsack. 1 j 4 H.n H__^^H ay jun ^^^^&^' vl £1-: ^^IHJI^'^ . A Right. Left. Fig. 90. — Bilateral cervical ribs. On the right, a small rudi- ment C R attached to the first rib. On the left, a larger rib which is continued to the sternum by means of a clasp S. R 1 — /// indicate 1st, 2nd, and 3rd ribs. C V — VII, D I — III &re placed on transverse processes of cervical and dorsal vertebrae. TUMOURS AND ALLIED SWELLINGS OF THE NECK ^73 Fig. 91. — Unilateral lipoma of back of neck. The subclavian artery either runs over the rib, or in front of it. The abnormality is usually bilateral, but more pronounced on one side than on the other. Very rarely two ribs ai"e found on the same side, with the subclavian artery running between them. If the medical attendant does not bear in mind the possibility of a cervical rib and is misled by the hardness of the structure, he will diagnose a malignant growth ; if he is struck by the pulsation of the subclavian artery, which is pushed forwards, he will regard the case as an aneurism, as the foUowijig instance illustrates. A middle-aged male consulted his doctor in reference to throat trouble. The latter found, after a conscientious examination, a small pulsating tumour in one of the supra-clavicular fossae, and he thought of a subclavian aneurism. But a closer investigation revealed a small hard structure over which the sub-clavian artery ran, but the artery was not enlarged — hence the con- dition was one of cervical rib. The diagnosis was clearly confirmed by a skiagram (fig. 90). The throat trouble was due to chronic pharyngitis. If the hard resistance were strikingly great, one \vould think of a cJioncl- roiua or ostcoinci starting from a cervical rib. If the pulsating structure near or over the cervical rib were larger than the circumference of a normal subclavian, one would en- tertain the possibility of an aneurism caused by a cervical rib. Fig. 92. — Symmetrical lipoma at back of neck. (From the Surgical Clinique at Berne.) 174 SURGICAL DISEASES OF THE NECK C— THE BACK OF THE NECK. We shall conclude tiie discussion of tumours of the neck with the new growths of the posterior cervical region. A median, cvstic, soft, elastic or fluctuating tumour is usually a meningocele or meningo-encephalocele (fig. i6); rarely a dermoid. The contents of the first two varieties are displaceable on pressure, and vary in tension according to variations in cerebral pressure. They are usually found in children only, because the patients generally succumb unless successfullv operated on. But dermoids are found at a later age also, as well as superficial sebaceous cysts. Apart from these, the most frequent tumours in this region are lipomata. If the structure is lobulated, soft in consist- ence, single, and laterally situated (fig. 91), it is an ordinary encapsiiled lipoma^ which can be shelled out with the greatest ease. If, on the other hand, there are two tu- mours, symmetrical^ placed near the middle line, which are not detinitely lobulated but rather nodular and hard,. with no tendency to become pendulous, the diagnosis is sxmiuetricciJ posterior cervical lipoma, a condition which occurs especially among dis- ciples of Bacchus. Frequently these tumours are accom- panied by another pair, situ- ated lower down (fig. 92). Beginners should be warned that the removal of these tumours should' not be lightly undertaken. They dip in between the interstices of the muscles, and have extensive adhesions, so that the operation is very troublesome and apt to be attended by severe haemorrhage. Peri-glandular lipoma is a third form of lipoma, which occurs not only at the back of the neck, but also in other situations of the neck and bodv generally, as circumscribed accumulations of fat around lymphatic glands (fig. 93). Diffuse lipoma of the neck, as described by Madelung, must be distinguished from the ordinary symmetrical lipoma of the back P'iG. 93. — Peri-glandular lipoma. (From the Surgical Clinique of Eerne. ABNORMAL POSTURES OF THE HEAD 1 75 of the neck. The whole neck is surrounded by a fatty mass, as by a coHar, out of which the head appears to emerge. Probably the two latter forms of lipoma have some connection with adiposis dolorosa or Dercimi's disease. This disease is recognized by the distribution of nodular or diffuse masses of fat in different parts of the body, associated with severe pain on pressure, neuralgia, and other sensory disturbances. Certain clinical and anatomical findings suggest a connection between this disease and functional disturbances of the thyroid or pituitary gland (see p. 24). Hard tumours, mostly situated at the side of the posterior cervical region, are either fibromata or sarcomata. They may arise from the aponeurotic connective tissue, more rarelv from the vertebral spine, but sometimes even from the skin. The rapidity of its, growth, its adhesions, its consistence and the condition of the superjacent skin will indicate whether the growth is more fibromatous or more sarcomatous in nature, or Avhether it is a pure sarcoma. A very rare case is recc^rded by Dower. This was a fibroma of the dura mater with a slender peduncle, which made its way between the second and third cervical vertebrae, and formed an orange-sized tumour at the side of the neck. The main feature of the case was the compression of the spinal cord. A very similar case was success- fully operated on by Wilms. CHAPTER XXV. ABNORMAL POSTURES OF THE HEAD. It is said that a politician once felt much encouraged durmg the delivery of a long speech by the remarkabh^ attentive posture of his immediate neighbour in the audience. He thanked the listener after the speech, but the latter, not quite appreciating the gratitude, said he had a stiff neck. Obviously the speaker was not a medical practitioner. IIV infer from a stiff neck something quite different to special attentiveness. We must first note whether the patient carefully avoids any move- ment of the head for fear of pain, or whether, although he holds the head in an abnormal position, he is able to move it partially without pain. A.— PAINFUL RIGIDITY OF THE NECK. Every painful condition about the neck has the efi'ect, on the cervical vertebrcC. which we call muscular tixation when it occurs 176 SURGICAL DISEASES OF THE NECK in otlier joints. A boil at the back of the neck suffices to produce this effect. The nature of the case is evident as soon as we see the patient coming with a compress on his neck or a plaster applied. There is no need for the patient to state his case ; but the underlying cause of the condition may be difficult to ascertain. If the muscles on both sides are equally tense and the head is held in the middle line, we may assume that the lesion which excites the pain is centrally situated, whereas if the head is held asymmet- rically the lesion is on one side. We shall discuss each variety separately, because the considei'ations we shall advance proceed from the beginning, in different directions. (1) SYMMETRICAL FORMS. As the muscular causes which may pro- duce rigidity are gen- erally unilateral and therefore result in iviy- iieck, we should at once think of a median struc- ture, the cervical spines when the rigidity of the head is in a straight posture. But even then, our conception of the case will vary with the sudden or gradual character of the onset. Fig, 94. — Complete forward dislocation of the 5th ceivical vertebra on the 6lh. Compare fig. 96. (a) Rigidity with Sudden Onset, If the rigidity has come on suddenly, we first enquire about an injury. In cases of severe injury to the cervical vertebras, the patient supplies his own indications thereof. In bilateral or complete dislocation, or in fracture-dislocation, with the dislocation still persistent, the profile show^s significant dis- placement of the head forwards, usually associated with flexion. The dislocation always occurs in a manner which causes the upper ABNORMAL POSTURES OF THE HEAD 177 vertebra to project beyond the lower, and which, with few exceptions, brings about sHght flexion at the same time. We must recall the actions of the various parts of the cervical spine in order to test the functions of the neck. The movement of nodding occurs between the occiput and atlas ; the movement of rotation between the atlas and axis, and lower down the chief move- ment is that of bending the whole neck backwards and forwards. It should be remembered that the various joints of the neck are able, to a great extent, to replace one another. On palpation an unusual space is to be noted between two spinous processes. The spinous process of the dislocated vertebra is also displaced upwards, touching the spine of the next highest ' .^^■^^^^^■■■■i ^T vertebra (fig. 96). In lean subjects the spi- nous process of the axis can be distinctly felt, but those of the third and fourth verte- brae are indistinct. The spine of the fifth vertebra is again distinct, and those of the sixth and seventh are very clearly felt. The demonstration of displacement of the lateral portion of the vertebra would be of value m diagnosis, but this is very cHfticult. On the other hand, a widening of the neck as seen in profile, in addition to bending of the head, is very significant. The displacement which is most common concerns the fifth vertebra, in relation to the sixth, wherein the spinal cord sometimes escapes injury, as was especially pointed out by Steinmann. Complete dislocations higher up are nearly always fatal. But should such a case survive, the diagnosis could be established by feeling through the pharynx and by external palpation of the side of the neck. But sometimes the displacement is very slight in compression fractures (fig. 96), and it is quite impossible to decide upon the nature of the injury merely by means of palpation. A diagnosis can only then be made by X-rays. These are the cases which form the inter- mediate stage towards contusion and sprain. There is no change in the shape of the cervical spine in these latter cases. Spine and lateral processes are in correct position. Fig. 95. — Fracture-dislocation between the 5th and 6th vertebraa, fixed in the position of sub- luxation. {Post-mortem preparation.) 1 78 SURGICAL DISEASES OF THE NECK It is only the active movements which are deranged, and this is quite relative. It is caused, as previously explained, by muscular fixation induced by the pain. Careful and slow manipulation will not only allow of the performance of all passive movements, but will also permit of their active performance. Theoretically there should be no pain in a case of sprain when pressure is made in the long axis, but it is sometimes present because, as a consequence of the normal curvature of the cervical spine, every thrust causes an increase of dorsiflexion and therewith some tearing of the ligaments. If such pressure is very pain- ful it suggests con- tusion of an inter- vertebral disc, or even a fracture unaccom- panied by dislocation. On the other hand, the pain caused by pressure in the long axis in cases of severe contusion and com- pression fracture, is sometimes less than might a priori be an- ticipated. Pressure on the spinous process may also be painful in cases of sprain, because it may produce slight displacement and tear- ing of the injured liga- ments. The site of the sprain ma}- be inferred from the character of the disturbed functions and from the position of the pain. If the nodding movement is affected, but the neck can still be bent, the injury exists at the occipito-atlantal joint. If there is difficulty in turning the head the sprain is probably between the atlas and axis. If the power of bending backwards and forwards is involved the sprain is more deeply situated. Very careful observation is required to distinguish between nodding movements and bending of the neck, but this differ- entiation can be made out quite accurately. The existence of damage to the spinal roots (neuralgias) is also of value for the diagnosis. The foregoing remarks require some amplification. There are Fig. 96.— Complete forward dislocation of 5th cervical vertebra. Compare with fig. 94. ABNORMAL POSTURES OF THE HEAD 179 Fig. 97. — Normal vertebra taken with mouth widely open, a, Joint between atlas and axis ; b, odontoid process of axis. some injuries of the first two cervical vertebrae which cause no striking alteration of posture, but produce very severe pain on movement and a corresponding muscular fixation. Fractures of the first two vertebras are immediately fatal if combined with definite dislocation, but if not so complicated they may re- cover, unless some unfore- seen movement or careless e X a m i n a t i o n causes a dislo- cation as a sup- plementary in- jury. A case of this kind is re- corded wherein the patient died suddenly as the nurse was help- ing to sit him up. These patients are constantly holding their head with their hands, because they feel very uncertain about hs stability. The fracture is either in the arch of the atlas or axis, or in the odontoid process of the latter. A fairly accurate diagnosis can only be made in the former condition, if by examination through the mouth of the palpable portion of the atlas it is possible to detect any dis- placement or abnormal mo- b i 1 i t y . No other diagnostic manipulation ought to be undertaken if there be any sus- picion of such a severe injury. But it is permis- sible to take an X-ray picture (from the side and from the front with the mouth open) as long as the process can be carried out with the necessary care. Fractures of the odontoid process cannot be diagnosed clini- cally, but they can be shown on a skiagram of the first vertebra, if taken with the mouth widely open (figs. 97 and 98), Fig. 98. — Fracture of odontoid process, taken through the mouth. The two articular surfaces between alias and axis are united by line of fracture. i8o SURGICAL DISEASES OF THE NECK It IS not very easv to distinguish partial fractures of the lower cervical vertebrse without displacement, from sprains. Detachment from the articular process with incomplete rotation — dislocation, is an example of such an injury. A long continuance of symptoms, assumed to be due to a sprain, is strongly suggestive of this lesion, but a decision can onh' be arrived at by a skiagram. A patient in whom sudden rigidity of the neck comes on, is not always aware of an antecedent injury. "Torticollis" is looked upon very much like " lumbago," and there is always a tendency to discover a chill as its cause. But the real cause may be a slight twist just as in manv cases of lumbago. It is brought about by some fortuitous movement of the neck, in which there has been neglect to fix the individual vertebree in the necessary manner by ap- propriate muscular action. Sometimes pains radiating towards the shoulders oc- occur, as in the case of the more severe sprains. But none of the spinous pro- cesses are definitely pain- ful on pressure, nor is pres- sure along the axis of the spine painful. Those who have themselves suffered from this kind of sprain are best able to appreciate its true nature. In some cases wherein the head is held fixed in a symmetrical position the cause is a slightly acute cervical adenitis due to sore throat. If there has been no injury and the symptoms of rigidity are accompanied by rigors and fever, we must think of the possibility of osteo-myelitis of the spine. Active movements in the adjacent vertebral joints are in abeyance, there is pronounced pain on pres- sure over the spine and lateral portions, and if the disease is situated high up, pressure through the pharynx demonstrates pain on the anterior surface of the vertebra. Pressure along the axis of the Fig. 99. — Caries of 5ih and 6lh cervical veitebrDe. Head displaced slightly forwards. Neck abnormally wide in profile. ABXOKMAL POSTURES OF THE HEAD l8r Spine is painful, corresponding to the extent of the inflammation. The diagnosis would be confirmed if the history revealed any recent acute inflammatory disease which might serve as the primary focus. Further confirmation is afforded by the course of the disease, in which nerve root and spinal cord symptoms supervene, and, unfortunately^ by the almost invariably fatal termination. I have seen osteo-mvelitis of this kind in a man aged 71, which came on as a sequel of a mild pneumonia. (b) Rigidity with Gradual Onset. If the rigidity has come on gradiuiUy the cause is usually tubercu- losis of the vertebrje (fig. 99), or more rarely a new growth. The examination must be conducted most carefully, because any excessive diagnostic zeal may be rewarded by the breaking off of the odontoid process of the axis — an accident which has actually occurred. We ascertain the extent of active movements, the amount of pain on pressure oyer the long axis of the spine, and on the spinous processes, and finally we test sensitiyeness to pressure through the pharynx. We diagnose the site of the lesion, just as we do the site of an injury by means of the disturbance of movement, the change in shape of the spine, and by the situation of the severest pain on pressure. Sharply limited neuralgias often facilitate the local diagnosis. We should also look for burrowing abscesses, and test the patellar reflexes in order to not overlook the commencement of some pressure on the spinal cord in the neck. Further information is given in the chapter on *' Inflammatory Diseases of the Spinal Column.'' (2) ASYMMETRICAL FORMS. If the posture of the head is not symmetrical, but is inclined towards one side and turned towards the other, the condition is one of " wry-ncch." If this has come on suddenly, the question of myositis should immediately arise. This diagnosis would be borne out, if a muscle, especially a sterno-mastoid, were not only tense but also swollen and painful on pressure. If the malady follows an acute infectious disease, oi" if it is only one manifestation of multiple myositis with high temperature, the condition is really serious, because it may lead to a permanent wry-neck, through subsequent fibrous degenera- tion of the muscle. But if there are no seyere symptoms and the swelling of the sterno-mastoid is the solitary morbid symptom, we may regard the case as one of rlicuiiuitic myositis and give a fayourable prognosis. l82 SURGICAL DISEASES OF THE NECK Many cases which are called rheumatic myositis are really due to acute adenitis of a cervical gland lying beneath the sterno-mastoid, and careful examination will often reveal some dental trouble or sore- throat as the primary cause. If the muscle is not swollen, but some injury has preceded the rigidity, the case is probably one of a simple sprain, which we shall be able to distinguish from a more serious accident by means of the rules previously given. The more serious one-sided injuries in this situation are usually one-sided dislocations. The head is held in such a distinctive manner in these cases, that the diagnosis presents no difficulty. The head is bent towards the dislocated side and turned towards the un- injured side (fig. lOo). At any rate this is the posture assumed in cases of one-sided dislocation with inter- locking of the articular processes, when the articular process of the upper vertebra has be- come displaced to the front of the corre- sponding process of the lower vertebra (figs. 102 and 104). But if the twist has onlv proceeded half- wav, that is to say, that the articular pro- cess of the displaced vertebra rests on the edge of the process of the lower vertebra (fig. 103), we should expect, theoretically, that the head would assume a different posture. The head should be inclined towards the uninjured side, so that the injured side would be lengthened and only slightly turned. This variety of dislocation is, how^ever, so unstable, and carries with it so little risk to life, that it has never been demonstrated post mortem. Only a skiagram could show whether such a picture, as conceived by most writers, represents the truth. We might suspect this form of dislocation, clinically, in a case wherein the amount of turning was insignificant in comparison to the bending, and where the spmous process and lateral portion were only slightly displaced. The much more frequent cases of complete rotation-dislocation with detachment of an articular process can likewise only be diagnosed by a skiagram. Fig. 100. -Left-sided dislocation between atlas and axis, rotation of head to opposite side. ABNORMAL POSTURES OF THE HEAD l8'> As in the case of other dislocations, the faulty position in the neck can be increased artificially, whereas considerable resistance is offered to opposed iiwvenieiit, especially when there is interlocking. Spon- >^^*? .-ff Fig. ioi. — Complete dis- location. Fig. I02. — One-sided disloca- tion with inteilocking. Fig. 103. — One-sided dislo- cation without interlocking. Fig. 104. — One-sided dislocation with interlocking. taneous pain is often quite trifling, but in recent cases all moveuiaits for the purpose of cxainiiiation, as well as pressure on the spine of the dislocated vertebra, are painful, not always because of the dislocation, 1 84 SURGICAL DISEASES OF THE NECK but, as Kocber remarks, because of the twisting of the non-dislocated side ; palpation affords the most feasible proof of dislocation. The spines of the upper vertebrae cannot ahvays be distinctly felt, so that we must examine through the pharynx and endeavour to make out whether we can detect a lateral portion forwardly displaced. Any kind of asymmetry is abnormal. If we are not quite sure about our results, we must examine with the index-finger of the other hand for the purpose of control. In this way it is quite possible to recognize dislocation of the first two vertebrae, and of the third vertebra also if the examining fin- gers are long enough and the patient's neck not too long. An examinerwith specially long fingers has been able to reach as far as the sixth vertebra in a patient with a short neck. This may be possible in toothless corpses, but not in living persons. On the other hand, no reliable results are yielded by the palpation of the spinous processes and the lateral por- tions in cases of rota- tion-dislocation. Spinal caries must be mentioned among the causes of ., 1 . .• 11V painful wrv-neck. If Fig. 105. — Congenital torticollis. r^ ■' the damage is only on one side, it may imitate the signs of a one-sided dislocation, or rather, it may lead to that condition. B._PAINLESS RIGIDITY OF NECK. It will, of course, be understood that these cases are always chronic. A symmetrical rigidity must be due either to some form of painless spinal caries, to an old bilateral dislocation, or to a healed compression-fracture. But if the condition is one of wry-neck and an old unilateral dislocation can be excluded by palpation, the case ABNORMAL POSTURES OF THE HEAD i8; must be grouped under the extensive class of so-called caput obstipum or muscular torticollis. The causation of this common malady is still a subject of contro- versy. Stromeyer and many others attribute it to injury of a sterno- mastoid during" birth, with subsequent fibrous dei^eneration and contraction of the muscle. Petersen's view is that the condition is of intra-uterine origin, due to the cramped space. He bases his view on the cases which are un- doubtedly con- genital and even heredi- tary. This con- ception is con- fi r m e d b y recent observa- tions (Voelker), because it has been shown that the shoul- der pressing against the neck /// iitcro leads to atro- phy of the sterno-mastoid. Kader, how- ever, as a result of definite ob- servations, at- tributes all wry- necks to the result of iiifec- iivc myositis, which comes on after birth, but very fre- quently owing to trauma dur- ing birth. According to Mikulicz, this explanation would account for iiitm-nteriiie shortening of the sterno-mastoid. However this may be, the chief factor in diagnosis lies in the circumstance that the malady has appeared during infancy. This explains the fact that the whole skeleton has become adapted to the abnormal posture of the head. The skull is asymmetrical, shortened and widened on the affected side, the spinal column shows cervical scoliosis with a continuation thereof in the dorsal region, the convexity being towards the healthy side. Sometimes there is, in addition to the cervical scoliosis, a dorsal scoliosis towards the opposite side Fig. io6. — Spastic torticollis. l86 SUKGICAL DISEASES OF THE NECK and lumbar scoliosis towards the same side as the cervical scoliosis. The one sterno-mastoid in the neck is shortened, resembling a narrow, hard, projecting band, whereas the other is often abnormally well developed. The most striking thing about the posture of the head, especially in children, is the inclination of the neck towards the affected side, with comparatively slight rotation towards the healthy side (tig. 10^). As the disease progresses this lateral inclination of the head diminishes but the rotation increases, so that the head may deviate entirely towards the healthy side. The complicated vertebral curvatures also belong to this latter category. There is, finally, another clinical picture, which essentially belongs to the department of medicine, but which often appeals to surgery when therapeutic measures have failed. As soon as the patient begins to describe his malady — which, however, is c|uite unnecessary — his head is suddenly and violently jerked to one side and turned towards the other. The more excited he becomes thereby, and the more anxious he is to impress us with his distressing condition, the more frequent become these spasmodic movements. Sometimes the facial muscles, the muscles of the floor of the mouth and even the shoulder muscles co-operate in these convulsive movements. They are sometimes intermittent and clonic, at other times persistent and tonic, involving not merely isolated muscles, but muscles which work co-ordinately, and muscle groups on both sides. For this reason the older designation of " spinal accessory convulsions " is incorrect. The clinical picture represents spastic torticollis in its most usual form, wherein one sterno-mastoid and the posterior cervical muscles of the opposite side act together. There are other allied forms such as bi-lateral contractions of the muscles which bend the head, nodding spasms and the contractions of the posterior cervical muscles — the '' retrocollis spasm " of English authors. There are some patients who experience the greatest difticulty in putting food in their mouths owing to these spasms. I know a practitioner in whom the disease started in the form of a writer's cramp in the right arm, and as the malady progressed the shoulder muscles participated in the spasmodic movements of the head. No wonder, then, that these patients turn to the surgeon for relief when internal treatment has failed. It is still uncertain whether the situation of the disease — which must be looked upon as a neurosis — is exclusively in the cerebral cortex or also in the more deeply placed centres of co-ordination. Possibly both are involved. At any rate it is quite certain that the results of operative treatment, division of the muscles which take part in the convulsions, cannot be attributed to pure suggestion. It is more probable that the irritable cortical centre is put out of action for a considerable time owing to the absence of centrifugal impulses from the tense muscle, and thus repose is ensured for it. PART III. SURGICAL DISEASES OF THE THORAX. CHAPTER XXVI. FRACTURES OF THE BONES OF THE THORAX. It is obvious that the ribs may be fractured by means of severe violence, directly — at the site whereon the force is applied — or indirectly at the site where the curvature is most pronounced. But it is not cjuite so easy to appreciate that a rib may break when the violence is very slight, or even as a result of muscular contraction only. Such cases, however, presuppose a debilitated osseous system through one cause or another, mostly senility. I knew an old man who fractured a rib through cutting a loaf. Ribs have been broken during labour through muscular contraction, and even while sneezing. After a severe injury, in which several ribs have been broken, it may be quite possible to hear crepitus with each breath, even in an adjoin- ing room, but in the slight cases just mentioned it is often necessary to search for the injury in order to make an accurate diagnosis. The outstanding symptom is pain felt as each breath is drawn, pain which effectually prevents any deep inspiration. Gaping, sneezing and laughing are particularly painful, and it was, therefore, a thoughtless joke on the part of a medical student who sent a colleague suffering from fractured ribs an amusing newspaper article to cheer him up, the perusal of which brought into play all the muscles required for a hearty laugh. The interference with respiration is not necessarily the result of a fractured rib ; it may be due to a hcematoma in the muscle or beneath the pleura. Both these con- ditions are, however, very frequent in cases of fractured ribs. If, on palpating the ribs, we feel or hear crepitus anywhere on deep respiration, there can be no doubt about fracture. The stethoscope may be of assistance in this examination. But some- times we only find a very painful spot without any signs of ab- normal mobility. This may indicate nothing but a contusion. The 13 SURGICAL DISEASES OF THE THORAX distinction is made by the possibility or impossibility of eliciting pain indirectly by making pressure and counterpressure on both extremities of the ribs, i.e., by increasing their curvature. Pain produced in this way, remote from the points of pressure, is significant of fracture or, at any rate, of incomplete fracture of a rib. If this examination elicits pain, both in the back and in the front, it follows that the rib has been broken behind as well as in front, a frequent incident in contusions of the whole thorax. In these cases there is usually concomitant damage to several other ribs. Fracture of the sternum sometimes runs its course quite un- noticed, because the injury is rather of the nature of a fissure than a complete fracture with a b n o r m a 1 movement and displacement. It is impossible to mistake this latter form owing to the superficial position of the sternum. The following case ]-efers to an unusual variety of dislocation : — A w o r k m a n fell against a box which he was hold- ing in front of him, in such a way that the ensiform pro- cess hit against its edge. When the patient undressed he noticed a re- markable projection in the epigastrium. The sternum had been trans- A'ersely split at the level of the fifth rib, and was displaced towards the skin. The rib cartilage was bent forwards and held the displaced fragment so firmly in position that reposition by the open method became necessary (fig. 107). In cases where tfie accident is nothing" more than a simple transverse fissure, notice is first attracted to the injury by the ecchy- mosis, which comes on in the course of a few days. As stated elsewhere, these fractures are generally indirect, and accompany fracture of a vertebra. It is, therefore, most important to examine the vertebral column in every case of fractured sternum, and vice versa. Fig. 107. — Fracture of the sternum with projection of lower fragment externally. INJURIES OB' THE LUNG 1 89 CHAPTER XXVII. INJURIES OF THE LUNG. If a liquid effusion rapidly makes its appearance within the thorax of a patient suffering from contusion thereof, or from fractured ribs, we must diagnose Iicviiwrrhngic effusion, which may originate either from a ruptured intercostal artery or from the blood-vessels of the lung. We can only be certain of the latter origin if signs of piicinno- thorax supervene upon those of the effusion, or if the patient conghs lip blood. The injury to the lung becomes quite obvious if air penetrates into the subcutaneous tissue and gives rise to the well known appearance of cellular einphyseuia, which often extends over a very wide area. Death ensues rapidly if a main bronchus has been completely torn away from the lung and opens into the mediastinal ceUular tissue and inflates it. The effusion of blood and the pneumothorax must be carefully watched, because their increase, in association with a worse condition of the pulse and respiration, may demand operative interference. Sometimes, how- ever, the initial symptoms of contusion of the lungs are so slight that the injury is overlooked, and it is only diagnosed after consecutive pneumonia has arisen. Pneumonia, following contusion, usually appears within the first four days, a circumstance which is very important in arriving at a medico-legal opinion in doubtful cases. Injuries of the pleura open to the skin are of more practical importance because they demand rapid decision as to treatment. The instrument inflicting the injury is usually a bullet, knife or dagger, even in times of peace. The thorax has been pierced right through, from axilla to axilla, by the domestic broomstick, as recorded by Franke, with subsequent recovery. Gunshot ivounds of the pulmonary tissue are remarkably well tolerated because of its great elasticity. Recent wars have afforded numerous instances of people shot through and through, who kept on marching or riding for hours, and who returned to duty after a brief detention in the field hospital. This applies, at any rate, to injuries inflicted by modern srnall-calibre bullets with their small surface of attack. More serious results follow, especially severe haemothorax and rapid haemorrhage, when shrapnel bullets are used, or when the projectile, on its way through the thoracic wall, has torn up buttons or splinters ot rib. The intensely severe conditions which result from shell injuries are usually so obvious that diagnostic reflections are quite superfluous. igo SURGICAL DISEASES OF THE THORAX Incised and penetrating wounds of the thorax cause expectoration of blood, whether the Iring is involved or not. A simple haemato- thorax is not conclusive of the precise nature of the injury, because it may originate from a wounded intercostal or mammary artery as well as from a pulmonary vessel. A pneumothorax is only significant of an injured lung if the condition continues to increase when the external wound is hermetically sealed. We must also be careful in diagnosing emphysema in cases of injurv to the thorax. Whereas an extensive surgical emphysema points definitely to an injury of the lung, the slighter forms are due to aspiration of air through the external wound if the latter is situated in the vicinity of the armpit, and the patient is frequently lifting and dropping his arm. Fig. k -Pneumothorax through detachment of right bronchus. Considerable clear area. Contracted lung lying against median shadow. In conclusion, a very important rule for the examination and treatment of injuries to the lung. Rest is of the utmost importance, because every change in position accelerates the respiration and may cause a fresh haemorrhage. Diagnostic energy must, therefore, not be pushed too far, and we must be satisfied to move the patient as little as possible. Although we may be clear about the injury to the lung, we must not forget that it is often accompanied by secondary injuries. The diaphragm and the viscera in relation therewith are especially en- dangered. A stab in the right side often involves, not only the lung but also the diaphragm and liver. We must, therefore, never neglect to examine for haemorrhage within the abdomen, lest a patient may be bleeding from a wound of the liver while we assume he has only INJURIES OF THE HEART 191 sustained an injury to the lung, not of a dangerous character. The same consideration apphes on the left side, to the spleen. The stomach is less frequently involved, because it more easily escapes the knife than the solid viscera. Injuries to the diaphragm on the left side produce immediate or subsequent diaphraginatic lieniice. The following case shows that this result is not limited to penetrating injuries like gunshot wounds or stabs. A workman was brought to hospital in a moribund state after a severe crush of the thorax. The autopsy revealed several broken ribs, with a deep laceration of the left lung caused by the point of one of the rib fragments. The same fragment had pierced the diaphragm, and the wound therein was immediately filled up by a fungiform plug of omentum which projected into the pleural cavity. Injuries to the lung are sometimes complicated by ivonnds of the heart, which then demand the chief attention, as being of the greatest danger. If the injury involves the large vessels in the mediastinum, an autopsy is inevitable. The easily deflected oesophagus is least exposed to danger. CHAPTER XXVIII. INJURIES OF THE HEART. TWEXTY years ago, death from wounds of the heart seemed quite the obvious thing, and recovery was ascribed to a lucky accident. Suture of the heart has however now been performed some dozens of times and in two-fifths of the cases the result has been successful. But it is necessary that the diagnosis should be made with rapidity and accuracy if surgical interfence is to be afforded adequate opportunity. The position and the character of the wound are the principal indications which raise the suspicion of injury to the heart. Any wound situated over the cardiac area or its vicinity should excite suspicion, and in this connection it must not be forgotten that the heart may be wounded, in exceptional cases, by stabs or shots from behind. If the wound is not directly over the heart, the direction and the length of the instrument which inflicted it will show whether it is possible that the heart may have been involved. The probe must never be employed in examination. The only reason for determining whether the wound is a penetrating one is 192 SURGICAL DISEASES OF THE THORAX to ascertain the presence of an injury to any underlying organ, but the probe is unable to give information in this type of case. The probe may actually impinge upon the heart and vet we may be unable to tell whether it is injured or not. Beyond this, there is an element of danger in probing an injured heart, for this procedure has re-started a haemiorrhage which had already ceased. The patient is also unnecessarily exposed to the risk of infection because the superficial parts of the wound are not always aseptic. If the wound is large, examination may be made witii the finger, which will, as a matter of fact, enable a conckision to be arrived at better than a probe, especially if the finger not only explores oz'cr the heart but also the actual wound itself, as recommended by Longo. But we should only resort to this not entirely harmless examination when everything ' is ready for operation and our finger is aseptic. in judging the symptoms, it should always be remembered that not all cardiac injuries present the same clinical picture, and that not all the classical signs appeal" in every case. The decision as to treatment and the framing of a diagnosis must therefore not be delayed until all the text-book symptoms supervene and the patient is moribund. The subjective sensations experienced at the, moment of the injury, often referred to as those of indescribable fear, are of significance. Rcftex signs such as fainting and vomiting may follow immediately on the injury, but these must be distinguished from its mechanical effects, which will be referred to forthwith. Apart from those rare cases in which the patient bleeds externally from his wound, there are two distinct forms of cardiac injury : (i) in which the pericardium and heart are alone involved, and (2) in which the pleural cavity is also opened. In a purely cardiac injury the most striking features, in addition to a certain reflex pallor, are the cyanosis and dyspnoea of the patient. The pulse is weak, rapid, and markedly irregular ; the heart sounds are feeble and appear to come from afar. The cardiac dulness is more or less increased, but the results of percussion and auscultation of the lungs are normal. We have just said that the cardiac dulness is increased. This is true of most cases of purely cardiac injury, but the extent of the increase varies considerably. It must not be estimated by the standard which obtains in cases of pericardial effusion, as the inexperienced are apt to do. An acute haemorrhage does not distend a healthy pericardium to the same degree as a gradually developing effusion. We can, therefore, only expect any considerable increase in the area of dulness after cardiac injuries in cases wherein blood is INJURIES OF THE HEART 193 slowly oozing for days. In the very severe cases, on the other hand, death is too sudden to permit of the recognition of any striking distension of the pericardium. Observation of the patient over a number of hours will probably show moments of improvement alternate with periods of exacerbation which appear to come on in attacks, signifying that the heart tem- porarily recovers, only to succumb in the struggle against unfavour- able mechanical conditions. The exacerbations get worse and worse and the patient sinks unless hjemorrhage ceases spontaneously or is checked by suture of the heart. This picture constitutes the condition known as couipression of the heart by means of the blood enclosed within the pericardium. Whether the usual explanation of auricular compression is correct or not is an open question. The following case will illustrate the foregoing remarks. A young melancholic stabbed himself three times in the cardiac region with a sharp file, and was brought into hospital three hours later with a miserable rapid pulse. During the examination dyspnoea and cyanosis became severe, the pulse inappreciable and the eyes glassy. A rib was immediately resected and the pericardium, which was fuU of bl-ood, was opened. At this moment the nurse who was looking after the blood exclaimed, " The pulse has come back again ! " No haemor- rhage had occurred into the pleura. The signs were therefore not those of anaemia but of compression of the heart. The patient was taken back to bed with a good appearance and full pulse. The heart was not sutured because the hasmorrhage ceased spontaneously, and the patient recovered. The picture is quite different when the cardiac injury is com- plicated by injury to the pleura. If the pleuro-pericardial wound is large enough the patient smiply bleeds into the thoracic cavity and he presents the appearance of an acute anaemia. The patient looks pale rather than cyanotic, the cardiac dulness is very little enlarged, if at all, but an increasing liquid effusion takes place in the injured pleural cavity. The pulse is rapid, small and irregular, and the patient manifests the same momentary improvements and sudden exacerbations which occur in purely cardiac injuries. On ausculta- tion the cardiac sounds prove to be feeble. Various valvular mur- murs are audible, but nothing distinctive. A splashing murmur like the sound of the wheel of a water-mill is of more importance, because this is conclusive of the entry of air into the pericardium. We must, however, not expect to find a typical picture in any individual case. If the pleuro-pericardial wound is small blood may escape from it into the thoracic cavity, so that the patient becomes to a certain extent anaemic ; but the opening may be eventually closed by a clot, so that symptoms of heart compression will be present \n addition to those of anaemia. In these intermediate cases it is not 194 SURGICAL DISEASES OF THE THORAX SO important to diagnose all the details of the injury as to recognize the fact of cardiac injury as soon as possible, and appraise accurately the indications for surgical interference. The following statement may be taken as a guide in practice : — If ail injury in a situation icJierein the heart may be involved is fol- lowed by derangement in cardiac action or by acnte anceniia, zve must assume the probability of an iiijurx to the heart, whether the cardiac dulness be increased or not. If the symptoms gradually increase despite transi- tory improvement, surgical measures must be adopted unless contra- indicated by external conditions. " Unless contra-indicated bv external conditions." The main- tenance of strict asepsis is so important in these operations which usually concern the pleura and pericardium that cardiac suture ought only to be undertaken when all external conditions are favourable, unlike the rule for tracheotomy. If at all possible the patient should be conveyed to the nearest hospital. Experience shows that there is ample time for this if the diagnosis has been made without delay. Do the foregoing remarks justify us in concluding that there is ;/o cardiac injury in the absence of anaemia and circulatory distur- bances ? Certainly not. Even penetrating wounds may run their course without symptoms and may remain unrecognized despite careful examination. An old man stabbed himself three times with a kitchen knife in the cardiac area. Although the heart was most carefully examined no sign of injur}' could be detected. The patient died in eight days from pneumonia, and the autopsy revealed a small stab wound which had gone right through the left ventricle, at the apex, but which had been sealed up by fibrin. The pericardium only contained a little blood-stained fluid. Such a case is not one for immediate operation, but it requires careful watching, lest subsequent haemorrhage necessitate an opera- tion eventually. A word of warning in conclusion. Too much zeal must not be evinced in this newly-acquired surgical province. Many uninjured hearts have been exposed, showing the necessity for most careful examination to avoid confusing an injury of some other thoracic organ with a cardiac injury. THE SURGERY OF IXFLA:\niATORY DISEASES OF THE LUXG 195 CHAPTER XXIX. THE SURGERY OF INFLAMMATORY DISEASES OF THE LUNG. There are certain diseases of the lung in whicli the patient is entitled to the benefit of surgical treatment. Nothing demonstrates this so clearly as the action of a physician who, doubting the efficacy of his prescriptions, recently betook himself to the knife and has now- become one of the most experienced of lung surgeons. The diagnosis of surgical diseases of the lung comes within the province of the physician and general practitioner, because these maladies are purely " medical " at first. The surgical sense of the practitioner should evince itself by recognizing the exact moment when resort to the knife is required. Empyema, abscess of lung and gangrene of the lung are the diseases which are of main interest in this connection. Bronchi- ectasis and actino-mycosis of the lung only rarely lead to operative procedures. The surgical treatment of phthisis and of emphysema is in much too early a stage to justify any discussion here. .4.— EMPYEMA, ABSCESS OF THE LUXG, GANGRENE OF THE LUNG. From an etiological standpoint the following possibilities exist : — (I) A pneumonia fails to resolve in the desired manner, or if pyrexia recurs after the crisis the first thought which enters one's mind is that of empvema. The diagnosis is made from dulness at the base, weakened respiration and loss of vocal fremitus and con- firmed bv exploratory puncture. An empyema extending to the spine of the scapula, and unrecognized, must be ascribed to a thoughtless- ness on the part of the medical attendant. A careful observer will never be taken by surprise by an empyema bursting through into bronchi or thoracic wall. If an empyema is indicated by lever, dyspnoea and emaciation, but physical signs are absent, we need not doubt the accuracy of the diagnosis, but must search for the empyema in the correct situation. It may be interlobular and therefore fail to yield the ordinary signs. A circumscribed area of diminished respira- tion and of dulness, generally with some adjacent bronchial breathing bounded about and below by normal lung resonance and well- preserved respiratory murmur, usually directs us to its position. A needle correctly aimed will demonstrate pus at once. (See under Sub-phrenic Abscess.) 196 SURGICAL DISEASES OF THE THORAX But in such a case the differentiation from abscess of the kmg is difficult. This is also a frequent sequel of pneumonia, and if not situated at the base has an area of more or less normal lung tissue below it. The greater extent of the dulness and the later occurrence or entire absence of perforation into the bronchi are, however, distinctive of empyema. A skiagram may render some assistance in this differentiation, because a more or less transverse non- transpa- rent area indicates an empyema, whereas a re- stricted roundish tliicken- ing points to abscess (fig- 109). If the expectoration has a peculiar foetid smell and contains shreds of lung tissue, the case is no longer merely one of abscess ; it has become gangrenous. If copious pncuinonia has been the antecedent disease, as we have hither- % to assumed, experience shows that some form of empyema is most pro- % bablv in question. (2) If the pneumonia has been caused by the inhalation of anv kind of foreign body, or of fluids, the conditions are differ- FlG. 109. — Skiagram of aljscess of lung (X). ^^^t. It is quite true that empyema is not a rare sequel, but nbsccss of ilie In/ig is of more frequent occurrence, and gangrene often follows it. As we have previously seen, foreign bodies include everything taken into the mouth foolishly by children and adults and inhaled through carelessness. The consequent abscess may run a very chronic course and persist for years, even ten or more. I have seen a female aged 40 suffering from a chronic pulmonary abscess and bronchiectasis which she rightly attributed to inhaling a bean in her youth. It is also necessary to note the occurrence of the inhalation of fluids, especially in the vomiting of anaesthesia and in operations on the mouth and throat, for the removal of putrefying carcinomata,. THE SURGERY OF IXFLA:\niATORY DISEASES OF THE LUNG I97 or for the extraction of teeth undei" general anaesthetics. The extrac- tion of numerous teeth under anaesthesia is no trifling matter ; never- theless the operation is, unfortunately, often undertaken when the patient is quite unfitted for it. If some lung complication supervenes with these circumstances the diagnosis is generallv easy. i\t first a pneumonia is diagnosed- If an effusion takes place in the pleural cavity puncture with a needle will show whether it is serous or purulent. If the sputum after settling separates out into three layers — the lowest of pure pus, then clear liquid and the highest of mucus — an abscess must be present. If we are met by a repulsive odour on entering the sick room, the case is either foetid bronchitis or gangrene. The sputum in the latter case is greenish or brownish and putrid, separating into three layers, and contains greyish or dark shreds of necrotic lung tissue, or, at any rate, elastic fibres visible under the microscope. If repeated examinations fail to reveal any of these structures, we must content ourselves with the diagnosis of foetid bronchitis. (3) In a third group of cases the lung symptoms are preceded neither by the inhalation of a foreign body nor by pneumonia. The disease follows some inflammatory process which may possibly be situated at some distance from the lung; and the exciting cause of the infection reaches the lung by way of an embolism. Any inflamma- tory process may serve as the cause, e.g. — sore throat, a furuncle, suppuration within the abdominal cavity, especially on the region of the female genitalia. If a few organisms only, or very minute par- ticles of infected material are conveyed, the result will be according to their localization either a pleuris}" or multiple small abscess forma- tion with the signs of pneumonia. If, on the other hand, a larger infective thrombus reaches the pulmonary artery a more or less extensive focus of gangrene will result. The history and physical examination, as we have seen, usually suffice for a correct diagnosis. If an empyema is confirmed by punc- ture the indications are for an immediate evacuation by surgical measures either by simple syphon drainage or by the more reliable method of rib resection. If we suspect an abscess of the lung or a gangrenous area, we must be more careful in regard to puncturing, because the pleural cavity is probably still free. We must therefore rather resort to a skiagram or a screen examination, and only proceed to puncture when everything is readv for an operation. It is even better to abandon the punctui-e altogether, or, at any rate, until the lung is exposed, The nature of the expectoration also testifies to suppuration, and its position is more correctly estimated by means of physical examination and a skiagram than by puncture. We have hitherto assumed that the diagnosis of disease within 19^ SURGICAL DISEASES OF THE THORAX the pleural cavity can be made with absolute certainty ; but this is not always the case. In discussing subphrenic abscess we shall see that it is very easy to mistake this for an empyema, especially on the right side. The diaphragm may be so tightly pressed against the thoracic wall, and the lung pushed up so far that although the needle shows the pus to be situated apparently in the sixth or seventh inter- costal space, the abscess is really below the diaphragm. On the other hand, a circumscribed diaphragmatic pleurisy in the depths of the inferior surface of the lung may be mistaken for a subphrenic abscess. /?.— BRONCHIECTASIS. Bronchiectasis is either of congenital origin or the result of some circumscribed inflammatory process of the lung or pleura, such as pneumonia or abscess. The diagnosis is based upon the paroxysmal attacks of expectora- tion, amounting sometimes to a whole mouthful, especially in the morn- ing ; to the separation of the sputum into three layers — after standing, and to the presence of the particles of pus known as Dittrich's plugs. On physical examination moist rales are heard in cases of small bronchiectasis, and when large circumscribed cavities are present the signs are those of infiltration and cavitation. A skiagram should always be taken, because we mav derive therefrom important con- clusions regarding the situation and extent of cavities, if not about the very nature of the disease (fig. 115). In the diffuse form there is only evidence of thickening of the lung tissue, which is indistinguishable from a severe tubercular infil- tration ; but in sacular bronchiectasis a cavity which is hardly distinguishable from a tubercular cavity may be visible. It is well known that clubbed fingers develop after some years in cases of bronchiectasis, but this condition may also be due to quite different causes, and is, therefore, not of much value from a diagnostic standpoint. In the differential diagnosis of bronchiectasis care must be taken to distinguish it from piilmonarx abscess and from tubercular cavities. If there are no tubercle bacilli in the sputum the latter may probably be excluded. Pulmonary abscess differs from bronchiectasis in that it supervenes directly after the primary disease, e.g., pneumonia or inflammation caused by a foreign body, whereas bronchiectasis takes months or years to develop. If there has been no causative disease, bronchiectasis is the most probable diagnosis. C— ACTINOMYCOSIS. The early stages of actinomycosis of the lung are either entirely overlooked or confused with tubercle. If the patient has a chronic TUMOURS AND ALLIED GROWTHS WITHIN THE THORAX 199 cough with purulent sputum :uid elevations of temperature, he will generally be diagnosed as a case of phthisis — and justly so. But there are certain signs which ought to suggest the possibility of actinomycosis even at this stage. These consist of a localization of the disease to the middle and lower lobes, leaving the apices free, and also the incidence of pleuritic attacks with simultaneous drawing-in of the chest. A positive diagnosis may be obtained by examining the expectoration, at any rate if it contains the actinomy- cosis granules. The diagnosis is easier when the disease reaches the thoracic wall and becomes evident on the surface. We shall return to this in a subsequent section, but would only add here that operative treatment of this disease has affected a complete cure in many cases. CHAPTER XXX. TUMOURS AND ALLIED GROWTHS WITHIN THE THORAX. Pathological growths within the thorax naturally fall under two groups : (i) Those of the mediastinum ; (2) those of the lungs. Each group possesses its characteristic symptom-complex, and will therefore be discussed separately. There are transitional forms here, as elsewhere, which introduce difficulties in diagnosis. Thus a small cancer of the lung with enlarged mediastinal gland will yield the symptoms of a mediastinal tumour, whereas a sacculated aneurism growing towards one lung will suggest the possibility of a pulmonary tumour. (1) MEDIASTINAL TUMOURS. No region is so inaccessible to direct examination as the medi- astinum, and nowhere do tumours sail so long under false colours as here. The diagnosis is only made under a feeling of great responsibility, because the impotence of therapeutics renders the diagnosis a sentence of death. Most of the new growths of the mediastinum chiefly involve the lung or the larger bronchi. An irritiiting congli, without expectoration, and dxspncea are, therefore, the symptoms which dominate the clinical picture for a considerable time and suggest some form of pulmonary disease — phthisis in young people, chronic bronchitis and emphysema 200 SURGICAL DISEASES OF THE THORAX in elderly patients. If there is, in addition, paralysis of the reciirreiif laryngeal nerve, the condition is looked upon with more gravity, although this form of paralysis may exist without any serious significance. If careful attention is bestowed on the form of the dyspnoea, it will often be noted that an attack comes on in certain postures of the body and that it ceases in other postures. The con- sideration of this symptom should suggest the possibility of some mediastinal growth, provided there is nothing in the neck like a goitre or other tu- mour to account for it. If the veins of the neck gradu- ally dilate, and a collateral venous anastomosis de- velop at the same time, our suspicion will secure new sup- port. At this stage there will generally be somewhere in the thorax, especi- ally over the ster- num, an abnormal didness on 'percus- sion, and the aid of the X-rays should also prove of ser- vice. As the tissue of the tumour is less transparent than lung tissue, a mediastinal grow'th of any appreciable size, of whatever nature it be, will throw a superimposed shadow on one side or other of the sternum. The peculiarities of this shadow often afford further diagnostic assist- ance and provide definite conclusions as to the nature of the growth. But other clinical methods will furnish information on this head. Let us consider the main possibilities : In infancy the most likely condition is hypertrophy of the thymus gland, or some unusually great hyperplasia of the bronchial glands. In older patients we endeavour to decide between an aortic aneurism or a genuine tumour. Fig. 1 10. — Diffuse colloid goitre with a considerable part iniiide the thorax (see fig. in). Pronounced caput medusae. Dyspnoea. TUMOURS AND ALLIED GROWTHS WITHIN THE THORAX 201 Innocent tumoars mainly consist of intia-thoracic goitres, dermoid and hydatid cysts, and malignant tumours comprise carcinoma and sarcoma, which may arise from the thymus, bronchi, lymphatic glands or connective tissue. Cancer of the oesophagus, which should properly be included here, is generally fatal before reaching dimen- sions which bring it in the category of mediastinal tumours. The early recognition of hypertrophy of the thymus is particularly important, because many cases have been successfully operated on. Hvpeiirophy of flie broiicJiinl glands in scrofulous, or rather in tubercular children, is only important surgically as a matter of dififerential diagnosis. Without a skiagram the diagnosis is usually nothing more than a suspicion, unless opportunely there are such definite signs as glands in the neck, dulness over the sternum, and paralysis of the recurrent laryngeal nerve. The skiagram, however, shows these glands with the clearest distinction, and should, thei'efore, always be procured whenever this diagnosis is entertained. In adults the differential diagnosis mainly lies between tumour and aneurism ; but the shape of the area of dulness permits of a definite conclusion being arrived at. In large aneurisms the dulness projects in front to one or both sides of the upper part of the sternum, and it appears posteriorly chiefly in the region of the left and some- times of the right upper lobe of the lung. Mediastinal tumours may present the same condition in regard to dulness, but they do not adhere to any rule. If the thoracic wall bulges and pulsates, and the hand feels a definite thrill, and if a souffle is heard with the stethoscope, the diagnosis requires no great skill, especially if the radial pulses are unequal and there is a history of syphilis (fig. 114). But sometimes nothing is heard on auscultation, the radial pulse is equal on both sides, and there is no previous history of syphilis. The actual symptoms, dulness, dyspnoea, paralysis of the recurrent laryngeal, intercostal pain, and possibly also inequality of the pupils due to pressure on the oculo-pupillary fibres of the sympathetic (to be examined in semi-darkness), the emaciation and even the shape of the demonstrable dulness might just as well be due to a mediastinal tumour, or, in exceptional cases, to greatly enlarged tubercular bronchial glands. We must, therefore, be guided by indirect diagnostic considerations. The symptoms of an aneurism usually come on very slowly, taking years to develop, and the patient is quite unconscious of them. Unless a sudden rupture occurs their progress is very gradual. A mediastinal tumour, on the other hand, develops more rapidly, and after having once given rise to symptoms proceeds uninterruptedly to the end. Sometimes we are led upon the right track by the condition of other organs. Thus we may conclude from the presence of enlarged 202 SURGICAL DISEASES OF THE THORAX glands in the neck, axillae" or groins, that the mediastinal disease also depends upon enlarged glands. The consistence of these glands may perhaps indicate whether they are leukccmic, but more reliance is to be placed upon the appearance of the patient and the blood count. But if the neck alone presents enlargement of the glands of recent date, we may assume the presence of a primary malignant tumour of the mediastinum or of the lung, unless it be a rare case of Hodgkin's disease beginning in the mediastinum. Fruit-juice, blood-stained expectoration would support the diagnosis of primary tumour of the lung. Old-standing pulmonary tuberculosis would Fig. III. — Tntra-thoracic Goitre. S — S, the goitre; consisting of both lower cornua, as shown by the operation, c = heart, d = diaphragm and liver. suggest mediastinal glands of a tubercular nature. If the patient has a malignant growth anywhere, we should discard all thoughts of aneurism and assume the presence of a metastasis in the mediastinum. Sometimes the primary tumour presents no symptoms at all^ and the secondary growth in the mediastinum is alone in evidence, as in fig. 113. But, as stated above, the most reliable conclusions are yielded in doubtful cases by Roiifgcn rays, especially by examination with the screen. TUMOURS AXD ALLIED GROWTHS WITHIX THE THORAX 203 111 the case of an aneurism a thick, sharply-limited, rounded shadow is seen. If the aneurism arises from the ascending aorta or aortic arch, the shadow is situated above the heart, fitting over it like a cap, corresponding to the dulness previously described (fig. 114). If it is an aneurism of the innominate artery the shadow is situated to the right of and above the aortic arch, and is not distinguishable from a saccular aneurism arising from the arch and growing towards the right. A semi-circular shadow on the left side, situated much lower down, indicates an aneurism of the descending aorta, if the shadow can be distinctlv defined separately from the heart shadow. LciL. Right. Fig. 112. — A mass of mediastinal glands encroaching on the right lung in a case of lymphadenoma. The penetration of an aneurism through the thoracic wall can be recognized clearly. All this is visible in the skiagram, but the screen allows us to see the pulsatile movement of the margins of the shadow. The absence of this pulsation is, however, no proof against aneurism, because there are such things as non-pulsating aneurisms ; but the presence of an extensive pulsatile dilatation of the margins of the shadow, especially if bilateral, mav be regarded as positive proof of aneurism. But if the pulsation is unilateral only, or if it is limited to one place, the case may be one of new growth pushing up the aortic arch. 14 J04 SURGICAL DISEASES OF THE THORAX The shadows cast bv mediastinal and pulmonary tumours are quite different to the typical shadow of aneurism. Like the dulness produced by these tumours, their shadows have no typical situation, but they invade irregularlv the median shadows cast by the spinal column and sternum, either to the right or left, encroaching into the lung area. Their limits are less sharp than in cases of aneurism (fig. 113), the border line especially being less regularlv defined. Sometimes it is possible to see quite clearlv that the growth is composed of separate nodules. We shall see later that there are exceptions to this rule. The following case illustrates the considerations which lead up to the diagnosis of aneurism. An alcoholic male, aged 42, who had been losing flesh for some time, suffered from indefinite general malaise, which was attributed Left. Righi. Fig. 113. — Mediastinal tumour. Metastasis from a hypernephroma which produced no clinical sjmptoms. to a cu-rhosis of the liver, with which he was afflicted. During the last few weeks striking dyspnoea and hoarseness developed, and the patient came into the consulting room emaciated and short of breath. He might have been taken for a case of advanced phthisis, had he not stated that he had had no cough up to quite recently, and even now there was no expectoration suspicious of tubercle. The breathing was rapid, but auscultation disposed of the idea of pulmonarv disease. Cardiac action was rapid, but the heart sounds were pure, there were no bruits or murmurs. The dyspnoea could not be accounted for bv pulmonary disease or by valvular defect. The clinical picture did not fit in with disease of the heart muscle. The only explanation was offered bv a slight dulness on both sides of the upper half of the sternum, which might be caused by an TUMOURS AXD ALLIED GROWTHS AVITHIX THE THORAX 20: aneurism or by a tumour. The radial pulse was equal on both sides. Rontgen-ray examination revealed a shadow, corresponding in form to an aneurismal shadow, above the heart, reaching to the throat. There was, however, no distinct pulsation, and it was proposed that the patient should come into the hospital for further examination ■of this point and for closer observation. But, instead of coming to the hospital, his doctor reported, in a few davs' time, that the patient had died from haemorrhage within a few minutes. If an aneurism manifests itself for a considerable time, merelv by a single symptom which is not very typical, much difiicultv may be encountered before a diagnosis is estab- hshed. Thus, I saw a patient who had been treated for two vears for intercostal neural- gia, the explanation of which was not revealed by phvsical examina- tion of the thoracic organs. Resection of three intercostal nerves afforded temporary re- lief. The recurrence of the pain suggested an X-rav examination, and then an aneurism was discovered ! Such cases show how easy it is to ovei"- look an aneurism. We do not, however, mean yiQ_ U^, — Aneurism of the aortic arch. a = heart, to suggest to certain d = aneurism, c = diaphragm and liver. journalists that they should diagnose " ruptured aneurism " anv more frequently than they do at present in cases of sudden death. If, after considering all the diagnostic signs of aneurism, we exclude this condition and diagnose a new growth, our next step is to determine its nature. We have already mentioned intra-thoracic goitre, dermoid and hvdatid cysts as innocent tumours. A goitre is easily recognized if it is merelv a continuation of one, visible and palpable in the neck (deep goitre)= The diagnosis is, however, more difficult if the whole goitre is concealed within the thorax, and the corresponding lobe of the thyroid gland cannot be felt or is only rudimentary (pure intra-thoracic goitre). In such cases the goitre originally develops 2o6 SURGICAL DISEASES OF THE THORAX from an inferior cornu of the thyroid gland, extendin^^ very low down. The goitre grows into the thorax and becomes so large that it can no longer slip out, and as it grows it drags the rest of the thyroid lobe down with it. It may also originate, as a true or false secondary goitre, from an accessory thyroid gland. A female, aged 68, who had been suffering from bronchitis for many years, came to the hospital because of extreme dyspnoea. She could only breathe in a sitting and bent-up position. There was dulness on both sides of the sternum, and the skiagram showed a sharply defined shadow, like a cap, above the heart, reaching as Left. Right. Fig. 115. — a — Cancer of the right lower lobe penetrating through the thoracic wall, b = Diffuse bronchiectasis of the right upper lobe, c — Old tubercle of the left upper lobe. far as the throat, which suggested an aneurism by its shape. But its edge did not pulsate, and other evidences of aneurism were also wanting. The right lobe of the thyroid gland contained a few small colloid nodules. Nothing could befelt of the left lobe of the thyroid except some mdefinite resistance in the throat. The case, therefore, appeared to be one of intra-thoracic goitre, which would also account for the bronchitis. The operation confirmed this diagnosis, and the: removal of the goitre permanently cured the malady. The operatioa TUMOURS AND ALLIED GROWTHS WITHIN THE THORAX 207 in the cases depicted in figs, no and 112 was followed by the same iesult. Dermoids of the mediastinum are mostly situated behind the manubrium, and are accessible to operative treatment. The diagnosis has occasionally been based on the expectoration of hairs, after perforation of the dermoid into a bronchus. Otherwise we cannot get much beyond suspicion. Hydatid cysts will only be thought of in districts where they are endemic, and then the diagnosis is something of a guess, unless tlie nature of the disease is betrayed by attacks of urticaria. Fig. 116. — Metastatic cancer of lung, x x = foci in both lungs. Malignant iinuoiin are recognized by their rapid growth and the correspondingly swift increase of all symptoms. They are also indicated by the significant extent and rapid increase of the dulness. We have already referred to their skiagraphic appearances. They are usually sarcomata, originating either in lymphatic glands or con- nective tissue. (2) TUMOURS OF THE LUNG. Tumours of the lung, like those of the mediastinum, consist of dermoids, hydatids, carcinomata, sarcomata, and of chondromata, the last starting in the bronchial cartilage. In their early stages all 2o8 SURGICAL DISEASES OF THE THORAX these growths, if they give rise to symptoms at ah, are mistaken for tuberculosis. A dermoid is only recognized when hairs are coughed up ; a hydatid onlv when it bursts into a bronchus and causes suffocation, or when this occurs under the very eyes of the unsuspecting practitioner as a resuh of an exploratory puncture. If the patient does not succumb, the microscopic examination of the fluid, and the occurrence of urticaria consequent upon the puncture, will establish the diagnosis. The skiagram, with its sharply defined spherical shadow, is very significant of hydatid cyst. If the symptoms do not accurately lit in with those of tuberculosis, we should think of a malignant growth, especiahy if the patient is expectorating reddish fruit-juice sputum. Sometimes cancer can be recognized bv particles of tissue in the expectoration. Malignant disease of the lung is more likely to be carcinoma than sarcoma,. but even carcinoma is quite rare. According to Schwalbe, the presence of stridor is in favour of sarcoma, and its absence suggests carcinoma. In sarcoma, the bronchial glands undergo more enlargement than in carcinoma. The accompanying illustrations of secondary cancerous nodules in the lungs show how clearly tumour areas can be marked out by means of X-rays. It is of interest to note the occurrence of lympho-sarcoma of the lungs in miners, who inhale arsenic-containing dust. CHAPTER XXXI. SWELLINGS AND TUMOURS OF THE THORAX. Swellings and tumours on the surface of the chest origmate fron> one of the thoracic viscera, usually the lung or pleura, or from the chest wall Itself. It is important to arrive at some decision on this fundamental pomt before making a physical examination, and this can be done by obtaining a careful chnical history. .4.— PRIMARY DISEASE WITH IX THE THORAX. If the appearance of a tumour on the chest wall is the final episode of a long history of illness, which began with an irritating cough with- out expectoration, dyspnoea and hoarseness, and which was followed by disorders of the circulation, we must think of a lung or mediastinal tumour, an aneurism or of some inflammatory condition. SWELLINGS AND TUMOURS OF THE THORAX 209 We must think of the possibility of aneurism because an explora- tory puncture, thoughtlessly undertaken, may place us in a very awkward predicament. We have already dealt with the important points which concern tumours of the mediastinum and of the lung. A swelling appearing in the thorax after a disease which began wxih iiifiainuiaiory syinptouis — either of an acute character like pneu- monia, or of a chronic character like a slow pleurisy — is suspicious of a pleural empvema which has made its way to the surface, a so-called " empyema of necessity." Nowadays we lay more stress on the " necessity " of operative treatment before the pus has become subcutaneous. We will give three typical cases illustrating the most important forms : — (i) The empyema which has burst through may be of an acute infective variety. A middle-aged man suffered from a circumscribed pneumonia, with which signs of pleurisy were associated. A diffuse, phlegmonous, rapidly extending swelling at the back indicated the urgency of surgical aid. Examination showed that there was an effusion into the left pleural cavity with a phlegmonous swelling of the soft parts on the corresponding thoracic wall. Diagnosis: ruptured empyema. This was confirmed by operation. The rupture was due to a cause which is in no way unique. Two days beforehand the pleura was punctured for bacteriological diagnosis, and evidently this afforded an opportunity for the introduction of infection from the soft parts along the puncture wound. This is a lesson that in acute cases opera- tion should immediately follow puncture, should pus be discovered. (2) Another variety is of tubercular origin. A young man, whose previous history pointed to tubercle, com- plained about the gradual development of a painless swelling, about the size of a goose's egg, immediatelv to the right of the sternum. The swelling could not be displaced, and it did not undergo any change in volume with respiration, indicating some connection with the interior of the chest. But there were definite evidences of tuber- cular disease over the right upper lobe of the lung, which led to the conclusion that there was some direct connection between the two conditions. Operation showed that the superficial abscess was in direct connection with an encapsuled collection of pus within the thorax. If the tumour could have been displaced our diagnosis would have been better founded. This symptom was absent because the intra- pleural collection of pus was quite small in circumference, and was bounded by firm and indurated tissue. If a cavity ruptures externally the swelling will evidently contain gas. There is always some secondary infection in a cavity, and this confers acute inflammatory characters upon the abscess, as happens when a purely tubercular collection of pus breaks through. 210 SURGICAL DISEASES OF THE THORAX We shall subsequently enter into the details of differential diagnosis between a tubercular empyema which has burst through, and tuberculosis of the ribs. (3) The third possibility is illustrated by the following case : — A young girl, suffering from symptoms of chronic pleurisy, was admitted to the hospital with a bilateral effusion. The needle met with pus on the left side, but not on the right. Resection of the ribs, on the left side, was performed. The chronic course of the disease and the curious appearance of the pus suggested tubercle at first; but the pus really contained filaments similar to actinomvces, without granules. After a little while a swelling appeared in the anterior axillary line parallel with the ribs. At the periphery it was board-like in consistence, without any reddening of the skin, whereas in the middle it was soft and red. Even without the bacteriological examination of the left side these appearances would have strongly suggested actinomycosis. As a matter of fact, the pus from the right side contained the characteristic granules in large amount. Here, as in all cases of pulmonary actinomycosis, the first thought was of tubercle. This rare disease can only be identified by the discovery of the actinomycotic filaments or the characteristic granules in the sputum or pus, unless the board-like infiltration pre- viously described, which indicates that the process has reached the surface, betrays the correct diagnosis to the experienced eye. L'.— PRIMARY DISEASE OF THE THORACIC WALL. If nothing in the history or physical examination points to disease of the thoracic viscera, we must assume that the structure under investigation arises from the boiiv ivall of tlic cJicst or from its integuuieiils. We are not here concerned, however, with tumours of the mammary glands, as these are dealt with in a separate chapter. (1) ACUTE DISEASES. Acute sivelliiigs need not detain us long, as they rarely occur on the chest. The principal one is acute osteomyelitis of the scapula or clavicle, which can hardly be mistaken for anything else. The sudden onset with rigors and high temperature indicate the nature of the disease, and the bone affected is shown by the position of the swelling and the pain on pressure. An acute osteomyelitis of a rib, which is very rare, might be mistaken for an empyema which has broken through, but in the latter case the distinctive antecedent symptoms would not have been present. Phlegmonous processes are not of rare occurrence in the vicinity of the axilla. They generally originate in lyiiipJiaiic glands, the infec- tion being introduced from the periphery. The experienced observer SWELLINGS AND TUMOURS OF THE THORAX 211 will at once examine the fingers, and look on each one for some lesion, however insignificant. Sometimes red streaks of lymphangitis lead towards the original wound. Frequently the wound is already healed by the time an abscess has developed in the axilla. Occasionally very deep axillary abscesses form, as a result of ^iciite pustules and funuides which are not infrequent in this region. Purulent inflammation of the siveat ghinds (hydro-adenitis) should also be mentioned. Finally, a phlegmon may develop under the pectorals, tracking towards the axilla, and it may be cpiite impossible, despite the most careful examination, to trace the entrance of the infection. (2) CHRONIC DISEASES. In a gradiiaUx developing swelling our first endeavour is to decide whether it is inflammatory or a new grow'th. As cystic tumours, apart from those of the breast, occur very rarely on the thorax, fiuid contents point to pus. The only difficulty is to be sure of the fluid, because it is not always easy to differentiate the fluctuation of fluid in small tumours from the soft elastic consistence of a lipoma, for example. The beginner is apt to confuse fluctuation with this soft elasticity, even in the case of larger tumours. When in doubt as between a lipoma and an abscess, one should remember that a lipoma is characterized by a lobulated structure and numerous slight puckerings of the skin, whereas the skin over an abscess is quite smooth. The doubt can at once be solved by a puncture, but this should be left to the end of the examirjation if it is indispensable. If ■suppuration has not yet occurred an inflammatory origin would be indicated by spontaneous pain and tenderness on pressure. (a) Chronic Inflammatory Processes. Tnbei-ciilosis and sxpJiilis are, with few exceptions, the principal causes of chronic inflammatory conditions on the thorax, whether the swelling be non-suppurative or whether it be an abscess. The inflammation may start in one of three tissues, viz., lyniphalic glands, muscles, or bones. Chronic inflammatory processes starting in the lyinpluilic glands are of a tubercular nature. They are situated in the neighbourhood of the axilla — ^sometimes in front in the infra-clavicular fossa, some- times below, between the anterior and posterior axillary line, and sometimes behind, under the scapula. The infra-clavicular glands cannot as a rule be felt separately, like the cervical glands, because thev are situated under a thick laver of muscle. When they are 212 SURGICAL DISEASES OF THE THORAX diseased they present the appearance of a diffuse sweUing of the deeper tissues, firm at first, but eventually declaring itself as an abscess which reaches the surface. But tubercular glands in the axilla feel exactly like those in the neck, and are therefore easily recognizable. The axillary glands are, however, rarely aft'ected alone. The cervical glands are, as a rule, also involved. As in the case of the neck, there is also here the liability of confusing tubercle with malignant lymphoma ; but we have already referred to the dift'erential diagnosis in discussing tumours of the neck. If an inflammatory area is situated within a muscle, the condition is usually fnberciilai', und rarely guminatoiis. It manifests itself as a painful hard little tumour^ and its intra - muscular situation is easily recog- nized by the fact that it is freely movable when the muscle is relaxed, and is quite fixed when the muscle is contracted. But most of these inflammatory processes arise from the bones, and all the bones of the thorax and shoulder girdle participate therein ; the clavicle is, however, rarely at fault. There is one important distinction in regard to disease of these various bones, for, whereas disease of the superficial bones, like the ribs, sternum, and parts of the shoulder blade, may be recognized in the earliest stage before an abscess develops, spinal caries is only diagnosed after an abscess has formed, unless attention has been directed to the matter by functional disturbances. In these cases the abscess has often tracked a considerable way before reaching the surface. A swelling of the clavicle of gradual origin should at once suggest malignant new growth, because tubercle and gumma are of very rare occurrence there. If no other new growth is discoverable we must regard it as a primary sarcoma. But microscopic examination will often surprise us, and indicate that a primary carcinoma is concealed Fig. 117. — Tubercle of the sternum. SWELLINGS AND TUMOURS OF THE THORAX 21^ somewhere. Cdiicer of the thyroid, breast, or prostate should suggest themselves, because their secondary deposits preferably affect the bones ; but tumours of other glandular organs, such as the gastro- intestinal tract, should also be thought of. If there gradually form over a rib a spindle-shaped swelling, rather painless in itself, but still sensitive on pressure, we should at once think of tubercle, but even here an error is possible. Sometimes a gumma of the periosteum of the rib may have features very similar to tubercle. Primary disease of the marrow (as shown by skiagram) points lo tubercle ; primary perios- titis is not decisive. A young man was admitted to the hospital with a spindle-shaped, somewhat sensitive swell- ing at the junction of the fourth rib and cartilage. The case had been dia- gnosed as tubercle, and the patient had been treated with iodoform injections. An aftirma- tive answer was given to the question whether he had suffered from ixplioid fever, and he added that the swelling started a few weeks after his recovery therefrom. It is quite conceiv- able that typhoid fever may excite tubercular disease when a predis- position exists towards it — I have seen this in lymphoma of the neck. But such an assump- tion was out of the question in this case. We know that post-typhoid osteitis and chondritis of the ribs represent a special type of disease, with a very chronic course. Sometimes recovery occurs spontane- ously, sometimes only after the extrusion or operative removal of a bony or cartilaginous sequestrum. On the stcniiiiii the diagnosis lies between tubercle (fig. 117) and gumma, but we should also think of malignant new growth as long as no suppurative softening of the tumour has occurred. The differential diagnosis is, however, difficult, and Kiister has removed a large gumma in mistake for a sarcoma. In doubtful cases a Wasser- FiG. 118. — Thoracic wall, perforated by aneurism of ascending aorta. 2 14 SURGICAL DISEASES OF THE THORAX man 11 test ought to be undertaken, and a trial made with specific treatment before operating. The constitution of the pus brought away by the syringe may afford some information, before the bacteriological examination is made. Flakv, verv liquid pus points to tubercle, viscous mucoid pus points to gumma, but this rule is not always maintained. On one occasion I saw a young man, who had a tubercular family history, with a swelling over the manubrium sterni. There was no evidence of acquired syphilis, and hereditary infection was im- probable. The pus ob- tained bv the syringe was brownish, viscous, and mucoid. Xevertlieless the guinea-pig which was in- oculated became tubercu- lous and the treatment by potassium iodide which had been started was quite ineffectual. Swellings of gradual orio'in on the shoiihlcj- blade Fig. 119. — Pigmented nreviis of the lumbar region, with partial sarcomatous degeneration. Fig. 120. — Fibro-sarcoma of the skin of the back. are usually tubercular or sarcomatous. In the early stages there mav be some serious difficulty, because adjoining the hard places are to be found soft portions, which resemble abscesses, a circum- stance which also occurs with tumours. But when suppuration takes place in tubercle it becomes evident, in a short time, and often becomes quite extensive ; so that in every case where the diagnosis is doubtful we must suspect sarcoma and treat accordingly. Anvhow, an earlv exploratory incision allows radical measures to be SWELLINGS AND TUMOURS OF THE THORAX 215 undertaken in a case of tubercle, and offers the only prospect of cure in sarcoma. A history of injury is of no special value either for the one or the other diagnosis, because an injury may excite either tubercle or sarcoma. The following is an example of the former. A young lad was for a long time engaged in unloading very heavy cement pipes, which he always carried on his right shoulder. After about two months a swelling appeared over the supraspinous fossa, and a number of abscesses developed which clearly contained tuber- \ Fig. 121. — Unilateral lipoma of the back. Fig. 122. — Symmetrical lipomata of the shoulders and loins. cular pus. It is difficult in a case like this to avoid considering the persistent trauma to be the opportune cause of the tubercular attack. But, of course, this does not mean that the tubercle was the " con- sequence of the injury," in the legal sense. If a cold abscess on the back appears to have no relation either with a rib or the shoulder blade, it probably arises from a vertebra — from the transverse process, vertebral arch or spinous process. The behaviour of these abscesses gives rise to many interesting 2l6 SURGICAL DISEASES OF THE THORAX problems of diagnosis, although they may have little connection with the origin of these abscesses. A burrowing abscess, after bursting through layer upon layer, from its deep origin, may spread widely over the surface. The superficial position of an abscess is, therefore, no argument against its origin from bone. But if we are able to demonstrate the deep origin of an abscess, we shall be all the more decided in our search for the diseased bone which gave rise to it. An abscess above the fascia is always more prominent because the contrac- tion of the underlying muscle gives it a firm base. If the pus is situated within or under the muscle, the shape of the abscess is obliterated by mus- cular contraction, and in the intra- muscular position the abscess which is movable together with the muscle is itself immovable over the muscle. The classical signs of spinal caries (which see) are of much more impor- tance for its diagnosis than the variable behaviour of the abscesses to which it may give rise. These signs are mus- cular fixation of the spine (rigidity), pain on axial pressure — not always — curvature, and local sensitiveness to pressure. The last S3'mptom is the one chiefly present in tubercle of the pos- terior portion of the vertebra, which is concerning us just now, the pain on pressure being manifest on the affected spinal process. But this sign is only of value if the sensitive spine is not con- tiguous with the wall of the abscess, but lies above it. In the absence of any sign of spinal caries, we cannot decide whether the disease arises from the vertebra or from the posterior seg- ment of a rib, unless a skiagram clears the matter up. But if this also leaves us in the lurch we must con- clude in favour of the more frequent occurrence, i.e., spinal caries. Fig. 123. — Fibro-lipoma of the muscles of the back. (b) Tumours. We now proceed to those morbid structures which are recognized as tumours, without any qualification. The innocent tumours on the skin are sebaceous cysts, angiomata and fibromata, the last in the form of soft warts. The ordinary SWELLINGS AND TUMOURS OF THE THORAX 217 rules are applicable to their diagnosis (fig. 124). Sarcomata of the skin usually start in pigmented or in non-pigmented warts (fig. 119). The chief signs of malignancy are sudden rapidity of growth, harden- ing of consistence, and bleeding on slight provocation. Every tumour of the skin which has not existed for a long time and which feels hard should be suspected of malignancy. Rarely, slowly growing sarcomata occur on the skin, and then "they may be more or less pendulous (fig. 120), but never so much as lipomata. Their firm con- sistence, from the begin- ning, excludes all doubt. Lipomata, which are so frequent on the back (fig. 121), have their seat of origin in the subcuta- neous fat. They are at once identified by their lobulated form and by the slight puckering of the overlying skin. There is no difficulty in dis- tinguishing them from cold abscesses. The back, just like the neck, may present symmetrical lipomata (tig. 122) as well as the more usual unilateral variety. They are gene- rally associated with a development of multiple lipomata over the whole body, and constitute a feature of so-called Der- cum's disease (see neck). Tubercular abscesses of the scapula often imi- tate perfectly the usual lipomata of the back, and are easily mistaken for them. They may be even more easily confused with the rare cystic lymphangiomata of the subcutaneous tissue. The latter, which are always of congenital origin, although they may not appear until later in life, often occur in the vicinity of the axilla. They feel soft like lipomata, but in some parts, where comparatively large cysts are present, there may be genuine fluctuation. But they are distinguished from lipomata by the fact that they are not clearly defined from the surface on which they rest, as they send processes downwards between Fig. 124. — Multiple fibromata of the skin in a woman. One situated on the perinreum looks like a scrotum. Under the right scapula there is a deeply- placed neuro-fibroma. 2l8 ; SURGICAL DISEASES OF THE THORAX the muscles. Sometimes the overlying skin is so thin that the whole structure is almost transparent, like a hydrocele over which the skin is made tense. If there is any doubt about the relations of a tumour of the sub- cutaneous tissue to the deeper parts it is only necessary to make the muscle beneath contract in order to see whether the tumour is held fast bv this action or not. Tumours may also arise from the nuisdes or fascia'. They are mostlv sarcomata, and more rarely fibromata or lipomata. One example will suffice. A little boy had on his back, near the spine, a flat, long, oval tumour (fig. 123) with a lobular outline which suggested a lipoma. But it did not actually lie in the skin, which could be easily picked up over it. On the other hand, it was not connected with the bone, because it was quite movable over it. The tumour was held fast on muscular contraction, showing that it was connected with the muscles. The aponeurosis became very definitely tense over it when the muscles contracted. It was so well circumscribed that no suggestion of an infiltrating malignant growth could be entertained. Its cake- like flatness pointed to an innocent growth, and this view was more consistent with the anatomical conditions, especially the pressure of the fascia, than would be the idea of a sarcoma. The diagnosis, therefore, appeared to be : sub-aponeurotic or intra-muscular lipoma or fibroma. As a matter of fact, it was a lipoma rich in connective tissue, which had been flattened out between the muscle and aponeurosis. If a tumour is not movable over the bone, it has either arisen therefrom or become adherent to it secondarily. We assume the former if this immovability has been noted early or from the very beginning. Primarv tumours of the bone are either enchondromata or sarco- mata ; and much more rarely osteomata. Histologically, the former are innocent, but their clinical behaviour manifests all transitions to pronounced malignancy. They appear as round protuberant growths, and are distinguished by the enormous circumference which they may attain. Sarcomata may also reach to a considerable circum- ference. It is important to know whether the growths extend into the chest, and how far. These tumours often resemble icebergs in the respect that the portion visible is the smallest part of their mass. Auscultation and percussion may yield definite information on this point. But a skiagram is more conclusive, and one ought to be taken before venturing upon any rash removal of such a growth. Finally, if we find in the middle line of the back a tumour only slightly movable over the spine, we should at once think of spina bifida and its sequelae, which we will refer to later on in detail. INFLAMMATORY DISEASES OF THE BREAST 219 CHAPTER XXXII. INFLAMMATORY DISEASES OF THE BREAST. Everyone feels capable of diagnosing such a superficial and easily recognizable disease as mastitis. Nevertheless it is sometimes mistaken for cancer — not only tubercular mastitis, but even the ordinary acute infective condition. The following considerations should, however, prevent error : — (i) Tumours rarely occur before 20, and they are not very frequent between 20 and 30. On the other hand, inflammatory conditions are rare after 50. I have, however, opened a large retro-mammary abscess, diagnosed as a new growth, in a woman of 60. The breast stood forth in a semi-spherical shape, and the swelling felt hard like a growth, because the abscess was behind the gland. Even intra-ixiammary subacute abscesses in old women are mistaken for carcinomata, an instance of which is depicted in fig. 126. The patient was 49 years of age, and the swelling in the breast was onl}^ slightly tender on pressure ; but the oedematous indurated condition of the skin over it enabled a diagnosis to be made quite easily. (2) An association with the puerperal period is of special importance for the diagnosis, because this always points to inflammation, notwith- standing the slow progress of the swelling and the absence of fever. A case was referred to me, with an induration in the breast, which came on gradually several months after the patient had recovered from puerperal mastitis. It was considered to be suspicious of carcinoma, but a small incision cleared up the matter, by the appearance of a small amount of staphylococcic pus. In these atypical cases of mastitis sugar is sometimes found in the urine. (3) On the other hand, it must be remembered that a rapidly growing malignant tumour with extensive destruction of tissue may cause oedema and redness of the skin before ulceration or bacterial invasion occurs, and this may lead to errors of diagnosis. But in these cases the history will usually show that a growth, independent of the skin, was present for some time before the inflammatory symptoms. (1) ACUTE INFLAMMATIONS. We will now consider the various forms of mastitis, beginning with the acute forms. [a) The inflammation of the breast which occurs in infancy or at puberty, but sometimes also in the intervening period, in both sexes, and which very rarely suppurates, presents no difficulty in diagnosis The gland feels like a hard round plate which is movable over 15 220 SURGICAL DISEASES OE THE THORAX the underlying muscle. It is very painful at first, and may remain tender for a long time after the subsidence of the acute symptoms. This persistence of pain caused me to shell out the breast of a young man, at his urgent^request, retaining the integument of skin and the nipple — an operation^ which is not justifiable in a female. An [EiG. 125. — Abscess in the outer half of the left breast. Retraction, but no elevation of the nipple. irritable condition of breast in girls at puberty has been attributed to masturbation — whether with justice remains doubtful — and this must not be confused with a bacterial inflammation. (b) Puerperal mastitis is the type of acute infiainination of ilie breast, and in its classical form is incapable of leading to an error in INFLAMMATORY DiSEASfiS OF THE BRf-AST 221 diagnosis. A mistake can only arise, as previously mentioned, when the onset of the inflammation is delayed until months after the confinement, and does not occur within the first few w^eeks as is generally the case. But in such a case there will have been slight inflammatory attacks soon after the confinement. The condition previously termed stagnation of milk is now^ known to be a mild infective process taking place, either in the milk congested within the ducts and their ramifications, or, as is more usual, in the connective tissue. It is important to recognize the degree of the inflammation and the site of the suppuration for the purpose of treatment. If the tempera- ture subsides after the initial rigor and the pain ceases after a few davs, suppuration is improbable. But if slight fever persists, and if a soft area, however small, appears in the middle of the infiltrated segment of the breast, it is quite certain that pus is present. As far as the position of the pus is concerned, we must distinguish between abscesses in front of, ///, and behind the breast. The superficial, purely subcutaneous abscesses are usually situated in the vicinity of the areola and arise from a circumscribed superficial lymphangitis. There is no difficulty about their diagnosis. Abscesses within the parenchyma appear at first as more or less w^ell defined firm nodules, over which the skin is still normal. If spontaneous resolution does not occur, the skin becomes immovable, cedematous, and finally reddened, a soft area developing in the middle of the hard portion. If the abscess is not opened at this juncture it spreads further under the skin and pronounced fluctuation can be detected. Deep, retro-mammary abscesses arise from deep intra-mammary foci, which take the nearest course and spread towards the loose connective tissue behind the breast. The whole gland may be dift'usely tender, but sometimes there is a complete absence of pain and the diagnosis must be based on apparent enlargement of the breast, due to its abnormal prominence, (c) An acute mastitis may occur at any age without the above mentioned causes, through infection of a nipple which has been mechanically irritated, but this is rare. (2) CHRONIC INFLAMMATIONS. These are generally due to tubercle, rarely to gumma or actino- mycosis. But one may repeat here what was said at the beginning of the chapter, that the sub-acute or chronic staphylococcic or strepto- mycotic infections also occur. {a) Tuberculosis of the breast may appear as an isolated nodule 222 SURGICAL DISEASES OF THE THORAX and thus be mistaken for carcinoma. But the presence of other tubercular stigmata, and enlarged glands in the axilla, which rapidly become adherent to the skin and soften, would be strongly suggestive of tubercle. The diagnosis is easier if several tubercular foci are present in the breast, and especially if some of these foci have softened in places, contracted adhesions to the skin, which has become reddened and broken down (fig. 126). In the latter case the diagnosis can be confirmed by bacteriological examination of the pus and histological investigation of a piece of the granulation tissue. It does not always follow that a cold abscess behind or near the breast really originates therein. As a matter of fact, it more frequently arises from a rib. If the lesion of the rib is not directly accessible to examination we must depend upon the absence of any change in the breast itself to sug- gest caries of the rib. The final ver- dict must, however, rest with a skia- gram, which may often reveal the le- sion of the rib quite distinctly. (6) Tuberculosis of the breast is some- what similar to ac- tinomycosis, a few cases of which have been recorded. In the latter, however, the glands are not enlarged, and the hard infiltration is very distinctive. If an abscess or a sinus be present we must search for the character- istic granules. The diagnosis of gumma of the breast can only be arrived at by exclusion ; and is confirmed by the previous history, the serum test, and the result of specific treatment. Very rarely, chronic inflammatory processes which do not suppurate, and which cannot be referred to any of the causes just mentioned, occur in the breast. Chronic cystic mastitis, which we will discuss in connection with tumours, is not of inflammatory origin. Fig. 126. — Tuberculosis of breast. TUMOURS AND ALLIED STRUCTURES IX THE BREAST 22 ^ CHAPTER XXXIII. TUMOURS AND ALLIED STRUCTURES IN THE BREAST. The breast, like other glandular organs, is often the seat of structures which are not genuine tumours, but which are not sharplv differentiated from them. They have nothing to do with bacterial mflammation. As the epithelium and connective tissue are both concerned in these processes they are best designated by the general term of libro-epithelial degeneration. Examples of this morbid process occur in the thyroid as goitre, and in the prostate as hyper- trophy. In the breast the following types mav be differentiated : — ■ (a) Preponderating cyst formation, either as a solitary cyst or as a con- glomeration of small cysts (Reclus' or Konig's disease). {b) Preponderating proliferation of the connective tissue ; formation of so-called fibro-adenoma phvllodes. (c) Preponderating proliferation of the epithelium: Fibro-adenomata of purely adenomatous or of papillary character. All these changes may occur, either in a diffuse form or as circumscribed encapsuled tumours. They may occur as single or as multiple nodules, and are frequently present in both breasts. Sometimes all the various types are combined in one growth ; at others, nodules which have arisen at the same time in both breasts may manifest quite different characters. Very fre- quently, as one might expect, cancerous or sarcomatous degeneration occurs. We have digressed somewhat into these pathological details, but in view of the existing controversy on the matter this was not superfluous. We will now proceed with the diagnosis proper of tumours of the breast. If we have decided that a sw^elling of the breast is not of inflam- matory or infective origin, and therefore regard it as the result of fibro-epitJielial degeneration, or as a genuine neiv groivth, we are met with the great question of innocence or malignancy — in other words, is the case one for immediate operation, or is it one wherein the advisability of operation may be discussed with the patient ? The precise histology of the disease is of very secondary importance in comparison with this question of innocence or malignancy. The first point to ascertain is whether the tumour is single or multiple. Fig. 127. — Superficial cyst of the breast. 224 SURGICAL DISEASES OF THE THORAX ^.—MULTIPLE TUMOURS. If the tumours have arisen in both breasts about the same time, or if there are several in the same breast, we may conclude with great probability that they represent the innocent process of fibro-epithelial degeneration. But in order to establish the diagnosis they must possess the characteristics to be described in the following section. It is, however, quite possible for one nodule of an originally innocent fibro-adenoma to become cancerous, or cancer may suddenly burst forth in any old harmless fibro-adenoma. Unfortunately, both patients and practitioners are liable to forget this possibility, and many hesi- tate to make the diagnosis of cancer because some old cysts are present, either on the same or the opposite breast. R— SINGLE TUMOURS. We will divide these ac- cording to their size, because the questions which arise in regard to them vary accord- ing to their dimensions. (1) SMALL AND MEDIUM- SIZED TUMOURS. We begin with suiall and iiiediuiii -sized tumours, i.e., those which do not exceed a fist in size. The fundamental sign which after a little palpation almost always differentiates between innocence and ma- lignancy is the movahility of the tumour in relatiou to the rest of the breast tissue. A certain amount of practice is required to estimate this mobility correctly, but it can be acquired by the attentive examination of a few cases. An index finger is placed on each of two points on opposite sides of the tumour, which is jerked backwards and forwards between them, a shaking movement being imparted to it at the same time. If the tumour yields easily to this manoeuvre it is innocent If this mobility is absent it is practically conclusive of malignancy, even if the growth is not adherent to the skin or to the pectoral Fig. 128. — Polycybtic fibro-adenoma. TUMOURS AND ALLIED STRUCTURES IN THE BREAST 225 fascia, and the nipple does not yet show any indication of being drawn in. Only an inflammatory attack can temporarily deprive an innocent tumour (cyst) of its mobility. If pressure is made on the tumour with the hand flat upon the chest it is less distinctly felt if it IS a cyst, whereas if it is cancer it is more distinctly felt. Whenever I was in doubt about the degree of mobility, I generally found at the operation that the tumour was malignant. Our decision must never be influenced by the patient. Every surgeon knows of cases wherein the apprehensive patient considered her harmless cyst to be a cancer, and also of cases wherein a Fig. 129.— Early scirrhus. Nipple drawn up and slightly "retracted. "hardening" of the breast has been shown casually to the medical attendant, when it had already reached the limits of cure by operation. (a) Having decided from the above considerations that the tumour is innocent, we may now proceed to determine to which of the fore- going anatomico-pathological groups it should be ascribed. If the breast is diffusely indurated over a large extent, that is to say, if it has become converted into a conglomeration of small hard movable nodules, the case is one of the formation of numerous little cvsts. Single nodules up to the size of a goose's egg are either cucapsuled 226 SURGICAL DISEASES OF THE THORAX fihro-adenouiata or solitary cysts. As the latter do not show any fluctuation owing to their extreme tension, the clinical differentiation is often impossible. Cysts are usually indicated by variation in volume, by increase in size and by pains during menstruation or at the onset of pregnancv, and bv the discharge of milky fluid from the nipple. Fig. 130.— Advanced scinhus with retraction and elevation of nipple and diminution in size of its areola. A brownish or sanious secretion especially signifies a papillary cyst, or an adeno-papilloma developed within a cyst, which stands just on the border line of malignancy (so-called "bleeding breast," see below). Superficial cysts have a bluish transparency and fluctuation is often present (fig. 127). If the nodule exceeds a oose's egg in size the case is not one of TUMOURS AND ALLIED STRUCTURES IN THE BREAST 227 a solitary cyst, but is some form of encapsuled fibro-adenoma, or the whole breast mav have become changed into a mass of multiple cysts (fig- 128). We have hitherto regarded the fact that a tumour is freely movable over the rest of the breast tissue as a positive sign of* innocence. Fig. 131. — Cancer of breast, slightly contracting, situated at the periphery. Elevation and retraction of nipple, diminution of areola. But, unfortunately, there are exceptions. A primary cancer occa- sionally remains quite movable for a long time ; but the history is distinctive in such a case. If the tumour has only been present a matter of months it is probably cancer ; if for a year or more 228 SURGICAL DISEASES OF THE THORAX it is a jfibro-adenoina. Further, fibro-adenomata not rarely undergo cancerous change, and this alteration is not signified by any recog- nizable clinical symptom. For this reason we should propose to the patient the removal of any circumscribed tumour, however innocent it may appear to be. If she agrees, the growth is removed while the conditions are healthy, or better still the whole breast is shelled out. The excision of a small piece of a mammary tumour for diagnosis is of no value, for the piece removed may happen to come from a portion which is harmless, whereas a cancerous portion may still be present. The following case indicates the difficulty of diagnosis : — A person, aged 50, noticed a small movable lump in each breast. They both felt alike, were diagnosed as cysts and removed. Histo- logical examination showed that the tumour on the right side was an early fibro-adenoma, and that the one on the left side was an innocent Fig. 132.— Ulcerated cancer of right breast in patient aged 65. Apparently a cutaneous cancer of the areola (with ulceration above and to inner side of nipple), but really a con- tracting cancer of the breast with elevation of nipple and diminution of the areola. cyst. The latter preparation was, however, examined again some years later, and a circumscribed, classical infiltrating carcinoma a few millimetres in size was noted close to the cyst. Meanwhile, enlarged glands appeared in both axillae, and after their removal it was shown that they were — tubercular. The patient came from a tubercular stock. (b) If the tumour is only slightly movable or quite immovable over the rest of the breast tissue, our diagnosis must be a malignant growth, especially a carcinoma, even if the ordinary criteria of this disease are absent, viz., retraction and elevation of the nipple, enlarged TUMOURS AND ALLIED STRUCTURES IX THE BREAST 229 glands in the axilla, and adhesions to the skin and pectoral muscles. All these signs eventually make their appearance, but the practi- tioner who awaits them before making a diagnosis is in no enviable position. Retraction of tlie nipple is an early sign only in the contracting forms of cancer ; but it sometimes occurs in chronic cystic mastitis and even in chronic abscesses. The diminution of tlie areola around the nipple is much more distinctive of cancer (fig. 130), and the elevation of the nipple is of great significance (figs. 128 to 132) because it indicates a process of contraction and points r ^ --'•=«•«'»:) to cancer, even if the i . x,- & nipple itself is scarcely ' '™"™™" ' retracted at all (fig. 129). Enlargement of the axillary glands occurs in some slight degree even in the case of innocent cysts, and nearly always in tubercular disease. Tubercular glands are usually softer than the malignant variety and break through the skin sooner. Sarcoma attacks the glands much more rarely than carcinoma. The difficulty of detect- ing early cancerous en- largement of the glands, in fat women, is fre- quently realized first at the operation. But the demonstration of cancer- ous glands lias a prognostic rather than a diagnostic importance ; cancer of ttic breast can and must be recognized icitiiout ttieni. Exceptionally, the enlargement of the glands dominates the whole clinical picture and the cancer itself is overlooked. Thus, a patient, aged 47, was treated for eighteen months for enlarged moveable glands in the left axilla, which, according to the family history, might have been tubercular. This diagnosis was apparently supported by the occurrence of similar glands in the right side of the neck. Careful examination, however, showed that there was on the left side a very slight induration behind the nipple, which had hitherto been Fig. 133. — Small contracting cancer in the fold under the breast. 2^0 SURGICAL DISEASES OF THE THORAX overlooked. Histological examination of the breast and glands confirmed the diagnosis of cancer. Adhesion to the pectoral muscles is recognized by the fact that the tumour is movable when the muscle is relaxed, and that it appears to be immovable when the muscle is contracted. n Fig. 134. — A rapidly breaking-down cancer of breast. The whole tumour converted into an ulcer. We have not yet said anything about jilccration, because this does not afford any fresh material for diagnosis. It occurs in those forms which have a tendency to rapid destruction and wherein the whole tumour resembles an ulcer (fig. 134), and also in the scirrhous variety wherein the skin is soon involved, especially when situated TUMOURS AND ALLIED STRUCTURES IN THE BREAST 231 near the nipple (tig. 132) or in the fold of skin at the lower border of the breast (fig. 133). Finally, almost every form of carcinoma will naturally ulcerate, if left long enough. The small contracting cancers of the nipple (fig. 132) and those which occur in the fold of skin under the breast (tig. 133) represent typical forms. Their early ulceration and their whole appearance lead the beginner to the diagnosis of cancroid. Thev are really cancers of the breast with portions deeply situated, and on palpa- tion they are recognized to be much larger than their superficial appearance suggests. If an eczematous condition of the nipple and its vicinity has pre- ceded the development of the tumour we diagnose the well-known form of cancer, termed Paget's disease. Every obstinate eczema in this region must be suspected, although there may be no tumour present. The only constant sign of cancer common to all forms is its slight iiiobilifv oil file healthy breast. All the other char- acteristics are variable, and there are numerous transitions from the soft medullary cancer rich in cells, which frequentlv attains the size of a fist and more (tig. 135), to the contracting scirrhus, poor in cells, which con- stitutes a loss of tissue, although it is actually a growth (figs. 1 29 and 1 30). ^ Having decided upon the diagnosis of cancer, the matter of accurate prognosis claims our attention. If secondary growths are found further discussion is useless. In this connection the vertebral column should be thought of, and it is worth while examining the breast in cases of unexplained sciatica or intercostal neuralgia. A patient was undergoing electrical treatment for several months by a neurologist for lumbar neuralgia. Notwithstanding the sparks, there was no illumination of the breast until the cancer therein became an inoperable scirrhus, which was accidentally discovered by the family practitioner. Paraplegia soon set in. Fig. 135. — Medullary cancer of breast. 23' SURGICAL DISEASES OF THE THORAX There are three other signs which exclude the possibiHty of a complete recovery, and these must be considered before any advice is offered: (i) cidlicsiou to ilic ribs; {2') the presence of scaitcrcd cancerous nodules in the surrounding skin (fig. 136); and (3) involve- ment of the supra-clavicular glands. If there are any indications for an operation in these circumstances it can only be one for relief of local symptoms. We have hitherto limited our discussion of malignant growths to cancer, and have said nothing about sarcomata. If these are of an infiltrating type from the commencement they are indistinguish- able clinically from a medullary cancer. All that we have said about the latter applies to this form of sarcoma, with the exception of the involve- ment of the lymphatic glands. Encapsuled sarco- mata, as long as they do not exceed a list in size, are only distinguishable from hbro-adenomata by their more rapid gro^vth. The diagnosis of sarcoma is of more importance in regard to the larger tu- mours of the breast, to which we will now turn. P'iG. 136. — Coniracling cancer of breast, with numer- ous cancerous nodules in the surrounding skin. (2) LARGE TUMOURS. A huge new gfowth of the breast niav be merely an example of hypertrophy (giant groictli), and then it is usually bilateral. Apart from this we have to distingui-h those that belong to the class of fibro-adenomata on the one hand — i.e., fibro-adenonna or cysto- adenoma and cysto-sarcoma phvllodes — from true sarcomata on the other hand. Xotwith>tanding the modern zeal for operation both classes are still responsible for cnoi-nioiis tumours. Thus a patient allowed lier tumour (tig. 137) to attain the weight of 5^ kilos and to become extensivelv putrefied in the course ot a year during which she was under "nature treatment." That the patient eventuallv became intensely cachectic was not a matter ot surprise considering the amount of putrefaction and the dietetic re- strictions which she underwent. Nor was it at all surprising that the TUMOURS AND ALLIED STRUCTURES IN THE BREAST " nature-curer " claimed the credit for the rehef which the operation gave. At the operation the growth was still well encapsuled, and histologically it was composed of a typical fibro-adenoma with some partial sarcomatous degeneration of the stroma. Two years after- wards the patient succumbed to multiple metastases, which consisted histologically of pure spindle-celled sarcomata. Fibro-adenomata or cysto-adenomata phyllodes, as well as the sarcomatous degeneration of the latter, known as cysto-sarcomata phyllodes, are well encapsuled tumours, which only ulcerate if the skin over them becomes tightly stretched. Metastases occur in the sarcomatous form, but more rarely than in the case of piiniarv sarcoma of the breast. The latter are either encapsuled or inHltrating, and occur under the most varied histological forms. Cystic formation also takes place in these cases, but not as the product of epithelial structures as in cysto-sar- coma proper, but as the result of tissue necrosis. If the tumour shows no infiltrating growth the differential diagnosis must be based on the history. If it has been present for a year or more, and has been growing regularlv or bv fits and starts, the tumour is a fibro-aden- oma. The sudden rapid growth of a tumour which has been quiet for years indicates sarco- matous degeneration. A tumour of wide extent, despite short duration, is a pi-imarv s;ircoma. A word must here be said about the "bleeding breast." The exudation of fluid, varying in colour from brownish-red to pure blood-red, either spontaneously or on pressure, is usually a sign of tibro-epithelial degeneration. It occurs especially when papillomatous proliferations are present in cysts, communicating with the milk ducts. The symptom is, therefore, not so serious as the patient usually imagines ; but she should not be reassured too cnnfidentlv, for 1 have also seen this bleeding in cancer. In this case, however, there were some iibro-epithelial changes, innocent cysts, from which the bleeding obviously emanated, in addition to the malignant portion of the growth. But the historv indicated that the luemorrhages occurred with the onset of the Fig. 137. — Fibro-adenoma phyllodes of breast, broken through and partially undergone sarcomatous degeneration. 234 SURGICAL DISEASES OE THE THORAX carcinoma, which was still recent. It follows, therefore, that the carcinoma must have indirectly excited the bleeding. As examples of purely innocent tumours of the breast, there should be mentioned lipoma, which is rare, and chondroma, which is still more rare. The former usually occurs near and not //; the breast, and is recognized by its softness, just as the latter is recognized by its cartilaginous hardness. The whole breast seems to be enlarged in lipoma, but it is in a dependent position, just like the healthy breast. Finally, it should be stated that the male breast may be affected with anv of these forms of tumour, but, according to Schuchart, in the proportion of i to lOO. PART IV. SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA. CHAPTER XXXIV. DISPLACEMENTS OF THE ABDOMINAL VISCERA. The accuracy of the topographical diagnosis of abdominal diseases depends upon the assumption that the viscera occupy their normal position. But this is not always the case. All the abdominal viscera are liable, in more or less degree, to displacements, some of which date from birdi, while others are acquired in later life. A. — We may begin with the congenita! displacements. The only paired viscera in the abdominal cavit}' — the kidneys — are occasionally subject to pecuHar conditions. The kidneys, for example, may be fused together and lie in front of the spine, in the shape of a horse shoe or a cake. They may also be fused together at their extremities and lie on the same side, one above the other. If one kidney is entirely absent, the other is abnormally large. Congenital displacement of one or both kidneys into the pelvis is of still greater importance diagnosticallv. Some- times the displaced kidney lies at the side, sometimes it is in the middle ; occasionally it is found in the false pelvis, at other times even in the true pelvis. With the methods accessible to the practi- tioner, it is impossible to diagnose these anomalies with any certainty ; more especially, as such kidneys do not exhibit the mobility of the ordinary movable kidneys, nor are thev capable of being replaced into their normal position. Therefore in operating upon a "tumour of the adnexa," the diagnosis of which is not clear, it is alwa3's desir- able to think of the possibility of this condition. The significance of a mistake in connection with a displaced solitary kidney need not be mentioned. i6 236 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA These cases can only be clearly distinguished by skiagraphy com- bined with catheterism of the ureters, or, better still, by a skiagram taken after the renal pelvis has been filled with collargol. The fundamental variety of displacement of the iinpaircd abdominal organs is the "typus inversus." This is comparatively easily detected on clinical examination, provided the thoracic viscera are affected in the like manner. But if the displacement only concerns the abdominal organs, it is very likely to be overlooked, although palpation and percussion wovild probably reveal the rare cases wherein the positions of the liver and spleen are reversed. A doubtful case is immediately cleared up by a skiagram, because the position of the stomach is also reversed in these circumstances. Displacement of the intestiiu alone is much more frequent and therefore of greater surgical importance. The following are the chief varieties which have been dis- tinguished : — (i) The large intestine lies in its whole extent, behind flic small intestine, because of the failure of the umbiUcal loop to revolve (retroposition). The mesentery may either be free or may contract adhesions with the posterior abdominal wall. (2) The entire large intestine lies on the left side of the abdomen because, although the umbilical loop has revolved in the right direction, it has failed to do so completely, i.e., to the extent of permitting decussation of the small and large intestine {sinistro- position). The mesentery may either be free or may have contracted secondary adhesions. In the former case both small and large intestine are connected with a free^ common mesentery, the so-called mesenterinm commnnc. (3) The entire large intestine is in the right half of the abdomen, because the umbilical loop has incompletely revolved in the wrong direction {dextro-position) . The condition of the mesentery is as in No. 2. (4) There has been complete decussation of the small and large intestine, but in a reversed position, because, although the umbilical loop has revolved completely the direction has been wrong [situs inversus abdominaUs partialis inferior). These are the extreme varieties, but a much more frequent abnor- mality is one which we may regard as an intermediate, form between the normal position and the left-sided position of the large intestine, with free mesentery. Here the caecum and ascending colon possess a free mesentery, which merges with that of the lowest coil of the small intestine. At the same time the ascending colon is frequently shortened, so that the caecum is abnormally high. If there is no ascending colon at all, and the caecum lies directly against the border of the liver, we are wiihin the border line of a left-sided position. We can tell this at a glance when the caecum is so far displaced to the left that the large and small intestine no longer decussate. The significance of this abnormahty may be gathered from the fact that DISPLACEMENTS OF THE ABDOMINAL VISCERA ^37 it is found in its mildest form — incsciitciiuiu comninnc ileo-ccvcalc — in lo per cent, of all autopsies. The more pronounced variety has certainly been encountered by all surgeons during the performance of laparotomies. There are two matters to which practical importance attaches in connection with these displacements : (i) The position of tlie appendix, and (2) the question of the decussation of small and large intestine. Let us begin with the appendix. Whereas this may lie in the true pelvis in cases of enteroptosis or when the caecum is abnormally long, it may be found high np in front of the right kidney, at the edge of the liver, or even under the liver close to the gall bladder in cases of shortening of the ascending colon, which are so often associated with a free mesentery of the ileo-caecal coil. I have found it in all these situations during laparotomy. The more free the ileo-caecal coil, the nearer it will be to the middle line. When the large intestine is displaced to the left, it usually lies in the umbilical region or even to the left of it. In complete transposition it is found in the left side of the pelvic cavity. In this condition the entire position of the intestine is that of the normal, as seen in a mirror. It follows, therefore, that the appendix has made a complete ciicuit of the abdomen, and we must be prepared to meet with it anywhere. The matter of the decnssation of the small and large intestine is not so much one of diagnostic interest as of technical importance for operation. In all cases of incomplete revolving of the umbilical coil with a free mesentery this decussation is absent. This demands special notice because it is customary in performing gastro-enteros- tomy to search for the highest coil of small intestine, where it comes out under the transverse colon. If, on opening the abdomen, the position of the intestine shows that decussation has not taken place, we must follow the duodenum in order to find the highest coil of jejunum. In cases wherein the large intestine is on the left, the duodenum winds towards the region of the right kidney, and thence passes into the jejunum in the vicinity of the right side of the pelvis. Besides these typical displacements, there are other rarer anomalies which do not admit of classification, and are only accidentally recog- nized in a skiagram or discovered during an operation. The intestinal displacements caused by diaphragmatic hernia belong to this group. On one occasion the transverse colon was found, drawn up as far as the ensiform process and held tightly there, by means of the omentum, which was involved in a congenital diaphragmatic hernia into Morgagni's space. Even the typical displacements previously referred to cannot be diagnosed clinically without the aid of a skiagram. We shall discuss the technique connected therewith later on. B. Acquired displacements of the abdominal organs are grouped 238 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA together under the term of enteroptosis. French chnicians have been famihar with this condition for many years, but a due prominence has lately been given to it by Stiller. In regarding it, however, as a symptom of '' asthenic constitutional disease," he merely paraphrases his observations and does not explain the pathology of the condition. We do not really possess any genuine explanation of the clinical picture presented by enteroptosis, and we will therefore not enter here into the discussion of theories. We shall only refer to the symptom- ology of those forms which are of diagnostic importance, leaving the clinical details to the chapters dealing with the individual organs. Even the public are aware that the kidney may be movable, and floating kidneys which, a few decades ago, were unknown to medical men, have now become the common property of the civilized world. Every practitioner recognizes the oval swelling which descends from the hypochondrium with each inspiration, and remains fixed in that position, but is capable of again being displaced under the ribs, by pressure. Similarly but much more rarely, the liver and spleen become mov- able. But whereas, a movable liver is due to general relaxation of the suspensory ligaments, a movable spleen depends upon some morbid enlargement of the organ. The downward displacement of the spleen is thus the only acquired visceral malposition which depends upon some morbid condition of the organ itself rather than upon weakness of its sus- pensory ligaments. A movable spleen is easily recognized by its sharp anterior border, and by the fact that the splenic dulness is absent from its normal situation. This sharp border serves as a guide, if the spleen is situated at a dis- tance from its normal position. I had a case of a young lady who was sent to Europe from a malarial country on account of an " ovarian tumour." She had a tumour, occupying the right half of the abdomen and the tnic pelvis, which presented on the right side a remarkably sharp border. The normal splenic dulness was absent. This sufficed for the diagnosis of a movable spleen, and the heavy organ, weighing two and a half kilos, was removed. The pedicle of the spleen was drawn out over the transverse colon, and ran down- wards to the right. We must consider ptosis of the stomach and of the intestine,. together, not only because of their clinical connection, but also because they are recognized by the same diagnostic methods. We shall begin with palpation. It has long been known that palpation of the kidneys, liver and spleen renders definite indications for the diagnosis of acquired ptosis, but it was not appreciated that indications of ptosis of stomach and intestine might be obtained in the same way. Glenard and his school have indeed been teaching, for the last tw^enty-five years, how DISPLACEMENTS OF THE ABDOMINAL VISCERA 239 to palpate the large intestine. They erred, however, in their view that only a diseased, or at any rate a morbidly contracted large intestine is palpable. This error has been exposed by Obrastzow, who has shown that a considerable portion of the course of the large intestine, and also a certain portion of the normal stomach, can be demonstrated by palpation, even in health. This has been confirmed by all who have worked systematically at the subject. The frequency with which one section or other of intestine, or portion of stomach, can be palpated, depends not only upon the experience of the examiner, but also upon the clinical material available. Patients suffering mainly from medical diseases (Hausmann) will yield a higher percentage of positive results than those suffering from surgical affections, because the latter group will include many cases of meteorism and in- flammatory diseases. The greatest care must be taken not to perform any systematic palpation of the individual portions of the intestine, if there is the slightest risk of causing any damage, e.g., in all recent acute inflammations of the biliary passages, the appendix or the bowel. It is much better to remain in doubt in regard to the course of the intestine, than to burst an encapsuled abscess, or to rupture an appendix which is threatening to perforate. . What are we able to feel through a relaxed abdominal wall, which is not too fat ? (a) Every portion of the digestive canal which contracts upon its contents, against an obstruction (gastric and intestinal rigidity). (6) The large intestine, even if it contracts in an empty state {la corde coUqiie) or when it is filled with faeces. (c) Any section of bowel, even if empty, which can be rolled, in a localized manner, on a firm underlying surface. This leads us to the following conclusions as far as the various sections of the gastro-intestinal canal are concerned (see also fig. 138). In the stomach, the pyloric region can be felt if it is not overlain by the liver ; and the greater curvature, if it is not too low down, on account of ptosis. If the stomach has dropped considerably, the pancreas, which undergoes less displacement, may often be felt lying transversely in front of the vertebral column. In regard to the small intestine, it is only possible to feel the termination of the last coil where it opens into the caecum, even in the most favourable circumstances, as Hausmann correctly remarks. It is very rarely possible, if at all, to feel the appendix in normal conditions. The termination of the final portion of the small intestine (Hausmann) or as I would suggest, at any rate its lower border, is often felt and this is assumed to be the appendix. In pathological conditions, a mass formed of appendix and adherent omentum, and frequently also of adjoming coils of intestine, is often taken to be the appendix. In most patients it is possible to feel the ca3cum and the ascending colon, almost as far as the hepatic flexure, and in the majority of 240 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA patients the descending colon is palpable together with the upper segment of the sigmoid flexure. We are sometimes able to feel the beginning of the transverse colon, to the inner side of the ascending colon, and its end, to the inner side of the descending colon. But the main portion of the transverse colon is only palpable when it is sufliciently high above the symphysis to permit of its being rolled on the vertebral spine, and if the patient is not fat and the small intestine only slightlv filled. This combination of circumstances does not,. however, often occur. A transverse colon which does not lie too low, and which is in a condition of spastic contraction can always be felt, but the renal flexure of the large intestine can practically never be palpated. Although palpation aft'ords many indications as to the position of in- dividual portions of the bowel, the results obtained by this method do not equal in reliability those which are furnished by a skiagram. A prehminary word in regard to method. It is simple enough as far as the stomach is concerned. Changes in position are visible immediately, upon the screen or upon the plate, if the patient is ex- amined directly after taking the appropriate contrast- forming meal {see under "Diseases of Stomach"). In regard to the large intestine, the most suitable procedure would appear to be that of injecting some contrast-forming, thin fluid emulsion, on the same principle as the old practice of distending the rectum with gas, or filling it with water — and this method has been largely employed. But it is becoming quite clear that the filling of portions of the bowel, which are intended to hold rather solid contents, with large quantities of liquid produces unnatural distortions thereof. However useful this procedure may be for some purposes, it can only present a caricature of the normal shape of the bowel {see Fig. 138. — Diagrammatic representation of the abdominal organs wliich can most frequently be felt. (l) Liver ; (2) Right kidney ; (3) Greater curvature of the stomach ; (4) Csjcum and ascending colon ; (5) Beginning of transverse colon ; (6) End of trans- verse colon ; (7) Descending colon and upper segment of sigmoid flexure. DISPLACEMENTS OF THK ABDOMINAL VISCERA 241 fif^s. i39« and 139&). A better conception of the position of the large intestine can be obtained by giving the contrast-forming meal by the stomach, and then following its progress through the intestine by means of screen examinations or plate impressions. It is as a rule sufficient to take impressions after six to eight hours, and after twenty- four hours, and again after forty-eight hours if there is any unusual sluggishness of intestinal movements, in order to draw a correct conclusion as to the position of the whole large intestine. The older methods of distension and injection of water are quite unreliable, and they had better be discarded as a means of diagnosing the position of the large intestine. Fig. 139a.— Skiagram of large intestine, twenty-four Imurs after taking tlie bismuth meal. Normal position and shape. Fig. l^<)b. — Skiagram of same case after bismuth injection, showing distortion in position and shape. The X-rays examinations have clearly pointed out what the essential feature, is in the diagnosis of visceral displacements. Thus, in the stomach neither a low-lying greater curvature, nor the position of the smaller curvature, which usually runs in a vertical direction, is of so much importance as- the position of the pylorus. A flabby weak stomach may become temporarily distended to a low level from the pressure of its semi-solid contents, without the pylorus necessarily having been dragged down. A case should only be regarded as one of genuine ptosis, when the skiagram shows that the pyloric orifice has been displaced downwards {sec fig. 140). 242 SURGICAL DISEASES OE THE ABDO.MIXAL AXD PELVIC VISCERA The position of the transverse colon was always looked upon as the criterion, as far as the large intestine was concerned, and this still holds good. Skiagraphv has, however, shown that the transverse colon may reach down as far as the true pelvis in consequence of its great development in length, without there being any visceral ptosis — Normal stomach. Ab- dominal position. Bull's horn shape. Normal stomach. Right side position. Normal stomach. Same case. Abdominal posilion. Normal stomach. Same case. Standing position. Slight degree of ptosis. Standing position. Extreme degree of ptosis. Standing position. Fig. 140. — Semii-diagrammatic representation of the more imporlant shapes and positions of the stomach. a confirmation of a fact previou>ly known, hut to which litlle attention was paid. Displacement of botli flexures is of greater importance; it is seen in its most marked form in the hepatic flexure, because of the greater mobility of the right kidney. The left flexure, like the left kidney, does not descend ^o low, even in pronounced ptosis. These DISPLACEMENTS OP^ THE ABDOMIXAL VISCERA 243 conditions can only be recognized ni a skiagram, witli complete certainty. This shows that the position of the transverse colon varies considerablv in the same patient, with the different conditions of contraction which it may present — a point which confirms results which can also be obtained from palpation. Transverse course of transverse colon. Descending course of transverse colon. Ascending course of transverse colon. Dependent position of transverse colon, rather low Same case, with low position of flexures. Dependent position of transverse colon, very low. Flexures at normal level. Fig. 141. — Semi-diagrammatic representation of the more important shapes of large intes- tine. Taken mostly twenty-four hours after administration of contrast-forming substance per os. TJie criteria fnynislied by skiagrapliy in regard to gastro- and cntcro- piosis may be briefty simunarizcd as follows : Low level of the greater curvature aud pylorus, loiv level of hepatic flexure, and very frequently an encroachment of the ccecuni beyond the linea inominata down into ihe true pelvis. 244 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA Although these are all matters of no slight diagnostic interest it does not follow that enteroptosis affords a successful field for thera- peutic activity. Xearlv all the abdominal organs have been stitched up^ and the statement has been made that all the viscera can be restored to their normal position. This may be true anatomically, but we cannot ascribe all the numerous discomforts of '' des eqiiilihris dii ventre, raerelv to the visceral displacement. Defective innervation of the digestive organs must bear some of the blame. This, of course, does not exclude the possibility of a vicious circle arising in certain cases, due to primary disturbance of function on the one hand, and change in form and position on the other hand — a circle which can only be broken by operative interference. But these are the exceptional cases^ and the surgeon is always anxious to participate with the physician in their treatment, however anxious the patient may be for operation. CHAPTER XXXV. ABDOMINAL INJURIES. From the surgical standpoint abdominal injuries demand careful examination, early diagnosis, and rapid decision. Lives are constantly sacriticed because diagnosis is delayed until tlie complete clinical picture of peritonitis is developed. .4.__IXJURIES WITHOUT AX OPEN WOUND. The cases wherein violence has produced no open wound present the greatest ditticulties, because we rarely know the precise spot of the application of the force, and therefore the range of possible organs involved is much larger than in cases of perforating, incised, or gunshot wounds. It is therefore necessary in every case to examine all the abdominal organs, for nothing is more fatal than to overlook, for instance, a rupture of the bowel in a case wherein a renal injury is the predominant clinical feature. In examining, we must think first of the most urgent danger which is liable to follow these injuries, i.e., luenwrrliage. If we can exclude this, we next investigate for rupture of the gastro-intestinal tract, and finally for an effusion from one of the hoUoiv viscera, such as the gall bladder or urinary bladder. ABDOMINAL INJURIES 2-|5 (1) GASTRO-INTESTINAL CANAL. If the injury has merely been a contusion, there may be no severe symptoms at first, except the initial shock. The injury may only be recognized from blood appearing in the stools, or by symptoms of slight intestinal obstruction coming on after two or three'days. Similar symptoms will be caused by injury to the portion of mesentery in contact with the bowel, or by a clean detachment of the mesentery from a coil of intestine, if circulatory disturbances short of gangrene have been produced in the intestinal wall. If the extent of mesenteric detachment has exceeded two centimetres, gan- grene will, however, not usually be long in appearing. In a case of rupture, the injury is not as a rule narrowly circum- scribed, as with a gunshot or perforating wound. There is usually laceration of a considerable part of the circumference of the in- testine, or even a whole loop may be completely torn through. The entrance of gas into the abdoininat cavity is therefore much more likely when the injury has produced no external wound than in the case of a gunshot or perforating wound. But if the intestine was empty at the time of the injury this symptom cannot always be demonstrated. One must never assume that there is no free gas in the abdominal cavity, as is often done, because the liver dulness is still present. The amount of free gas maybe very small, and in that case it would only show itself in the highest point of the abdomen by its very tympanitic or metallic note, and by its change of situation with the altered position of the patient. These two signs are so reliable, and their method of demonstration so harmless, that we may entirely abandon puncture, as a test for the presence of gas in such cases. The following case is instructive in this connection : A young man was caught between the buffers of two locomotives, and was brought to the hospital two and a half hours later. The liver dulness w^as still present. The pulse was quiet — 80 per minute — temperature and general appearance normal. But there were spontaneous pains and tenderness on pressure in the epigastrium and in the left hypochondrium. The abdominal muscles were reflexly contracted. On percussion there was dulness in the lumbar regions, extending lower on the left than on the right. Liver dulness was present, but careful percussion elicited a metallic note over a very limited area in the region of the ensiform process. When the patient was turned to^ the right the metallic note shifted to the left; when he was turned again on to his back it returned once more beneath the ensiform process. The patient vomited once. Diagnosis: injury to intestine when comparatively empty, with exit of an insignificant amount of gas which occupied the highest portion of the abdominal cavity. Immediate operation was undertaken, which revealed a loop of the jejunum torn transversely. This was sutured and recovery followed.. This movable metallic note, which is demonstrable immediately 246 SURGICAL DISEASES OF THE ABDOMIXAL AND PELVIC VISCERA after the injurv, must not be confused Avith a similar change m note which occurs later on in the vicinity of the injured coil, and which is immovable. This latter is due to local meteorism, consequent upon inflammatorv changes. Neither must it be confused with the collec- tions of gas which form in the free abdominal cavity, or in encapsuled abscesses later on in the course of peritonitis. In soine cases there is no exit of gas at all, as I have mvself seen in a case wherein there were three complete transverse rents. This is especially true of ruptures of the jejunum; and in these cases the diagnosis must be based on the symptoms to be subsequently discussed. The presence of diihicss is of uncertain value in diagnosis. When the intestine is empty, a portion of the abdominal cavity is often dull, even under normal conditions, especially the left hypochondrium and the hypogastrium. Even if the dulness is to be attributed to the injury, it might just as well be due to blood as to an effusion of gastric or intestinal contents. Pronounced defense niusculaire points to the effusion of intestinal contents, but slight muscular contraction is rather in favour of haemorrhage. Striking pallor points to haemor- rhage, and if cyanosis begins, it is probable that the intestine has been ruptured. If there is nothing suspicious on tht tirst examination we should wait, watching the patient carefully, examining him again and again at short intervals. If the condition becomes at all worse it must arouse grave suspicion. If a widespread contraction of the abdominal wall persists, associated with tenderness on pressure and pain on deep inspiration, then the more certain can we be of an intestinal injury the more circumscribed were the limits of the contusion. Thus experience shows that ruptures of the intestine are especially frequent after kicks with a hoof. // must again be emphasized thai, in this eariy stage, one must not expect pincliedfeatnres, dry tongue, distended abdomen or thread-like pulse, even if the injury lias been severe. Vomiting may even be completely absent. We may summarize our diagnostic reflections in the following sentence: //' a patient, a few hours after an abdominal contusion, has a soineichat rapid pulse, reflex muscular contraction, tenderness on pressure, pain on deep inspiration, and manifests slight i-estlessness without simultaneous signs of a severe heBniorrhage, then the case is so suspicious of an injury to the intestine that an exploratory incision is urgently indicated, if the surrounding circumitances are adapted thereto, as in hospital. The symptoms just described, apparently slight, but very ex- pressive, may persist for twelve or even twenty-four hours without any striking changes. But then the scene changes, and vomiting meteorism, a rapid small pulse, show us that peritonitis has set in and threatens to defy all therapeutic measures. ABDOMINAL INJURIES 247 Xo skill is required to recognize a rupture of the intestine in this stage, but it is then of no use, and only gives the medical attendant the satisfaction of not allowing the patient to die without a diagnosis. The foregoing remarks concerning the intestine also apply to the stoniacli, which, however, is much more rarel}^ injured by violence without an external wound. (2) THE SPLEEN. If an increasing area of dulness in the left half of the abdomen is accompanied by symptoms of continuous haemorrhage, without signs of an injury to the intestine, Ave must think of a ruptured spleen, although such an incident as an isolated injur}' is exceedingly rare when the spleen is nonnal. It is quite different when the spleen is enlarged, as in leukaemia, malaria, chronic congestion, and cirrhosis of the liver. In these cases the spleen is no longer protected by the ribs, and is therefore more liable to injury. The following case illustrates this. An alcoholic female, aged 50, was found one morning dead in bed next to her husband. The autopsy showed all the signs of severe alcoholism, and revealed the cause of death in the rupture of a spleen three times the normal size, with the effusion of three litres of blood into the abdominal cavity. Numerous traces of bruises on the body, and the evidence of a night scene between the deceased and her equally inebriated husband, elucidated the cause of the injury to the spleen. The danger to which an enlarged spleen is exposed is shown by the circumstance that a malarial spleen has ruptured simply owing to palpation through the abdominal integuments. (3) LIVER AND BILE-DUCTS. Injuries to the liver and bile-ducts are much more frequent than ruptures of the spleen, occurring even after falls from a height. The danger is caused both by the risk of luvinorrhage and the effusion of bile into the abdominal cavity. Haemorrhage supervenes very quickly, and shows itself by dulness over the right side of the abdomen, in addition to the usual signs of loss of blood. It is stated that this dulness does not usually descend into the hypogastrium, thus contrasting with splenic haemorrhage. If at the same time the liver region is sensitive to pressure, and there are radiating pains towards the right shoulder, the diagnosis is obvious. But it is not always as easy as this ; some- times it is difficult to discover whence the blood is issuing, even after the abdomen is opened. It is even more difficult to recognize a flow of bile into the abdominal cavity. The dulness is of much more gradual onset, and its position will var}' according to the direction in which the bile is 248 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA poured out. It may flow behind the stomach into the lesser omental sac, or into the lateral and inferior portions of the abdomen, or it may be limited, by rapidly formed adhesions, to the mid-abdominal region. If a diagnosis of injury to the bile ducts is based on an existing and gradually increasing fluid effusion into the abdominal cavity, without signs of acute peritonitis or of anaemia, a careful consideration of all the clinical symptoms will often indicate the approximate position of the injury. An example will save the necessity of any long disquisition. A nine year old lad was caught under the wheel of a cart. After the subsidence of the first severe symptoms, a complete dulness of the whole upper abdominal region supervened, with subsequent bilious vomiting, partial but not complete absence of colouration from the stools, and slight jaundice. The gradual onset of epigastric dulness without anaemia pointed to an effusion of bile, and the jaundice showed that the bile was absorbed into the circulation. But as there was vomiting of bile and as the faeces retained some biliary colouring matter it was obvious that the bile duct was not torn. But the possibility of an injury to the gall-bladder or to a branch of the hepatic duct remained. The operation showed that the bile had collected in the lesser omental sac, pushing the stomach forward. This, of course, excluded an injury to the gall-bladder, so the lesion could only be a rent of a branch of the hepatic duct, with rapidly forming fibrous adhesions around the foramen of Winslow. This observation confirms the general experience that the flow of liealthy bile into the abdominal cavity is comparatively well tolerated. A fibrinous peritonitis usually develops around the effusion of bile, which shuts it off from the rest of the abdominal cavity, and if not subjected to anything but very slight disturbance, leads to spontaneous recovery. But if the effusion of bile is considerable, and if instead of reaching the intestine it becomes absorbed by the peritoneum, the patient finally succumbs to cholaemia. It is quite diff'erent when an infected ulcerated gall-bladder bursts in the course of cholecystitis or becomes perforated by a stone. A fatal general peritonitis generally supervenes in a very short time. (4) THE KIDNEYS. Despite the comparatively protected situation of the kidneys, they are often involved in injuries which produce no external wound, especially after a fall from a height or after being run over. Pain on pressure over the renal region, and blood in tJie urine confirm the diagnosis, at any rate where it is possible to exclude injury to the lower urinary tract, that is to say, when there is no injury to the pelvis or perineum and micturition presents no difficulty. Sometimes the pain on pressure over the injured kidney is not very great ; but, ABDOMINAL INJURIES 249 on the other hand, the reftcx spasm of the liiuibar muscles on the injured side is very striking. Unilateral renal colic is very significant (obstruction of the ureter by a clot). Hcvmorrliage is the principal danger in renal injuries. The extent of an extra-peritoneal injury, at any rate, can be estimated by feeling a swelling over the renal region by means of palpation from before and behind, noting its increase and also the onset of extending dulness in the front. The most reliable conclusions are iiowever to be drawn from the signs of an increasing anaemia, which we must not confuse with the initial signs of shock. If the swelling and dulness increase in the course of the following day, without corresponding signs of anaemia, we must assume that urine as well as blood is being effused, and this must be regarded as an urgent indication for interference. But some- times anaemia may occur without any corresponding palpable change in the renal region. We must not, in such a case, assume that the blood is retained in the renal pelvis or retro-peritoneal tissue, but rather that it is flowing freely into the abdominal cavity, that is to say that the peritoneal covering of the kidney is torn through. These intra-peritoneal injuries of the kidney are especially prevalent among children, because their kidneys are not so closely enveloped in peri- renal fat as those of adults. One may feel inclined to differentiate between extra and intra- peritoneal injury of the kidney on the basis of the presence or absence of the gastric and intestinal symptoms, i.e., vomiting and meteorism. But caution is necessary ; because gastric disturbances are sometimes noted in extra-peritoneal injuries of the kidney. This may be due to reflex causes, but it is also known that the effused blood may extend widely in the retro-peritoneal tissue and produce functional disturbance of the large intestine, with all the symptoms of obstruction. On the other hand, vomiting and meteorism, as a sign of peritoneal irritation, are not indispensable accompaniments of an intra-peritoneal rupture of the kidney. Indeed a certain amount of blood and even of urine is well borne by the peritoneum. The formation of fibrinous adhesions, as shown by experiments on animals, acts as a defence against a persistent inflow of urine, a circumstance which justifies waiting, as long as symptoms are not on the increase. There remain therefore two definite evidences of intra-peritoneal injury of the kidney, viz. (i) the absence of definite swelling in the renal region, with (2) the simultaneous presence of a fluid effusion free in the abdominal cavity, arising from the neighbourhood of the affected loin. But not even this absolutely assures our diagnosis, because we must be able to prove that the fluid effusion does not originate from an injury to some other abdominal organ. For instance, an extra-peritoneal contusion of the kidney may occur together with a rent in the liver or spleen. But in these cases our diagnosis cannot get beyond the range of probability. Even if the first few critical days after an injury to the kidney 250 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA have passed, the onset of local inflammatory signs and an aggravation of the general condition after an initial improvement may, at this later stage, indicate the necessity for immediate laparotomy. Tissues in- filtrated by urine are especially liable to infection, and even if sepsis of the urinary tract by catheterism has been avoided, bacteria may gain access from the blood stream or from the neighbouring intestine. (5) THE BLADDER. Rupture of the bladder only occurs when the viscus is full, and the accideiit is especially liable to happen to an intoxicated person, because he tolerates an abnormally full bladder with equanimity, owing to his state of alcoholic anresthesia, and because after a bout of wine and beer, at any rate, the bladder possesses the fulness necessary to permit of the injury. The following is an illustrative case : An alcoholic had reached the stage when he began to assault one of his comrades. He was therefore ejected, but not in a very gentle manner. Very shortly afterwards he died, and his friends were charged with causing his death from a ruptured bladder. The clinical picture varies according to the site of the rupture, viz., within the abdominal cavity — inim-pcriioncal rnpiurc, or into the peri-vesical cellular tissue — exira-pi'vitoneal ntpfurc. Let us imagine that a patient is brought to us on account of a severe abdominal contusion. He complains of persistent strangury, but cannot micturate. Our tirst thought is of a urethral injury with obstruction of the passage. But no blood flows from the urethra, and the bladder is not distended above the symphysis pubis. We percuss the abdomen immediately, but elicit nothing therefrom; but while we are examining the patient, he succeeds in passing a few drops of blood-stained urine. These few symptoms suffice for the diagnosis of a recent iutra-pcyitoneal riipiun' of tlie bladder. We introduce an ordinary metal catheter, with rigid aseptic precautions. It enters quite easilv, but only a few drops of bloody urine escape — although the patient assures us that he has not micturated for several hours. On moving the catheter about, we miss the sensation which we obtain when it is in a full bladder. The differential diagnosis lies between one of two things only — (i) refle.x: anuria following trauma, or (2) intra-peritoneal rupture of the bladder. The strangury and the presence of blood in the scanty urine are, however, decisive, for the latter. If the patient is seen for the first time, a few hours or a day after the injurv, an additional sign is present on percussion — viz., a fluid effusion in the lower abdominal region, which, however, does not present the convex half-moon shape at the superior border, which is found in a free intra-peritoneal efiusion. The catheter enters the ABDOMINAL INJURIES 251 empty contracted bladder, but after moving it about therein, we may suddenly find that it becomes quite free, and a large amount of fluid escapes, which, on chemical examination, is shown to be highly albuminous. This means that the catheter has gone through the rent in the bladder into the abdominal cavity, and has drawn off the collection of urine, mixed up with albuminous exudation. The dulness which was present immediately before the catheter was passed has now vanished. If the patient is seen in a still later stage, there will be found some slight peritoneal irritabilitv with increasing effusion of fluid in the abdominal cavity. If attempts have been made to pass a catheter there is every prospect that this peritoneal irritability will rapidly become a definite peritonitis. We should, however, avoid this result by sewing up the bladder before any large collection of urine takes place within the peritoneum, or before uraemic or septic symptoms arise. Extra-peritoneal rupture is quite different. The patient complains principally of strangury, but he passes much more urine than in cases of intra-peritoneal rupture, and the catheter shows that the bladder is not completely empty. The fact that there is an injury to the bladder is indicated by the presence of strangury, while the urethral canal is quite permeable, and by the presence of blood in the urine without symptoms pointing to the kidneys or urethra. It is just in this circumstance that careful attention will demonstrate a symptom concerning which Dittrich stated : " // air enters the bladder hv means of the catheter, ice shall detect a limited area ivith a metallic note immediately over the symphysis." The symptoms hitherto mentioned are apparentlv mild, but they are rapidly complicated by the onset of infiltration of urine into the pelvic cellular tissue, which causes dulness over the symphysis. This may be followed by infiltration and phlegmonous swelling of the lower abdominal region, and even by signs of uraemia. Signs of peritoneal irritation may supervene, but these play quite a subordinate part. Though typical cases of both forms of injury are easilv distin- guished, the diagnosis may be very difficult between an intra-peritoneal rnptnre of slight extent and an extra-peritoneal injnry of very extensive character. In the former case errors are caused by the fact that the bladder always contains some urine, and in the latter case because a peritonitis may be associated with the manifestations of extra- peritoneal rupture. The main thing, however, is to recognize the fact there is a rupture of the bladder. B.— INJURIES T(3 THE ABDOMEN WITH OPEN WOUNDS. Open injuries are generally caused by stabs, incisions, or by bullets. Diagnosis is facilitated because the position and direction of the injurv to the soft parts give some definite information about the 17 252 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA possibility or probability of injury to one or other abdominal organ. The following case shows that one must take into consideration the course of origin of the injury in order to decide upon its direction. A young man was hit in the gluteal region by a Flobert bullet, which came from a weapon carelessly placed on the floor behind him. He complained at once of abdominal pain, which his friends attributed to something he had eaten — a quite probable cause, as the accident happened on a public holiday. It was not thought at first that a bullet in the gluteal region could cause abdominal pain. Thirty hours later he was brought to the hospital with symptoms of acute peritonitis. The wound of entry was found above the left gluteal fold, but no wound of exit could be seen. The bullet had struck posteriorly and interiorly, and must have gone through the left great sciatic foramen to reach the abdominal cavity. As a matter of fact the X-rays revealed the bullet in the right lower abdominal region, and the operation showed that there was a double perforation in the last coil of the small intestine. (I) GUNSHOT WOUNDS. Gunshot wounds of the stomach and intestine caused by the ordinary small firearms differ from subcutaneous lacerations by the smallness of their extent. In the case of bullets of very fine calibre, the opening is so small that it is very difficult to discover it even at the operation. This also applies, as recent wars have shown, to the bullets of modern military firearms, especially to the conical bullets, which cause little deformity, except those which strike diagonally. But on the other hand, several loops of intestine are often shot through at the same time. The symptoms of gastric or intestinal injuries are naturally the same as those caused by violence without an external wound. But the symptoms may be so very slight when the diameter of the intestinal wound is small, and the bowel is empty, that spon- taneous healing is much more likely to take place than in the case of subcutaneous lacerations. Advantage is taken in war of this favourable outlook, where the impossibility of opening the abdomen at the right moment compels us to dispense with this procedure. It is quite different in civil practice, when, as a rule, timely surgical assistance is available for the injured. We must not, therefore, wait and see what the man's luck is going to be, but must give him the best opportunity of recovering by means of an immediate laparotomy. Every ahdouiiiuil gitnsJwt wound ivhich by its direction may involve the stoinadi or intestine is so suspicions of having caused injury to the intestinal canal if the projectile can- not he found in the abdominal integunwnts, that it is absolutely urgent to bring the patient to the hospital at once. ABDOMINAL INJURIES 253 We have just said "if the projectile cannot be found in the abdominal integuments." This is, however, not an instruction to undertake a search for it, on the spot. Formerly the surgeon used to take a probe out of his pocket-case, insert into the wound, and if it reached any depth would exclaim " The case is hopeless." Of course it is quite clear that the probe can often inform us whether the injury has perforated, but it is equally clear that the procedure may arouse a fresh haemorrhage, tear through protective adhesions, and infect a wound which has hitherto remained aseptic. It would be a safer plan to lay the gunshot track freely open, after thoroughly cleansing it, in order to see whether the bullet still remains therein or has gone through the peritoneum. But this procedure is only permissible when everything is in readiness to undertake a regular laparotomy and suture the stomach or intestine. Otherwise, w^e should leave our probe in the pocket-case, with the other instru- ments, apply a first aid dressing and send the patient to hospital forthwith. I have never seen projectiles discharged at close quarters lodge in the abdominal integuments. This could only occur with a defective charge, or when the bullet has been stopped by pieces of clothing. To enlarge the wound of entry in a hurry simplv affords opportunity for infection before laparotomy can be undertaken, and deprives the surgeon of the important indication which the direction of the track gives him in his search for the injured intestine. We should limit our activity to a careful estimate of the state of affairs — the distance and direction of the bullet — and leave the wound alone, despite the urgent demands of the patient and his friends for the " instant removal of the bullet." Gunshot wounds of the liver, kidneys and bladder are diagnosed on the same principles as injuries of these organs without an external wound. (2) STABS AND INCISED WOUNDS. Slabs and incised wounds which penetrate the abdominal wall are so suspicious of intestinal injury that it is our duty to make the same search, as in the case of gunshot wounds. How do we ascertain whether a gunshot wound of the abdominal wall has perforated ? The rules laid clown in this regard apply equallv to punctured wounds, i.e., ii " search " may only be instituted if it can be immediately followed by a laparotomy. In all other circum- stances the indications are — first aid dressing, careful history and removal to hospital. If thei"e be no protrusion of bowel in ijicised ivounds, we should, when circumstances permit, separate the wound with clean hands, and this will often show whether it has penetrated to the abdominal 254 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA cavity. In cases of extensive incised wounds, and of the notorious laceration inflicted by the horns of bulls, the intestines are frequently protruding when the patient is brought for treatment. In such circumstances no attempt must be made to replace the bowel ; a large first aid dressing must be provided, and the injured at once sent into hospital, after having been given opium as an intestinal sedative. It is not always easy to discover the perforated coil, even at the operation. For example : A fat man was stabbed in the left lumbar region with a slaughtering knife. No symptoms of internal haemor- rhage, no signs of intestinal injury, and no blood in the urine. The position of the wound accorded with an injury to kidney or spleen ; the length of the knife was sufficient to have wounded the bowel. On opening up the wound, an injury to the lower pole of the kidney was discovered, and laparotomy revealed the expected complete rent of two-thirds of the circumference of the descending colon at the renal flexure, although this is a rare event. Stabs of the large intestine are, as a rule, much rarer than knife wounds of the small intestine. CHAPTER XXXVI. ACUTE INFLAMMATION WITHIN THE ABDOMINAL CAVITY. Before attempting to discover the origin of any inflammatory disease within the abdomen, we first make sure that an inflammatory process really exists. This is, however, not always easy. Let us consider two tvpical cases. A patient suddenly begins to complain of abdominal pains and to vomit. The temperature is slightly raised, the pulse is accelerated, the breathing is shallow, and almost exclusively thoracic in type ; the abdomen is not distended— it is, however, tender on light percussion, and responds thereto by nuiscular contraction. Pressure over the huubar regions is painful either on one or on both sides. Neither flatus nor stools pass ; but there is no visible peristalsis. The patient complains of a constant, dull pain, which varies in severity, but does not cease completely. There is no doubt at all that peritonitis is beginning in this case. Let us compare this with the other case. The illness also begins with abdominal pains and vomiting ; but the pulse is quiet and full, except at the actual time of nausea and vomiting; the temperature is ACUTE IXFJ.A^niATIOX WITHIX THE ABDO:\nXAL CAVITY 2:^5 normal, the breathing is not accelerated, nor particularly shallow. The abdomen is not distended, or only slightly so ; during the periods of repose it is not tender either to pressure or percussion, and the abdominal muscles do not markedly contract on palpation. Neither flatus nor stools pass. An attack of pain occurs from time to time, during which peristalsis can be seen if the abdominal wall is thin. The attack hardly lasts a minute ; when it is over, the patient feels well until the next attack warns one that some severe disturbance is in progress. Evidently this is a case of inicstinal obstritcfioii. The differential diagnosis between peritonitis and intestinal obstruction is usually quite easy in the early stage. But this early stage must be most careful!}^ watched, and if we are called too late for this we must obtain its histoiy as accurately as possible, because as the illness advances the differentiation becomes more difBcult. In peritonitis the abdomen distends gradually, the temperature is not alwavs raised, but often becomes sub-normal, and symptoms of functional or mechanical obstruction are frequently added to those of simple inflammation. In obstruction, on the other hand, the pulse becomes small and rapid, as the case progresses, the temperature mav rise, and the abdomen remains tensely tympanitic even in the intervals which are free from pain. The pain eventually becomes persistent, and the mechanical obstruction is supplemented bv intestinal paralvsis, or even bv peritonitis. If the initial symptoms lead us to the conclusion that some inflammatory irritation of the peritoneum exists, we must not be content with the vague diagnosis of " peritonitis," but must endeavour to trace its sources as quickly as possible. Careful investigation and observation at the beginning are of the greatest importance for this purpose, for once the peritonitis has become generalized we are no more able to discover its origin than we can detect the origin of a fire when the whole house is ablaze. In this stage it is generally too late to successfully overcome the inflammation. The method by which inflammation of a limited area spreads over the whole abdomen follows various tvpes : — (i) In the first group, we are confronted within the first few hours by a diffuse, and generally a simple toxic irritation of the peritoneum, presenting all the symptoms of a mild generalized peritonitis ; but there may be no specially sensitive spot to indicate the origin of the mischief. In fact, in these cases, the patient is unable to say where the pain started. On opening the abdomen a serous, or even a some- what turbid exudation containing leucoytes, but always odourless, is found ; but no organisms can be cultivated therefrom. In a few hours, or at any rate after a few days' interval, the general symptoms abate, the spontaneous pain as well as the pain on pressure limit themselves more and more to an area which corresponds to the original seat of the mischief. Indeed an abscess is forming, and cure 256 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA may take place either by its absorption or by perforation into the bowel (fig. 143, a — //). (2) In the second group the initial symptoms resemble the above^ but the reaction of the peritoneum is more acute. The exudation soon contains bacteria — usually from the second day in cases of appendicitis — and often has an offensive odour if the infection has come from the intestine. Subsequently the peritonitis diminishes in some places, in others fibrinous investments form, whereas at the periphery of the abdomen there is a tendency to the development of encapsuled abscesses, entirely independent of the original area of the disease (fig. 143, k), the so-called "residual abscesses" (Restabszessen). We agree with Sprengel, &c., in interpreting in this sense, the "progressive fibrino-purulent peritonitis" of Mikulicz and Burckhardt, (3) In other cases, after the general peritonitis subsides and the inflammation has become localized, a fresh and more severe attack of peritonitis may supervene, which signifies that either the primary or a residual abscess has burst into the peritoneal cavity. (4) In the severest cases the symptoms are generalized from the beginning, and remain so until death. The sero- purulent peritonitis merges into the diffuse purulent form, and the clinical symptoms depend more upon the virulence of the micro-organisms than upon the anatomical conditions. Some additional general remarks are required to introduce the discussion of the individual forms of peritonitis. The previous history is often very valuable. Suft'erers from appendix trouble and gall stones, who have already experienced attacks, recognize the seat of their malady. In females, a reliable history is indispensable, but is often difficult to obtain. For instance, in criminal abortion, as well as in spontaneous abortion which the patient is reluctant to confess, she often endeavours to make her friends and medical attendant adopt the view that the case is appendicitis. If some general disease has preceded the peritonitis we should think of typhoid perforation. These perforations are more frequently overlooked than one imagines, because the symptoms are partially masked by the underlying disease. A few years ago a well-known surgeon died from an undiagnosed perforation occurring in the course of an undiagnosed typhoid fever, although he was surrounded by physicians and surgeons — which ought to be very consoling to the general practitioner. The (igc and sex of the patient must be taken into consideration. In the male sex, up to the age of 20, the vermiform appendix is so frequently at fault, that this ought to be our first thought, in every case of peritonitis, even if it has not started on the right side. After the age of 20 such comparatively rare causes as perforated gastric or duodenal ulcers may suggest themselves, or exceptionally, perforation of a tubercular ulcer of the small intestine. From the age of 40 or 50, or even earlier, we sliould also think of the gall-bladder. Indeed^ ACUTE INFLAMMATIOX WITHIN THE ABDOMINAL CAVITY 257 with the advance of age, the probabihty of the gall-bladder being responsible, and not the appendix, increases. Intestinal perforation due to cancer falls within the same age period. I have only once seen a case of calculous cholecystitis imitate appendicitis before the age of 20, and this was in a girl aged 18. In the fcinalc sex, among girls, we have to think, in addition to perityphilitis, of pneumococcal peritonitis — a rarity among boys. This often develops quite independently of the vermiform appendix, and we shall deal with it again later on. After puberty, once the hymen is ruptured, all the inflammatory processes which may start in the sexual organs must be taken into consideration. An intact hymen, as JMcRae rightly savs, points to appendicitis in doubtful cases. We begin our pJiysical cxaui'uiation with 2. general view of the entire patient. Nothing is so reassuring as a face in repose. Nothing fills us with so much apprehension as the restlessness which the patient manifests about everything ; the haste with which he persuades us that nothing ails him, that he feels well, although his pulse is hardly perceptible. Flushes on the face and ears indicate that he is within the grasp of peritonitis, and cyanosis, first to be detected on the finger nails, signiBes that the toxaemia is well advanced. Jaundice, sometimes nothing more than a slight pigmentation of the sclerotics, is not rare in general peritonitis, and it is of bad omen. A moist tongue is a good sign, although it may be coated. A dry tongue, even uncoated, shows that mischief still persists somewhere, that the system has not yet mastered the infection. We conclude from rapid shallow breathing in which the nostrils participate that the peritonitis is on the increase, or when the face is generally flushed that some complication exists in the lung. Quiet, painless breathing shows that the inflammatory area has become limited. A full pulse, slow in relation to the temperature, IS a good sign ; a small soft pulse, rapid in relation to the temperature, is of bad import ; a pulse of normal amplitude, but soft and rather dicrotic, indicates an inflammatorv focus in the abdomen, which has not yet been overcome. The age and sex of the patient must be taken into consideration when estimating the pulse-rate. Sometimes a peritonitis may be fully developed, especially in men, and the pulse does not exceed 90. On the other hand, in children, a pulse-rate of 120 to 140 is not of serious significance. If the pulse persists at 130 and over, in adults, the condition is very grave. The temperature as taken in the axilla is of but little value. Often enough, it does not exceed the normal, even in fatal peritonitis. But it is important, v^dien compared with the rectal temperature ; for the greater the divergence, the worse the outlook. 258 SURGICAL DISEASES OF IHE ABDOMINAL AND PELVIC VISCERA We now proceed to the examination of ilie abdomen. We must first empty the bladder with a Nelaton catheter : even if the patient has micturated in our presence. Patients with abscesses in the lower abdomen do not completely empty the bladder, and it often happens that the full bladder is mistaken for an effusion " because the patient has only just micturated." We seize the opportunity of using the catheter, to examine the urine, and if albumen or much indican be present, we conclude that the illness is severe. Bile pigment indicates disease of the bile ducts, and sugar suggests some pancreatic affection. In estimating meteorism, we must remember that the abdominal circumference in young people and in the male sex is, ceteris paribus^ smaller than in females. In percussing, very light movements are required in order to detect a superficial thin layer of effusion. Direct, one-finger percussion, known as palpation-percussion, is a valuable method, in patients who are not too stout. The whole abdomen is percussed lightly with the middle finger applied flat, by which device, dulness can he felt as well as it can be heard. It is best always to employ both methods of percussion and compare the results. The presence of a metallic note over individual loops of intestine is of special significance. It is an important sign of a strangulation, a kink, or of local peritonitis ; the same applies to circumscribed crepitations always heard over the same place, or to the peristaltic metallic note so carefully described by Wilms and Leuenberger. Palpation must be very cautious. It is better to remain uncertain of the precise extent of an abscess, rather than to break down protective adhesions through want of care. The more carefully one proceeds the more reliable will be the result of the examination. If the per- cussion is carefully conducted reflex muscular contraction will cause much less interference and liability to error, than when a rough method is adopted. We cannot entirely avoid this muscular contrac- tion ; its presence is very well known, but is not sufficiently appreciated as an aid to diagnosis. This contraction, or " defense musculaire " which we have already mentioned in connection with abdominal injuries, occurs in the muscles which cover over the diseased area and it constitutes the first sign of inflammatory irritation of the parietal serous membrane. It diminishes with the course of the disease, or limits itself to those areas which the inflammatory process has involved, in its spread. In cases wherein the whole abdominal cavity is inundated by infective material, particularly after extensive gastric perforation, the entire abdominal wall becomes firmly contracted, or at least contracts as soon as the slightest touch impinges upon it. In perityphlitis, the contraction is usually limited to the right lower abdominal region, and if the process spreads towards the loin then the lumbar muscles of the right side contract. If the lumbar muscles of the left side also contract on pressure, we may be sure that the peritoneal irritation ACUTE INFLAMMATION WITHIN THE ABDOMINAL CAVITY 259 lias spread to that quarter. This is the more pronounced, the more the parietal peritoneum is involved in the inflammation, and it may therefore be entirely absent when the inflamed area is deeply situated, e.g., in meso-caeliac or pelvic appendicitis. The respiratory fixation of the muscles in the vicinity of the diseased area is also due to this reflex contraction, as shown by Kuster. It is noteworthy that this reflex contraction is much slighter in puerperal cases than in those infected from the intestine. In examining for sensitiveness to pressure, we must not be misled by expressions of pain which nervous people will manifest, just like spoilt children, even when pressure is made on healthy organs. If the peritoneum is really inflamed, pain will be elicited when the hand is suddenly removed after gentle pressure. It is necessary to make a brief observation here, regarding the perception of pain in the abdominal organs. Although Harvey and Haller had already shown that the viscera do not respond to ordinary irritation, by pain, nevertheless the site of morbid pain sensations at any rate, was localized in the viscera themselves, until a few years ago. Lennander opposed this view^, as a result of his careful investiga- tions, and he sought to explain all sensations of pain by dragging or friction of the nerves of the anterior or posterior abdominal wall, including the mesenteric attachments. Ross, and subsequently Head, assumed that local pain sensibility may occur in the abdominal viscera themselves, giving rise, reflexly, to sensations of pain in a correspond- ing area of the abdominal wall. Head went a step further and endeavoured to show by numerous investigations, that disease of a thoracic or abdominal organ produced severe localized- hyper- sesthesia in a very definite segmentary area of skin integument, corresponding to the abdominal organ. If we adopt this theory, we must not any longer attribute local hypersesthesia to pure func- tional disturbance (hysteria), without considering the possibility of some deep-seated disease. James Mackenzie has made numerous observations which have led him to certain conclusions of no small diagnostic interest, and which we will here briefly summarize. Like Lennander, he assumes that stimuli such as pinching, pricking, and burning are inadequate to excite the sensation of pain in the abdominal organs themselves. Even an adequate stimulus like con- traction does not suffice to excite a sensation of pain, under normal circumstances. But if these stimuli exceed a certain degree they irritate, in the sense of a viscero-sensory reflex, sensory fibres in the spinal cord, which come from the corresponding area of the abdominal integument, and they also irritate, as a viscero-motor reflex, motor fibres which proceed to coiTcsponding muscle segments. Thus, if we pinch an intestinal segment, we excite no pain. But if the intestine contracts in an unusually marked degree, the irritation reaches the spinal cord and stimulates therein spinal pain fibres, causing the brain to appreciate pain in the corresponding spinal segment. This pain is referred to the corresponding area of abdominal skin and not to the abdominal viscus, from which the irritation arises (referred pain). The muscles of the corresponding 26o SURGICAL DISEASES OF THE ABDOMIXAL AXD PELVIC VISCERA segment may be simultaneously irritated, causing reflex abdominal contraction. Although this view is to some extent hypothetical, it explains Lennander's observations, which are in themselves very accurate, much better than his own theory. Finally we should make a rectal or a vaginal examination, which will clear up the condition of the female genital organs, afford intormation as to the existence of a peh/ic abscess, and allow us to decide whether it should be opened from above or below. The more deeply it is situated the more evident it will be, not only bv the bulging but also by the cedematous swelling of the mucous membrane — feeling like velvet — and bv the profuse discharge of jellv- like mucus. Tenesmus is rarely absent. In arriving at a decision in cases of peritonitis, we must bear in mind a fact which is often forgotten in practice, that all cases do not present a typical, clinical picture. Sometimes on operating we find the intestines swimming in pus, although the clinical symptoms may not have led us to anticipate any severe disease. The pulse remains good, the reflex muscular contraction is slight. There is neither vomiting nor intestinal paralvsis, and the patient i-ecovers despite the gloomy outlook. There are two reasons for these ex- ceptional cases. In the first place the peritonitis is not so generalized as it appears to be. The convolutions of the small intestine, although bathed in pus, are not infected between the individual loops, being protected by the omentum and bv fibrous adhesions (Lennander's peripheral peritonitis). The second reason is just as important, if not more so : the slight virulence of the pus organisms. For instance, the pneumococcus is comparatively harmless in children, and a central peritonitis due to it mav run an excellent course although the condition found at operation leads us to think that the case must prove fatal. Other micro-organisms mav also be equally innocuous, in exceptional instances. We need only think of cases of acute peritoneal sepsis which are fatal before anatomical changes have had time to form in the serous membrane, to realize that the prognosis of peritonitis depends more upon the virulence of the micro-organisms than upon the extent and intensity of the anatomical changes. In concluding these general observations we must mention that our attention must not be devoted to the abdomen alone. There is often a recurrence of fever in the course of peritonitis, after some improvement has begun. The tongue becomes dry again. Nothing is, however, to be felt in the abdomen ; but the remarkably rapid breathing, the diffuse congestion of the face, and the dicrotic pulse will forthwith suggest some lung complication to the experienced observer. Careful examination will reveal either a pneumonia or a pleurisy, or both together, usually as a metastatic process, but in the case of pleurisy it may be the result of direct extension through the diaphragm. ACUTE IXFLAM.MATIOX WITHIX THE ABDOMIXAL CAVITY 261 Attempts have been made for a number of years to base indications for diagnosis and prognosis on the condition of the white corpuscles in cases of inflammatory disease — especially of the abdominal cavity. As a point of diagnosis it is established that a great leucocytosis, independent of digestion, probably indicates an inflammatory disease. On the other hand, a normal or even a diminished leucocyte count does not by any means exclude an infective disease (typhoid). As far as prognosis is concerned a high leucocvte count in the presence of severe general symptoms is a good sign ; a low count is a bad sign. Endeavours have been made to arrive at more definite indications from a differentia/ coiiiif of ill e zvhite cells of the blood and from special changes in the neutrophil polynuclear leucocytes. Schindler takes into consideration the number of myelocytes ; Arneth counts the nuclei, or fragments of nuclei, of the neutrophil polynuclear leucocytes, and draws conclusions from their greater or lesser fragmentation. Sondern finds an aid to prognosis in the proportion of the leucocytosis in general, to the percentage of the polymorpho-neu- trophil leucocvtes. All these various methods give some information concerning the defensive activities of the organism. But it is indis- pensable, in the case of them all, that the examinations should be made at regular intervals, just like the taking of temperature. This, however, requires adequate laboratorv equipment and a certain amount of technical experience, in addition to more time than a prac- titioner can usually devote to individual patients, and therefore these methods must be practicallv limited to hospitals and clinics. The practitioner does not possess the necessary leucocyte curve at the moment he is called to the patient to enable him to arrive at a decision, and to wait for the preparation of one may frequently delay surgical intervention until it is too late. As Kocher once said, the main thing in appendicitis is not to demonstrate a hyper-leucocytosis, but to prevent its onset by early operation. On the other hand, a leucocyte curve is of value for the hospital surgeon in deciding, for instance, whether a late case of appendicitis requires operation, or whether a second operation is necessar\" in the course of a suppurative disease of the abdominal cavity. We now proceed to construct a diagnosis from the conditions found upon physical examination. The most frequent of these conditions may be classified as follows : — (a) Symptoms of pain without perceptible changes. (b) Symptoms of pain, with signs of general peritoneal irritation without definite localization. (t) Peritoneal irritation, with circumscribed changes. /!.— ABDOMINAL PAIN WITHOUT PERCEPTIBLE CHANGES. The first group of symptoms, characterized by spontaneous pain and by local pain on pressure, without any obvious change, is responsible for most of the errors of diagnosis. We may hesitate 262 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA between hysteria, crises of tabes, a mild attack of appendicitis, an attack of mucous colic, renal or biliary colic, some disease of the female genitalia, acute intestinal obstruction, and even an inflam- matory disease of the thoracic organs. Suspicion of some hysterical condition will be aroused by any striking contrast between the complaints made and the actual con- dition found. Formerly, hypersesthesia of the skin suggested hysteria, but as we know now that disease of deeply situated organs may be recognized by superficial hyperaesthesia, we must be cautious in the interpretation of this sign. Simultaneous deep and superficial hyper- algesia may be due to hysteria, but is not necessarily so. But "appendicitis" is certainly hysterical if the hyperaesthesia is exclusively confined to the skin. We must examine for tabes in every case, wherein the other conditions are reconcilable with this diagnosis. A female, aged 50, became ill suddenly one night with severe abdominal pain, which suggested an acute gastric or intestinal perforation. Although physical examination proved negative, the question of laparotomy was contemplated, but the history made one hesitate. Her husband had died twenty years ago from paralysis, she had had one miscarriage, and a swelling on the skull which had been cured by potassium iodide. Further examination show^ed that the pupil reflex was lost, and that the knee jerks were absent — the only signs of tabes. The abdomen was not opened. Rectal crises occurred later on, in confirmation of the diagnosis. Attacks of mucous colitis are often mistaken for inflammatory diseases. Muco-membranous colitis, with its ileo-coecal pain, tender- ness on pressure over the appendix region, and its transitory pulse of collapse arid vomiting may completely resemble an attack of appendicitis. We merely refer to the matter here, but will discuss it more fully in connection with chronic appendicitis. Other symptoms of pain in the large intestine, the significance of which is often difficult to decide, will be dealt with together later on. The gums should always be examined in unexplained colic, lest a case of lead colic be missed. In renal colic either a normal or enlarged kidney, sensitive to pressure, is felt, or, at any rate, pronounced reflex contraction of the lumbar muscles is present. The pain radiates into the genital organs and even to the thigh, and the corresponding testicle may be abnormally sensitive to pressure. Gall-bladder colic is distinguished from renal colic and appen- dicular pain by the situation of the sensitive area, which is internal to the outer border of the rectus, and at the level of, or above the umbilicus. They may easily be mistaken for duodenal pain ; but gall-stones usually occur in females and duodenal ulcers in males. ACUTE INFLAMMATION WITHIN THE ABDOMINAL CAVITY 263 Temporary strangulation of a hernia, which has been overlooked both by patient and doctor, may be mistaken for a mild attack of appendicitis, quite apart from appendicitis in a hernial sac. On one occasion I removed the appendix of a middle-aged woman on account of the history of appendicitis, and the diagnosis made by the medical attendant during the attacks. But the attacks returned, and I eventually discovered the cause in a right-sided crural hernia, which could hardly be detected by the most careful examination. The mistake could have been avoided by accurate observation of the temperature during the attacks. There is invariably some rise of temperature in appendicitis, but if it is slight it may have passed away before the arrival of the doctor. If there are no physical signs to account for a high temperature taken bv the patient himself, we should then take it ourselves, so as to exclude any artificial pyrexia due to friction against the theruiometer. In one hysterical case the thermometer was so manipulated by the patient that the surgeon removed his appendix — in good faith. One should not forget the possibility of painful menstruation in females. Iiitni-abdomiudl ineustrnation must also be thought of, if this c otten responsible for a primary abscess in the middle Ime. In rare instances a perforated Meckel's Diverticulum causes a median abscess, or one situated rather more to the right beneath the umbilicus. This is also the favourite place for the pointing of an abscess due to pneumococcal peritonitis in little girls. If these Fig. 142. — Pneumococcal peritonitis on the point of bursting through the umbilicus. abscesses are not opened in time, they eventually burst through the navel (fig. 142). Thev are distinguished from other abdominal abscesses by their remarkable softness. Ovarian cysts with twisted pedicles or which have suppurated are usually situated in the middle line. A superficial examination is liable to mistake them for abdominal abscesses, or for appendicitis if they are situated towards the right side. Their sharply defined upper border should usually establish the diagnosis. Twisting of the pedicle is comparatively frequent, while suppuration of an ovarian cyst is rare. The former condition is very sudden in its onset, and to some extent is distinguished from a suppurating ovarian tumour by the course of the temperature. In the latter, the leucocyte count of the blood is high. 18 268 Fig 143- Diagrammatic Kepresentation of the more Important Phases and Forms of Appendicitis, and of some Considerations in Differential Diagnosis. Green = abscess contiguous to the anterior abdominal wall. Shaded green = abscess covered by intestine. Yellow = serous or sero-puiulent exudation, aseptic on first day, infected early exuda- tion on second day. Yellowish-green =^ sero-purulent exudation. Blue = extra peritoneal abscess. Red = blood effusion. Appendix forwards and inwards. Appen- dicitis, antero-parietal. First stage. Puru- lent appendicitis. Localized serous peri- appendicitis. (Early exudation beginning.) Same form. Second stage, second to third day. Purulent peri-appendicitis beginning. Extensive early exudation. Same form at end of first week. Third stage. Large antero-parietal encapsuled abscess. Early exudation has subsided. Same stage, but appendix situated in convolution of small intestine. Abscess covered by intestinal loop. Meso-coeliac appendicitis. Same stage. Appendix ia true pelvis. Pelvic appendicitis. Same stage. Appendix situated outwards and downwards. Ileo-inguinal appendicitis. ii) Same stage. Appendix directed upwards and outwards. Abscess partially behind CEECum. Ileo-lumbar intra-peritoneal appen- dicitis. Same stage. Caecum and appendix drawn upwards. (Beginning of left-sided trans- position of colon. Common ileo-ccecal mesentery.) Sub-hepatic appendicitis. (Ab- scess in same position when ciscum is normal, but when very long appendix is drawn upwards and outwards.) 270 Fig. 143. Diffuse sero-purulent peritonitis, in a very virulent infection, large perforation or gan- grene of appendix, or secondary rupture of encapsuled abscess. This form of peritonitis is fatal, or recovery only occurs with abscesses remaining. Multiple abscesses (residual) after general sero-purulent or purulent peritonitis. The figure shows the most common positions. These abscesses frequently intercommunicate, thus a and b, often a and c, or a and d, &c. The "progressive fibrinous purulent peri- tonitis" of Mikulicz and Burckhardt depends upon this process. Appendix inclined upwards and outwards. The abscess is extra-peritoneal, sub-serous and finally became superficial in the form of a phlegmon in the lumbar region. Lumbar appendicitis or ileo-lumbar sub-serous appen- dicitis. The abscess is under the iliacus fascia. Ileo- inguinal sub-fascial appendicitis. The abscess may reach the thigh by tracking under Poupart's ligament. ACUTE INFLAMMATION WITHIN THE ABDOMINAL CAVITY 2/1 Fig. 143. («) (0) Purulent peritonitis, exciting serous peri- Bilateral pyosalpinx, with some serous peri- tonitis in the vicinity. U = uterus. salpingitis. Parametritis extending as far as Poupart's ligament. Rupture of a pregnant tube. P = placenta, with a peri-tubal haematoma around. 272 SURGICAL DISEASES OF THE ABDOMINAL Ax\D PELVIC VISCERA Abscesses in the abdominal wall, below the umbilicus and above the symphysis, must not be mistaken for abdominal abscesses. The sub-umbilical abscesses usually arise from infective disease of the peritoneum, while those above the symphysis originate either in some infective trouble of the urinary tract or from osteomyelitis of the pubis. The sensation that the abscess is immediately beneath the hand, and the absence of intestinal symptoms with the occasional presence of bladder disturbance, makes the diagnosis quite easy. (6) If the resistance is at tlie side we are fully justified in thinking of the appendix on the right, and we shall often have to assume the same origin, even if the abscess is on the left side, in males. In females we must think, in addition, of salpingitis, parametritis, extra- uterine pregnancy, and more often than in males, also of the gall-bladder. It should be added that the position of the diseased area, in appendicitis, is not always at McBurney's spot, between the anterior superior spine of the ileum and the umbilicus ; indeed it is usually not there. The appendix, as we shall see later on, varies very much in its position (fig. 143, a, d, g, Ji). We first consider the history. If abdominal pain and vomiting constituted the onset, and similar attacks have preceded, the case is probably appendicitis or may be cholelithiasis. If the symptoms have come on with the menstruation, or if they have apparently brought it on early, this should not tempt us from the first diagnosis. But if the illness has followed a miscarriage or a confinement and is not accompanied by signs of peritonitis, we can only assume that it is a case of phlegmon of the broad ligament (fig. 143, p). The following case serves as an example for diagnosis : A woman, aged 38, was brought in, for a suspected strangulated hernia. She was three months pregnant, and had a threatened abortion a few days before. No haemorrhage now. There was a hard swelling in the right hypogastrium, reaching below Poupart's ligament. There were prominent lung symptoms and blood-stained sputum. Many examinations were made and many diagnoses suggested. Contra- dictory statements regarding origin of symptoms. Suspicion of criminal abortion, with injury to right vaginal vault and phlegmon of right cellular tissue, venous thrombosis and pulmonary embolism. Uterus apparently not afl^ected, as there was neither pain nor haemor- rhage. Per vagiiiani, uterus three months pregnant, somewhat fixed on the right. Circumscribed, hard infiltration of mucous membrane in right vaginal vault. Right-sided parametritis. Speculum showed that the portio was uninjured, that there was a thrombosed varix with two wounds of the mucous membrane, a few millimetres each, in the right vaginal vault. These could have been inflicted by a knitting needle or similar instrument. The threatened abortion was therefore a haemorrhage from a perforated varix, upon which followed infective thrombosis, phlegmon of pelvis and thigh, pulmonary embolism and multiple abscesses, — and finally the patient recovered. ACUTE INP"LAMMATION WITHIN THE ABDOMINAL CAVITY 273 A cylindrical or irregularly circular sharply-defined swelling at the border of the true pelvis and the iliac fossa, which has taken months or years to form, is a salpingitis. In its development, frequent, but not severe inflammatory attacks occur, and careful investigation will generally reveal a history of gonorrhoea or tubercle. The disease may be unilateral or bilateral (fig. 143, 0). The history of gonorrhoea can only be obtained by confidential questioning of the husband, if there be one. If we are informed that irregular haemorrhage occurred after one or two periods had been missed, and that the lateral swelling which we detect has been accompanied by severe pain, collapse and perhaps by vomiting, we shall seldom go wrong in diagnosing a ruptured tubal gestation, or a tubal abortion (fig. 143, q). We derive most information from physical examination. By this method we are able to define morbid conditions above, towards the gall bladder, as well as those below, towards the pelvic organs. If the resistance is more clearly limited below than above, and if the maximum point of pain on pressure is high up we should think of disease of the bile ducts. If the gall bladder is greatly enlarged and inflamed, this point of maximum pain may be displaced below the line of the umbilicus, especially if the adjacent loops of intestine are involved in the inflammation. Jaundice naturally points to biliary disease, but not unconditionally, any more than the absence of jaundice is an argument against it. The age of the patient, whether male or female, is of significance; as the probability of cholelithiasis increases with age. If the morbid process tends downwards, we decide upon appendi- citis if the pain and the maximum point of tenderness on pressure are found above the true pelvis, while the symptoms are definitely less, lower down. On the other hand, we diagnose parametritis, if the swelling and tenderness have started close to the uterus, whence they have spread upwards towards Poupart's ligament, or even to the pelvic fossa or lumbar region. Vaginal or rectal examination may detect a perityphlitic exudation reaching into the true pelvis, beliiiid the uterus, or an extra-peritoneal parametritic exudation at the side of the uterus, displacing it towards the healthy side, and more or less fixed to the pelvis. In a case of extensive pyosalpinx, a more or less sausage-shaped, sharply defined resislance can be felt from above, and its connection with the uterus can be made out by bi-manual examina- tion. But even apart from this, the sharply defined limitation of the structure facilitates its distinction from an acute perityphlitic abscess. The frequent exacerbations of peri-salpingitis occurring in a pyo- salpinx render the diagnosis difficult. But even in these instances the limitation above is quite sharp, which is not often the case with appendicitis. 274 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA The diagnosis of a ruptured right-sided pyosalpinx is difficult. The following is a typical case. A girl aged 20 was seized at night, after a festive occasion, with " appendicitis," and was admitted within twenty- four hours with the symptoms of a commencing diffuse peritonitis. Temperature was io4'8 F., face was remarkably flushed. Indefinite resistance was felt on the right side, per rectum. As the flushed face was very unusual for appendicitis, and as the height of the temperature was still more unusual for the first day, we thought of rupture — sub coitu ? — of a right tube, and the operation confirmed the diagnosis. The pus contained a pure culture of SfapJiylococciis aureus. Cases wherein an acute appendicitis becomes engrafted on an old salpingitis are not very rare, but it is quite impossible to unravel the maze of symptoms and make a diagnosis. There may not be any less difficulty in differentiating between appendicitis and a ruptured tubal gestation. The swelling is situated midway betw^een the position of an appendicular abscess and a parametritis. It is intra-peritoneal like the former, but connected with the uterus like the latter. It often reaches as far as the appendix, so that the roof of the blood cavity is formed by the appendix, caecum and last loops of the small intestine, all combined. On one occasion I found a shrivelled foetus of about ten weeks gestation tucked away with a thrombosed placenta under the caecum. It will of course be understood that the oval swelling close to the uterus is only one of the symptoms of ruptured tubal gesta- tion, or of tubal abortion, i.e., the peri-iubal Iweuiatouia. If the history is indefinite or unreliable, it may be very difficult to dis- tinguish it from a unilateral pyosalpinx in which peri-salpingitis has occurred — as gynaecologists know very well. If the haemorrhage is severe or is repeated, then the haema- toma is no longer lateral, but becomes retro-uterine, and should rarely be confused with an appendix abscess in the pelvis. But if there should be any doubt, extra-uterine gestation is confirmed by softening of the vaginal cervix, enlargement of the breasts, the exit of drops of milky fluid when they are squeezed, anaemia and slight jaundice. The presence of fever is no contra-indication. A glance at the patient's ears is the most rapid indication of the degree of anaemia. Their marked pallor is as significant of a severe internal haemorrhage as their blueness is of peritonitis, other sym- ptoms being equal. If some abnormal swelling can be felt in Douglas' pouch in the first twenty-four hours, the case is probably a haematocele, because appendicitis does not lead to an abscess in Douglas' pouch so soon. If, on the other hand, the history points to extra-uterine pregnancy, and the tumour is strikingly movable, we must think of an unruptured tubal gestation or of an abdominal pregnancy. Too energetic an examination may cause a severe haemorrhage in such a case. The condition of the abclouiinal luuscles is important in a doubtful case. The degree of their reflex spasm depends upon the nature and ACUTE INFLAMMATION WITHIN THE ABDOMINAL CAVITY 275 intensity of the irritation, and the extent to which it has involved the anterior abdominal wall. It is most pronounced in appendicitis, less so, or absent in salpingitis and ruptured tubal gestation. In the latter case, it depends upon the extent of contact of the haematoma with the abdominal wall, and the sensitiveness of the individual towards an intra-peritoneal effusion of blood. It should also be remarked that individual differences in reflex irritability, and the special characteristics of the micro-organisms concerned, play an important role, even in suppurative diseases. The blood examination is of value, in so far as a great decrease in the haemoglobin and red corpuscles indicates haemorrhage. But leucocytosis does not necessarily indicate an inflammatory process, because this may occur, even in an extreme degree, in ruptuied tubal pregnancy. If the displacement of gas from the descending colon towards the caecum, by pressure upwards from the left of the pelvic fossa, causes pain in the appendix, this always means appendicitis, according to Rovsnig, or, at any rate, some inflammatory process involving the caecum. I agree with Hausmann, that — at any rate in many cases — the pressure is communicated to the inflamed area, not by the column of gas in the large intestine, but through the distended small intestine. Diseases of the left side of the pelvis require mention, although they only half belong to the surgeon. He shares the diseases of the female genitalia with the gynaecologist, on account of the frequency of errors of diagnosis. The physician occasionally refers to him cases of sigmoiditis, i.e., localized subacute, or acute, inflammation of the sigmoid flexure. This condition should be thought of, when a sausage-shaped swelling is felt in the left lower abdominal region, in association with symptoms of colitis : diarrhoea, mucous discharge and blood. It is still a medical disease in this stage, but if signs of peri- sigmoiditis, i.e., irritation of the peritoneum, supervene, the cases become surgical and the question of operative assistance arises. We shall refer to this again in another connection. (6) TRUE PELVIS. To discuss inflammations within the true pelvis is apparently an intrusion into the province of gynaecology. We may, however, dis- arm this criticism by beginning with the male sex. It often happens that nothing can be felt in the whole abdomen, and then it is found that Douglas' pouch is occupied by an inflammatory swelling. What may this be ? It is most probably an appendicular abscess, origi- nating in an appendix hanging down into the true pelvis. But I have found there an intussusception of the small intestine, which I looked upon as an appendicitis until the operation. An inflamed coil of small intestine, obstructed by a gall-stone is often found in the true pelvis. Cancer of the rectum often gives rise to peri-rectal suppura- tion. Finally, there occur abscesses arising from the urinary tract, 276 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA which are speciall}^ to be attributed to prostatic suppuration, of suppurating diverticula, in prostatic patients. A rare cause of inllammation may be mentioned here, as arising from the multiple diverticula of the descending colon, varying in size from a millet-seed to a cherry-stone, which have been described especially by Graser. With the exception of prostatic suppuration, all the above con- ditions also apply to the female sex, who also suffer from the special diseases associated with the female genitalia. Some controversy has raged around the proper limitations of the work of the surgeon and gynjecologist. In order to avoid this, I will only mention here the association of pregnancy or the puerperal state with appendicitis. When pains occur in the hypogastrium of a pregnant woman we naturally connect them wnth the pregnancy, but the possibility of appendicitis must not be overlooked. This combination is most unfortunate, as it generally leads to abortion, or miscarriage. If the pregnant uterus forms a portion of the abscess wall, as is usually the case, rupture of the abscess is almost inevitable, and therewith fatal peritonitis also. The midwife or doctor is usually blamed for this, unless an autopsy throws light on the tragedy. I have seen a similar catastrophe at the end of a normal pregnancy. For this reason, one should not shirk removing, during pregnancy, an appendix threatened with inflammation. If an abscess has formed it is imperative to open it before abortion or labour occurs. It is sometimes very difficult to distinguish exacerbations of acute (generally of gonorrhoeal origin) salpingitis, which occasionally occur in the puerperal period, from attacks of appendicitis, especially when there is a previous history of appendix seizures. CHAPTER XXXVII. SUB-PHRENIC ABSCESS. If a patient has continuous high fever without any obvious suppuration in any of the easily accessible regions of the body, we should bear in mind the various possibilities of sub-phrenic abscess. The existence of such an abscess is highly probable, if the patient has recently had any inflammatory disease within the abdominal cavity. About half the cases of sub-phrenic abscess originate in appendicitis ; the rest are due, in the abundant experience of Korte, to affections of the stomach, liver, spleen, kidneys, pleura, ribs, intestine and pancreas — in descending proportion. SUB-PHRENIC ABSCESS 277 The main aid to the diagnosis of sub-phrenic abscess is to bear it in mind and search for it. We shall describe a typical case before detailing the symptoms. A young man passed through a severe attack of perityphlitis, which was operated on, in the stage of widespread peripheral peri- tonitis. All the symptoms gradually abated. The temperature rose again two months after the beginning of the illness, but examination with the view of detecting a sub-phrenic abscess revealed nothing. But as the fever persisted, the patient was re-examined. The lower border of the liver was at first in the normal position, its dulness did not extend upwards above the usual limit ; the condition of the lung was normal and there was a complete absence of subjective symptoms. A small patch of broncho-pneumonia on the left side misled us and prevented us from making an immediate exploratory puncture on the right side. Eventually the liver dulness began to extend upwards and its lower border downwards, and slight pain on breathing super- vened. This confirmed our suspicion. Screen examination by X-rays showed normal movements of the right arch of the diaphragm, but its shape was remarkably semi-spherical and it appeared to be very high. Exploratory puncture and immediate operation demon- strated a sharply localized sub-phrenic abscess, which caused considerable upward bulging of the diaphragm. The diagnosis is rendered very difficult by the fact that percussion over the lung as well as over the abscess may yield very varying results. The lung may give a normal note, or a dull note if there be any associated pleurisy, whereas a sub-phrenic abscess will be tympanitic if it contain gas; otherwise it will be dull. The situa- tion of the abscess is not constant, sometimes it is confined to the upper surface of the liver, sometimes its position is more forwards, at others it is situated backwards and downwards, in which case it resembles a peri-renal abscess. We will treat this subject in two parts, corresponding to the fundamental difference of the presence or absence of pleural effusion. (1) SUB-PHRENIC ABSCESS WITHOUT PLEURAL EFFUSION. If the abscess contains little or no gas, as in the previously described case, the only local sign is that the edge of the liver is lower, whereas its upper border of dulness is higher. The lower limit of the healthy respiratory sounds is also pushed upwards, corresponding to the liver dulness. There may be more or less definite signs of compression, but they may be quite absent. How can we distinguish this physical condition from pleural effusion ? The degree of the downward dis- placement of the liver and the bulging of the lower part of the thorax, in sub-phrenic abscess, are too variable to be of any value as differen- tiating signs. Very marked signs of pulmonary compression and 278 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA infiltration point to empvenia ; if these signs are absent thev are in favour of sub-phrenic abscess. But it is more important to reahze that the upper border of the duhness in sub-phrenic abscess is convex, whereas m empvema it is rather liorizontal or runs (jbliquely towards the spine. A screen examination by X-rays is of great value, and its result furnishes even stronger evidence. The shadow cast in empvema is either horizontal, or oblique towards one side or the other, mostly towards the spme, whereas in sub-phrenic abscess it is convex upwards. But the history is most conclusive. Empyema usually follows some dis- ease of the lung ; a sub-phrenic ab- scess is the con- sequence of an infective process within the abdo- men. But as a secondary pleurisy 15 of frequent oc- currence in this latter condition, we must take into consideration the manner in which the secondary ill- ner-s has started. A secondary pleu- risy arises after the manner of an em- bolism, and sets in with more or less sudden and severe respira- tory difficulty ; but a s u b - p h r e n i c abscess develops slowly, and does not as a rule cause pain until it has attained a definite "size. The pain is also much duller than the pleuritic pain which makes the breathing so difiicult. If a pleurisy should subsequently develop into a sub-phrenic abscess, it will be obvious from the chronological order of the symptoms that the latter was not the original trouble. In anv case we should not be satisfied with the demonstration and Fig. 144. — Green = pus in contact with the chest wall. Collections of pus in contact with the chest wall. On the right side, the usual basal empyema ; on the left, interlobar. SUB-PHREXIC ABSCESS 2/9 evacuation of a serous pleural effusion, if the symptoms have set in gradually and a high temperature persists. If the effusion is sterile, the presence of a sub-phrenic abscess is at any rate extremelv probable. The diagnosis is easier if the abscess contains much gas, for per- cussion will yield the well-known zones : below, dulness corresponding to the liver and the fluid contents of the abscess, then a tympanitic note due to the gas, and finallv the normal note of the lung (fig. 144). This also applies to the left side, uuitcitis inntaiidls. An ab- scess which con- tains no gas is more easily recog- nizable on the left than on the right, because of the ex- tensive dulness and the displace- ment of the spleen downwards; some- times also by the upward displace- ment of the heart. If the abscess con- tains gas the three zones just men- tioned can be de- tected. The large gas- containing ab- scesses described of old are seldom seen nowadays, be- cause thev are not ^^^- I45- — Shaded green = pus beneath lung and diaphragm. 11 . ^ " lv • i. VeIlow = serous effusion. Black = air vesicle. The chest wall in contact allow ea SUrnCient ^vith collections of pus. On the right, a sub-phrenic abscess with gas tmie to develop. vesicle and serous pleural effusion ; on the left, an abscess of lung. (2) SUB-PHRENIC ABSCESS WITH PLEURAL EFFUSION. The conditions are much more complicated if there is a pleural effusion in addition to the sub-phrenic abscess. On the right side it is quite impossible to make a definite diagnosis from phvsical examination alone, because of the normal presence of the liver dulness. The etioloi^v and course of the illness must be taken into 28o SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA consideration. A skiagram may yield some information, because the serous effusion will be more transparent than the greatly bulged arch of the diaphragm. It is easier to differentiate on the left side, between a sub-phrenic abscess and a simple pleural effusion, because of the extent of the dulness downwards. If the abscess contain gas, the diagnosis is easier on both sides, but on the left side the stomach note must not be mistaken for an indication of gas. The percussion over the supposed air cavity must always be compared with the true stomach note. The most certain method of diagnosis in both groups of cases is by means of exploratory puncture. But we must not resort to it until all other diagnostic methods have been exhausted, and we are prepared to proceed immediately to radical operation. Otherwise, by puncturing through the pleural space we run the risk of making a way for the pus, which is under pressure in the sub-phrenic abscess, to open into the pleura. If the exploratory puncture shows that pus is present, we can judge of its origin by the depth at which we reach it. A depth of several centimetres points to a sub-diaphragmatic collection, but a superficial situation is no argument against it. One may be inclined to draw conclusions from the pressure conditions. Theoretically, pleural pus should flow out during expiration, and sub-phrenic pus during inspiration. But as a matter of fact, adhesions and indurations may also put pleural pus under pressure during inspiration. The same applies to the respiratory move- ments which the diaphragm imparts to the needle inserted into it. If exploratory puncture only reveals serous fluid, this does not exclude a sub-phrenic abscess. Indeed, it strengthens our suspicion, and we must explore at a greater depth. If then we strike gas or pus, our diagnosis is confirmed, and the pleurisy is to be regarded as a neighbouring symptom dependent upon toxic irritation of the pleura. If clinical symptoms, including pain on local pressure — a symptom we have not yet mentioned — definitely point to sub-phrenic abscess, we must not be content with one exploratory puncture which gives a negative result. We must insert the needle at one or several sittings in different directions, and thus we may at times be able to discover localized abscesses, or those difficult of access. I have, more than once, seen the gradual disappearance of a sub-phrenic abscess which has been diagnosed from the clinical symptoms, but which the needle has failed to find. There can be no doubt that the peritoneum has the power of absorbing pus from this situation also. But if the puncture has revealed the abscess, we must not content ourselves with this possibility, but it is our duty to open it. TUBERCULAF-J PERITONITIS 281 CHAPTER XXXVIII. TUBERCULAR PERITONITIS. The surgeon has a double interest in tubercular peritonitis, which was for so long considered an exclusively medical condition. In the tirst place, it demands his consideration in the differentiation of the various diseases of the abdomen, and, secondly, he is often called upon to pave the way for its cure, by the performance of laparotomy. Our knowledge of the disease has been derived, to a considerable extent, from its surgery, which has also greatly increased its general interest. Every student knows from his reading of special pathology that tuberculous peritonitis is of frequent occurrence, that it may exist in a serous, nodular or adhesive form, and that these forms may all be combined in one case. Nevertheless, it is a most common occurrence in practice to overlook these cases in their early stages. This is accounted for, to a considerable extent, by their protean nature. Many cases are diagnosed as "nervous dyspepsia," chronic, gastric, or intestinal catarrh, &c., when a careful examination of the abdomen would already reveal an effusion, or palpable tubercular masses. This oversight is due to the fact that in its early stages the disease has no specially characteristic symptoms to draw attention to its existence, and it is therefore most important to examine carefully and repeatedly patients who complain of indefinite discomfort in the abdomen. This indefinite discomfort consists of loss of appetite, a sensation of pressure in the stomach and bowels during digestion, irregularity of the stools, occasionally diarrhoea, attacks of colic and a vague feeling of heaviness and soreness in the abdomen ; sometimes also dysuria. If these symptoms have persisted for weeks or months, anaemia and emaciation supervene, and both patient and practitioner begin to think of some serious malady. If the patient is young, if he comes from a tubercular stock and has probably some previous tubercular history himself, it requires no complicated association of ideas to think of tubercular peritonitis. But in the absence of such indications, even the most experienced practitioner may grope in the dark, especially in a patient over 50 years of age. After general examination, directed especially to the lungs and kidneys, in addition to any striking external signs of existing or old tuberculosis — scars of glands, bone disease — we proceed to an investi- gation of the abdomen. This may be quite flat, and without any abnormal dulness. But we are struck by slight rigidity of the 282 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA abdominal muscles ; much less than in an early septic peritonitis, but still quite demonstrable. Palpation is not really painful for the patient, but is unpleasant. Such a condition, found at repeated examinations, ought to excite serious suspicion. This represents the stage wherein the parietal peritoneum, which alone is capable of receiving sensations of pain, has become sensitive owing to the implantation of tubercles. Later on, this sensibility be- comes diminished by the fluid effusion which lies as a pro- tection between the intestine and abdominal wall, and by adhesions. This stage is common to all varieties, but its subse- quent course varies considerably. In most cases, it is possible to detect a movable effusion after a few weeks ; sometimes, how- ever, not until after a few months. This effusion is not always abund- ant. If the patient when viewed in profile has an abdomen too prominent for his figure (fig. 146), if he has shifting dulness over the symphysis — N.B., when the bladder is empty — and above Poupart's ligaments, this suffices to establish the presence of effu- sion. It is not necessary to wait until the whole abdomen fluctu- ates and the carriage of the patient resembles that of a preg- nant woman. In other cases we may look in vain for any sign of j effusion. On the contrary, some portions of the abdomen will be Fig. 146. — Tubercular peritonitis. Moderately r u + i u i +i 1 i extensive effusion. Abnormally prominent abdo- I^lt tO be harder than USUal, and men for a man. to develop into flat, firm, cake- like masses or into roundish, and somewhat fixed nodules, which are neaily always painful on pressure. In certain other cases the abdomen gradually gets larger, without effusion and without these hard masses, being tympanitic all over, but remarkably incompressible and tender throughout. This is the TUBERCULAR PERITOXITIS 283 adlicsivc form, wherein the coils of intestine are glued together in layers, by the tubercular process, thus hampering their free movement and peristaltic action. This explains the slight compressibility of the stomach and the meteorism. Among the mixed forms, it is necessary to particularize those wherein there exist encysted effusions of fluid, caused by a combina- tion of adhesive and exudative processes. These effusions are generally situated in the middle or lower abdominal region, and usually contain serous fluid, but sometimes their contents are purulent, or in layers of a sero-iibrinous-purulent fluid. The nodular form of tubercular peritonitis is not as a rule pure in character, but is combined with exudative or adhesive processes, Each of the above described varieties has its special difficulties of differential diagnosis. (i) The purely exudative variety may be confused with cirrhosis of the liver, especially if the patient is elderly and previous addiction to alcohol cannot be excluded. In such a case, an evening rise in temperature points to tubercle ; but a normal temperature is no argument against it. It should be emphasized here, that it is not enough to take the temperature now and again, at the doctor's visits. In all cases wherein tubercle is in question it must be recorded regularly for weeks, at least morning and evening. In tubercular peritonitis, as in other tubercular processes, periods of normal temperature may alternate with periods of a slight rise, or definitely high temperature. A firm consistence of the liver, if it be palpable, and pronounced enlargement of the spleen, are points in favour of cirrhosis of the liver, whereas tenderness on slight pressure and spontaneous pains are in favour of tubercle. The difficulty in differential diagnosis is illustrated by the circum- stance that tubercular peritonitis may lead to cirrhotic changes in the liver, and that some of the effusion may be due to circulatory distur- bances in the region of the portal vein. Peritoneal tuberculosis may be confused with cJiylous ascites, more especially as the latter comes on as the result of tubercular swelling of the retro-peritoneal glands. It is, however, distinguished by the remarkably rapid onset of debility and the great enlargement of the abdomen, which becomes distended to an extent which is, at any rate, unusual in tubercular peritonitis. A definite diagnosis can only be obtained after exploratory puncture, which we will discuss later on. Chronic serous peritonitis of the older authors does not enter into the problems of diagnosis. This term really mcludes tuberculosis, 19 284 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA miliaiy carcinoma or sarcoma, and endothelioma of the peri- toneum. The exceptions are exceedingly rare; they cannot be diagnosed even when the abdomen is opened, and can only be detected by histological or bacteriological examination. (2) The considerations in regard to the nodular form are entirely different. In these cases, the diagnosis lies between tuberculosis and new growth. To a certain extent, we should be influenced by the age of the patient ; at any rate below 30 the chances are in favour of tubercle, but discretion must be exercised. After 40, the age factor has very little weight in diagnosis. For instance, a female, aged 60, was referred to me because of numerous abdominal tumours, which at. first sight suggested cancer. Careful examination, however, showed that the case was one of nodular tubercular peritonitis, and this Avas confirmed by operation. On the other hand, cancer of the ovary is no rarity among women of 30 to 35 years of age. More importance must be attached to any kind of rise in temperature, but here also caution is necessary. A young woman, after undergoing treatment in a sanatorium for pulmonary disease, came under surgical treatment for a small, mov- able tumour in the right lower abdominal region. The structure w^as hardly as big as a walnut, but close to it were some deep, but less movable lumps, and a little free effusion was present. There were no signs of narrowing of the intestine. The elevations of the tempera- ture w^ere very striking : they often exceeded I02°F„, and could not be explained by the condition of the lungs, in which there w^as nothing abnormal. Everything pointed to tubercle, but the striking mobility of the small tumour made one think of the possibility of carcinoma, because tubercular masses soon lose their mobility. Operation revealed a small carcinoma of the small intestine which had pro- duced no constriction, and early infection of the peritoneum with carcinomatous infiltration of the retro-peritoneal glands. In women the clearest information can be obtained by examining the uterine appendages, which constitute the most frequent starting point both of tubercle and cancer of peritoneum. Bilateral, sausage- shaped, or nodular induration of the tubes points to tubercle or chronic gonorrhoea ; the presence of a nodular tumour in the vicinity of one ovary points to cancer. But primary ovarian cancer is sometimes so small that it can hardly be detected. The demonstration of nodules in Douglas's pouch may signify either tubercle or cancer. The presence of tubercle in the urinary tract is more decisive, because it is a very frequent accompaniment of tubercular peritonitis. (3) The purely adhesive forms, as far as they cause symptoms, are most likely to be mistaken for intestinal obstruction, due to chronic adhesions, which are the result of some previous inflamma- tory process within the abdomen. But their chronic course, the - TUBERCULAR PERITOXITIS 285 diffuse character of their symptoms, and the tenderness on pressure constitute vakiable evidence for tubercle. (4) The differential diagnosis of encysted tubercular effusions is of great importance, although not always easy. In these cases the question arises whether we are not dealing with a cystic tinnour — i.e., an ovarian, omental, or mesenteric cyst. This question is all the more pressing, because these encysted tubercular effusions often occupy the median line, as we have already seen. The character of the dulness is the same in both — i.e., dulness in the middle of abdomen with a normal intestinal note above and at the sides ; whereas in a recent effusion the conditions are just the reverse. The decision depends upon the mobility of the structure as a whole, and it will often be necessary to give an anaesthetic in order to abolish the abdominal rigidity before determining this. A cyst, even if extensively adherent, is usually somewhat movable, and gives the impression of a round tumour, independent of the abdominal wall, if the latter is completely relaxed. An encysted effusion, on the other hand, is hardly movable at all ; and even if it appears to be round in shape, is usually connected to the anterior abdominal wall. The case of a little girl, who was suspected of having an encysted tubercular effusion, occurs to me. Careful examination showed that the structure was movable, though only slightly so, and therefore the diagnosis seemed to be a cyst, whose situation suggested an origin either from the omentum or mesentery. Operation proved that it was a large serous omental cyst, and its histological examination excluded the possibility of its tubercular origin. Finally, it is necessary to refer to the confusion of a tubercular exudation with a sacculated pneiunococcic peritonitis. A pneumo- coccic exudation causes so little surrounding inflammatory reaction that it is very often mistaken for tubercular peritonitis (tig. 142), unless the practitioner has followed the whole course of the case from the beginning. If the patient is a young girl, and there is a history of a sudden illness, starting with high fever, rigors, vomiting and diarrhoea which subsided into a quieter stage after one to two weeks, we may be quite sure that the case is one of tubercular peritonitis. The " regular" course of tubercular peritonitis, as described above, is often interrupted by intervals which are caused by partial or complete intestinal obstruction, due to kinking of the bowel, by localized adhesions, or omental bands. We will again meet with these con- ditions, in discussing intestinal obstruction. Our task is not exhausted with the mere diagnosis of tubercular peritonitis. We must endeavour to determine its point of origin, at any icite, as far as it concerns treatment. We have already mentioned tubercle of the tubes. A second source of origin is to be found in the 286 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA intestine. We do not recognize intestinal tuberculosis so much by- palpation as by functional disturbance, because the results of palpation in extensive tubercular peritonitis are very equivocal. Tuberculosis of the small intestine often leads to stenosis ; ileo-caecal tuberculosis nearly always does so. We therefore witness the picture of chronic intestinal obstruction, the description of which will be found in the appropriate chapter. It must not be assumed that the association of tuberculosis of the mucous membrane of the bowel with extensive tubercular peritonitis is the regular thing. On the contrary we often see intestinal tuberculosis combined with very localized tubercular changes in the peritoneum. The production of a widespread tubercular peritonitis probably requires the simultaneous invasion of a large amount of infective material, such as is most likely to be derived from a tuberculous tube or a softened mesenteric gland. If a tubercular ulcer of the intestine leads to tubercular peritonitis, there is usually an intermediate stage provided by tubercular glands. Tubercular peritonitis often follows a pleurisy of similar origin. As is well known, the diaphragm is not bacteria proof. Exploratory puncture is not always harmless in cases of tubercular peritonitis, and, therefore, should only be performed when the indica- tions are definite ; for instance in the ascitic form, if the differential diagnosis between it, cirrhosis of the liver and chylous ascites cannot otherwise be made. It only now remains to consider how an accurate diagnosis helps us in framing indications for prognosis and treatment. That tubercular peritonitis, even in the anatomical sense, is susceptible of cure has been proved by surgical experience. Recent statistics show that one-third of the cases recover, even without operation. It has been suggested that the numerous cases which have been treated medically without any benefit, and then have promptly recovered after operation, were really on the point of spontaneous recovery. But this only begs the question and does not explain it. In the early stage, operation should only be undertaken to remove the primary disease, e.g., a. tuberculous tube. Otherwise we must continue for weeks, or if the patient's social circumstances permit, for months, with dietetic and climatic treatment, sunshine and X-rays. Sunshine seems to be the most important of these methods. If this is meffectual, operation is indicated, unless there are other foci of tuberculosis which are threatening the patient's life. The recognition of the variety of tubercular peritonitis is important, therefore, not merely as a general indication, but as an element in the prognosis. This is very much more favourable in the ascitic form than in the other varieties. The prospects are rather unfavourable if the nodules undergo caseation or suppurative softening. But we should not abandon operation in these cases, because every now and again an unexpected and per- manent success compensates for man}^ failures. It is only in the purely adhesive form that operation is hopeless. DIAGNOSIS OF ABDOMINAL SWELLINGS IN GENERAL 287 CHAPTER XXXIX. DIAGNOSIS OF ABDOMINAL SWELLINGS IN GENERAL. The abdomen is the seat of various false tumours. Everyone knows how easily the ahdoininal aorta is felt in thin subjects, and its pseudonym " student's aneurism " is fully deserved. More than one practitioner, even, have been deceived by it. On the other hand, a genuine aneurism may be mistaken for a new growth. If the abdominal wall is not very yielding, so that the structure cannot be adequately grasped, it may be impossible to distinguish between a heaving and an expansile impulse. The phantom tumour caused by contraction of the upper part of the abdominal rectus is also well known. Error can generally be avoided by palpating the opposite side. If the pylorus is sensitive to pressure, the right rectus contracts when it is palpated, whereas on the left side the muscle remains quite lax. If the patient is directed to sit up without the help of his arms, it can be readily felt that the doubtful swelling is the muscle itself. The pancreas may constitute another false tumour. In very emaciated persons its head may be distinctly felt to the right of the spinal column, and it may easily be mistaken for a thickened pylorus. Dis- tension of the stomach, however, causes the pancreas to recede, whereas a pyloric tumour would become more superficial. In persons with relaxed or thin abdominal integuments, it is quite possible under favourable conditions to feel parts of the normal stomach — the pylorus and greater curvature. Fcecal accunndations should rarely lead to mistakes, if one remembers the course of the large intestine, and if the patient has been purged before the examination. It can happen but rarely, that a mass of faeces in the caecum will resist for many days attempts at purgation, although I have had Such a case in an old woman. In " Hirschsprung's disease" the sluggishness of the bowels may permit of the accumulation of faeces to the extent that a sarcoma is diagnosed. Sometimes intussusception imitates a tumour, apart from the cases wherein a new growth — e.g., a polypus — has caused the intussusception. The typical tumour of intussusception is recognized by its cylindrical shape and its position quite close to the spinal column. Tumours and swellings of the abdominal wall, described in a separate chapter, must not be confused with abdominal tumours. Finally, it must be remembered that inflammatory changes may resemble abdominal tumours. This applies to inflammatory swellings of the omentum, which develop as a result of an omental secretion, 288 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA that is not quite aseptic, as first shown by Braun. A clue is afforded by the history and the pyrexia. An ordinary appendicitis may sometimes develop into a hard immovable lump, as large as a fist or larger, filling up the pelvic fossa, and requiring weeks or months for its absorption. This phenomenon is due either to some special peculiarity of the organisms causing the inflammation, or to some abnormally sluggish reaction of the system. In a case of this kind, in an elderly man, even at the operation I made a provisional diagnosis of cancer of the caecum, and per- formed an intestinal anastamosis. A few months later the whole resistance had disappeared, and the patient enjoyed good health for seven years after the operation. Such cases are very similar to the " phlegmon ligneux " of the neck. If we consider the extent and duration of the induration which may be caused by a small perimetritic abscess, it is not at all surprising that a similar result may ensue from appendicitis. Actinomycosis occasionally causes a movable swelling in the ileo- caecal region, but, in contrast to cancer, it does not usually lead to symptoms of obstruction. If a genuine — or false — abdominal tumour is definitely movable, its pedicle aft'ords the best indication of its origin. But as this pedicle cannot always be felt, we can draw some conclusion as to its origin from the segment of the circle which can be described by the tumour, as pointed out by Pagenstecher. This task will be facilitated by marking the segment of the circle on the abdominal wall. For instance, if the case is one of movable swelling of the gall-bladder, wherein the tumour can be displaced even as far as the left hypochondrium, the centre of the segment of the circle described by the tumour will always be at the normal site of attach- ment of the gall-bladder. The curve will be concave upwards in contrast to the curve of a pedunculated ovarian cyst, which is concave downwards, with a centre which is either in the mid-line or more or less to one side. In a similar manner, it is possible to ascertain the origin of a swelling which consists of a floating kidney. An organ which under normal conditions is only slightly movable, may be susceptible of considerable displacement when it is the seat of a tumour, especially the pylorus. For instance, I found a carcinoma of the lesser curvature, the size of a large fist, situated at the anterior superior spine of the left ilium, in a young girl ; the tumour could be dragged about, almost all over the abdomen (see under Cancer of the Stomach). Tumour formation in an organ which is congenitally displaced may render the diagnosis difficult. This applies particularly to the kidneys, which may be found lying transversely in front of the spine, or more laterally at the inlet of the true pelvis. It has occasionally been noted that an ovarian cyst may become DIAGXOSIS OF ABDOMINAL SWELLINGS IN GENERAL 2S9 free and take up its quarters elsewhere. This of course causes an insoluble problem in diagnosis, before the abdomen is opened. On one occasion, I found a left ovarian dermoid engrafted on the hepatic flexure of the colon. The remains of the tube were still attached to the left side of the uterus. If a swelling is remarkably movable, but no indication is afforded by its pedicle or by the curve described by its movement, we should think of a tumour of the small intesline, niesenlery or ouietifinn, if it is situated in the middle of the abdomen. The first is the most probable if the tumour is hard or uneven ; the other two if it is roundish and elastic in consistence. The determination of the point of origin is easier if the tumour is less movable and not loo large, because the number of organs with which it might be connected are more limited. But even then, the diagnostic problem may be very difficult, as for instance the differen- tial diagnosis between cancer of the duodenum and of the pancreas, enlarged gall-bladder and a commencing hydronephrosis, cancer of the intestine and a displaced kidney which has become fixed, &c. A correct diagnosis can only be formed by taking into consideration at the same time the history, the functional disturbance, the condition found on palpation, and a skiagram. Tumours which occupy the ivJiole or almost the whole of the abdominal cavity are particularly difficult to diagnose. If they are hard, they are essentially fibro-niyoinala of the nlenis, rarely ftbro- sarcoinala of the ovary ; in children they are usually enormous sarcoinala or mixed Uunonrs of the kidneys. Bimanual gynaecological examination, and if necessary the sounding of the uterus, afford a conclusive decision. A sarcoma of the kidney is recognized by its somewhat lateral position, if it has become very extensive, and by the fact that it reaches up into the hypochondrium. Tumours of the fatty capsule of the kidney, just referred to, do not adhere to any rule. If the tumour is softly elastic, or fluctuating and therefore probably a cyst, it is necessary to distinguish between ovarian cyst and hydro- nephrosis. The former should be diagnosed if its consistence is unequal, being imeven and hard in some places, soft or tensely elastic in others. The ditficulty in diagnosis really begins when the cystic tumours are uniform. An ovarian tumour of moderate size can be best defined at its superior border, a hydronephrosis at its lower border. In more advanced stages, external examination may be quite inconclusive. If both ovaries can be felt on bimanual examination, the matter is decided, because parovarian cysts are not in question where large tumours are concerned. But if, as usually happens, the two ovaries cannot be felt, the large intestine should be distended to see whether the bowel lies to the outer side of and above the tumour, or to its 290 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA inner side and beneath it. In the latter case it is probably a renal tumour ; in the former, probably an ovarian tumour. We say ''prob- ably," because we have also seen the large intestine running above and to the outer side of a renal tumour. But if this proceeding leads to no definite conclusion, we are thrown back on a consideration of the previous history. In the case of hydronephrosis there will prob- ably have been attacks of renal colic with sudden and profuse micturition of clear or blood-stained urine. The ' patient will also have noticed that the tumour which before had been situated high up has now gradually become lower. An ovarian tumour, on the other hand, is practically painless, unless subjected to torsion occasionally, and grows from below upwards. Finally, a decisive conclusion may be arrived at by cystoscopy. If urine escapes from one ureter only, we have every reason for assuming that there is a closed hydro- nephrosis on the other side. If both ureters are functional we must exclude hydronephrosis. If the tumour does not fit in any of these categories, we should think of one of the rare mesenteric or omental cysts (the latter, as experience shows, especially in girls under 10), or an encapsnled tubercular peritonitis, if the structure seems to be less movable and less, well defined than a genuine cyst. The rare condition of cystoma of the uterus is very apt to cause error. In one such case, the tumour filled up both hypochondria, although the cervix was prolapsed between the labia. We must also think of the pregnant uterus which has sometimes been subjected to the surgeon's knife, to the silent but malicious satisfaction of the accoucheur. It is therefore by no means super- fluous to examine the breasts in doubtful cases, and also to employ the stethoscope. It is of course well known that too much reliance cannot be placed on the history, in these circumstances. If in a case of suspected pregnancy the size of the uterus is too large for its estimated duration, and if no foetal parts are felt, we should think of a hydatidiform mole. If, in a case of suspected pregnancy, a slightly movable or a definitely movable tumour is found at the side of a somewhat enlarged and soft uterus, we should diagnose an extra- uterine gestation. Every tumour raises the question of innocence or nnah'gnancy ; a question which we can very often answer, even if the origin of the tumour is not clear. Three signs indicate malignancy : (i) Rapid growth, and early emaciation of the patient ; (2), the presence of free fluid in the abdominal cavity ; and (3) multiplicity of the new growth. To demonstrate a small amount of effusion, it is necessary to percuss as gently as possible, with the patient on the back and on the sides. If the onset of effusion has been preceded by an exacerbation of acute peritoneal symptoms, we should always think of the possibility SURGICAL DISEASES OF THE STOMACH 291 of torsion of an innocent ovarian tumour. Multiplicity of the tumours indicates either malignancy or tubercle. We have already discussed their differential diagnosis. As in the case of other abdominal diseases we have purposely refrained from mentioning exploratory puncture. Its value is still always over-estimated, its disadvantages under-estimated. Puncture of a solid tumour is harmless, unless the bowel is perforated by too powerful a needle, but it is quite useless. If we succeed in punctur- ing a cyst with an adequately strong needle, we must inevitably permit the escape of some of the contents of the cyst into the abdom- inal cavity. This may be a matter of indifference if the swelling is innocent, but it is most undesirable in cases of cancer, hydatid or suppurating cyst. Thus I w^as once consulted in the case of a young girl who developed acute peritonitis as a consequence of exploratory puncture of a cystic abdominal swelling. Operation was performed immediately, and it revealed a suppurating ovarian cyst in which the puncture was still visible as the starting point of the suppurative peri- tonitis. As every ovarian cyst, and every tumour whose differential diagnosis is doubtful should be operated on, and as exploratory puncture so often leaves us in the lurch, this procedure is limited in practical value to the information which it may give as to the aseptic or purulent condition of the contents of the cyst. But, as just stated, puncture is least permissible if there be any suspicion of suppuration. If, how^ever, we consider puncture to be indispensable, it should not be done until everything is in readiness for operation, or better still until after the abdomen has been opened and the cyst exposed. We can then, at any rate, prevent the unnoticed entrance of pus into the abdominal cavity. CHAPTER XL. SURGICAL DISEASES OF THE STOMACH. If this heading should be understood to include all diseases of the stomach which have been treated surgically, it would be necessary to detail the diagnosis of every chronic gastric disease. There are very few^ diseases of the stomach upon which the surgeon has not operated, some would say, out of pure pruritus operandi ; others, because of the failure of medical treatment. Although the indica- tions for a few of the diseases are still uncertain, the main lines of most of them are well defined and recognized alike by surgeon and physician. To these mainly we will devote attention, and only touch incidentally upon ground which is still contested. 292 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA Gastric diagnosis, as already mentioned, has made great advances within the last few years. Thanks to the labours of Rieder, the skiagram has enabled us to complete our diagnoses directly by the sense of sight, instead of relying upon indirect conclusions, as hitherto. X-ray examination of the stomach has its own sources of error, however, just as every method of diagnosis. A diagnosis should, therefore, not be based exclusively on a skiagram, which should rather be used as a supplement to other methods. A knowledge of the technique is indispensable, in order to under- stand the subsequent remarks. The patient is given a contrast-forming meal, on an empty stomach. It consists of 40 grm, of carbonate of bismuth or 80 grm. of sulphate of barium, with 400 grm. of some carboh\'drate porridge (in cases of dilatation, 600 grm.). A skiagram is taken immediately in the abdominal and in the erect position. If a well filled pars pylorica is not shown in either of these positions, another picture must be taken with the patient lying on the right side, or with the upper portion of the body lowered. These pictures are indispensable because the surgeon must possess some actual record on which to base his decision. He cannot rely upon the report of a professional radiographer, who may not have had any surgical training, as to what was found on the screen, especiall}^ as a screen examination does not bring out adequately certain details, which may sometimes be of great importance. This applies particularly to cases wherein there is a question, not only of displacement of the stomach, but also of ulcer or can.cer. A screen examination may be taken afterwards, and this will enable a decision to be made regarding the motor functions of the stomach. It is useful to get a rapid idea of the position of the organ by means of the screen, before plates are taken, but this opportunity must not be employed to study its move- ments. In order to obtain a useful picture showing a well filled stomach, the skiagram must be taken very soon after the contrast- forming meal. Another skiagram should be taken in six hours, to ascertain whether the stomach is empty or whether there is retention. Before one decides that the shape of a stomach is pathological, it is necessary to consider carefully the normal range of shape of the organ. The main varieties are illustrated in lig. 140, which shows the varied appearances of the stomach, according to its state of replenishment, the position of the bodv, its condition of motility, quite apart from the influence exerted upon it, of external tumours and growths of adjoining organs. The following morbid conditions come within the province of the surgeon, either entirely or partially. J.— FOREIGN BODIES IX THE STOMACH. It is well known that a variety of articles may gain access to the stomachs of jugglers and the insane. As a rule, even large objects, such as spoons, forks, thermometers, &c., pass on spontaneously, and find their way through the much narrower SURGICAL DISEASES OF THE STOMACH 293 intestinal canal, without injuring it. Surgical intervention is, there- fore, but rarely required. Should it, however, be necessary, there is no difficultv about the diagnosis, and if the history is unreliable a skiagram will generally elucidate any obscuritv. It is noteworthv that small foreign bodies are more likely to remain in the stomach than larger ones In proof of this it is onlv necessary to refer to the case in which the whole contents of a nail-box were removed from the stomach : over 1,500 nails, hooks, tacks, conglomerated into a mass weighing I kilo, certainly a record, even if similar cases have been described more than once. We may refer here to concretions which develop in rare instances, within the stomach itself. If we feel a strikingly movable hard lump through the abdominal wall, and the patient is a man who has much to do with varnish, and is addicted to strong drink, we should think of a rcsin stone. If such a swelling is found in a girl with a long plait, who confesses to biting her hair frequentlv, the diagnosis is obviously a liair iimioiw. i^.— DISPLACEMENTS OF THE STOMACH. We have referred to these, briefly, in discussing the abnor- malities in position of the abdominal viscera. These displace- ments possess two distinctive signs : (i) The low level of the gi"eater curvature, sometimes even as low as the svmphvsis, easily demon- strable by ordinary clinical methods; and (2) the low level of the pylorus, which can often be demonstrated by palpation, but quite easily by a skiagram. This does not, however, convert the case into a surgical one. A displaced stomach so often discharges its functions quite normally, that we must rather attribute the main cause of symptoms to inefficient muscular power, or t(3 inefficient — or more correctly to purposeless — innervation, and not to the mechanical circumstance of the gastric ptosis. Even if it has been proved clinically, and where possible also by a skiagram, that the stomach does not empty itself quickly enough, i.e., in the course of six hours, this is not sufficient to justify operation, if it is the only symptom present. In testing the motor functions of the stomach, it is most important to limit the contrast-forming meal to a carbohydrate porridge, because fats and albumins delay the course of gastric digestion. It may be mentioned as a curiosity that the stomach has often been found twisted, with the circulatory disturbances corresponding to a volvulus. This condition has not yet been diagnosed, but it should be suggested by fruitless movements of vomiting and by the impossibility of emptying the distended stomach by means of the tube. 294 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA C— GASTRIC ULCER. Until quite recently, the diagnosis of gastric ulcer was exclusively reserved for the physician. But since surgeons have been operating on certain cases of simple ulcer, quite independently of the complica- tions to be discussed subsequently, and since the X-rays have rendered it possible to establish the diagnosis with certainty, even in many uncomplicated ulcers, the diagnosis of gastric ulcer has been tending to fall within the provnice of the surgeon. (1) UNCOMPLICATED GASTRIC ULCER. A gastric ulcer was "suspected" formerly — although its presence could not be proved — if a patient complained, not of vague indiges- tion, but of pain coming on at a definite time, mostly immediately after meals, radiating to the back and towards the left side. This symptom was usually associated with a pronounced and well-defined pain on pressure over a sharply localized area, generally in the neigh- bourhood of the smaller curvature. Confirmation of the diagnosis was derived from the discovery of hyperacidity, and it was further strengthened if the patient -happened to be a young chlorotic girl. But as long as no severe symptoms came on, the diagnosis always remained a " suspicion." It became more probable if blood could be detected microscopically in th-e faeces after a diet which contained no meat. I say the diagnosis only became " more probable," because the case might be one of duodenal ulcer or of some ulcerative condi- tion lower down in the intestine. Confusion with a duodenal ulcer was not a matter of great importance because the treatment — at any rate, the non-operative — was the same in both, and because a duodenal ulcer may often be so close to the pylorus that its site of origin may remain in doubt, even at the operation. The only clinical differences consisted in the facts that the seat of the spontaneous pain and the pain on pressure in the case of a duodenal ulcer was a little more to the right than in gastric ulcer, and that the spontaneous pain in duodenal ulcer did not supervene immediately after food, but was delayed for a few hours, indeed, until the need for another meal was felt, constituting the so-called hunger pain, often coming on in the course of the night. These clinical differences still remain the only ones known. Finally, it should be mentioned that gastric ulcer is most frequent in the female sex, whereas duodenal ulcer is practically limited to males. There can be no doubt that, in this manner, ulcers were often dia- gnosed which were not present, and were very frequently overlooked when they were present. X-rays have enabled us to make great ad- vances in this respect, although many a case may still remain obscure. SURGICAL DISEASES OF THE STOMACH 295 The skiagram is of value in the following way : — A superficial gastric ulcer is not visible as such, but if it has attained a depth of 2 to 3 mm. it appears, under favourable conditions, as a slight, sharply defined bulging in the shadow, and thus looks like a depression as viewed from the stomach. If it has penetrated the gastric wall and has extended to adjacent tissue (retro-peritoneal connective tissue, liver, pancreas, or spleen), the depression becomes quite like a recess — the so-called Haudek's diverticulum, and there is often a layer of gas over its bismuth shadow when the skiagram is taken in the erect position. But certain consequences of the ulcer are visible before the ulcer itself, the most important of these being persistent spasm of the gastric wall at the level of the ulcer. In the very frequent cases of ulcer of the lesser curvature, this spasm appears as a sharply limited contraction of the greater curvature. Such muscular spasms, always persistent in the same place, also occur in cases of scars of old ulcers and in operation scars, but probably do not occur in normal stomachs. Accidental spastic contractions, which are often met with as momentary pictiu"es of a peristaltic wave, can only be distinguished from persistent spasm by repeated examinations. Reflex delay in the emptying of the stomach is a second indirect sign of ulcer. Skiagrams have also shown that pyloric spasm may result from an ulcer which is not situated at the pylorus, but anywhere along the lesser curvature. Cicatricial contraction of the stomach at the level of the ulcer, or the development of hour-glass contraction, may be mentioned as a third indirect sign. This matter will be referred to later on. How is the so-called '' indolent" nicer to be diagnosed ? It cannot be detected clinically, but can only be determined at operation or at an autopsy. All ulcers which penetrate the entire thickness of the gastric wall possess indolent, i.e., thickened edges. The thickening varies very much in degree in accordance with the position of the ulcer, its relations to adjacent organs, and probably also with the constitutional reaction of the patient. An indolent ulcer may there- fore be diagnosed, if we feel a tumour-like structure, without being able to find any diagnostic signs of cancer. But an indolent condition of the ulcer does not necessarily signify the presence of perigastric changes. An ulcer may cause perigastritis long before the " indolent" changes occur, and on the other hand the perigastric changes asso- ciated with such an ulcer may develop so slowly that no clinical manifestations arise. How does radiography help in distinguishing a gastric from a duodenal ulcer ? Principally by a negative sign. If the clinical suspicion of .an ulcer is supported by the presence of blood in the stools, but a careful X-ray examination of the stomach fails to find any abnormality, we are bound to diagnose a duodenal ulcer, by exclusion. Moynihan and Haudek state that this diagnosis is all the more probable the more rapidly the stomach empties itself, because a duodenal ulcer 296 SURGICAL DISEASES GF THE ABDGMINAL AND PELVIC VISCERA produces a reflex patency of the pylorus, in contrast to a gastric ulcer. The absence of any downward displacement of the pylorus in a skiagram of the full stomach in the erect position is additional evidence of duodenal ulcer. Positive changes in the duodenal shadow have not often been obtained in cases of ulcer. They consist, either of cicatricial contrac- tion of the duodenum, or of the formation of recesses in this situation. These changes are, however, very rare. Does the skiagram offer any indications for surgical treatment, apart from the complications to be discussed below ? This is hardly to be expected ; the necessity for operation depends upon the sub- jective symptoms, and the possibility of their relief by medical measures. It is entirely a cHnical matter ; but skiagraphy has rendered it possible to confirm the diagnosis, in those cases wherein operation is suggested, with unquestionable accuracy. (2) H>EIV10RRHAGE. We learn from general medicine how to recognize the gastric origin of a haemorrhage, and how to distinguish it from haemorrhage due to cirrhosis of the liver. But special reference should be made to hysterical Jicviiioirliage, because this is apt to be frequently repeated, and therefore to simulate just that kind of gastric ulcer which should receive surgical treatment. Josserand points out that in hysterical vomiting of blood there is much admixture with mucus, so that it looks like fruit juice, and as a rule it does not coagulate. Josserand suggests that the blood comes from the oesophagus. I was once misled, in common with the physician in attendance, by such vomiting of blood, and, after considerable internal treatment, decided upon gastro-enterostomy. The further progress of the case showed that we had been deceived by hysteria. The comparatively trifling degree of anaemia, by which we were indeed struck, should have made us hesitate. The course to adopt in regard to haemorrhages is rather difficult to decide. The practitioner calls in the surgeon even when small hzemorrhages threaten life by their frequent repetition, and the decision as to operation is left to him. We should advise non- interference in the case of a single severe haemorrhage if this seems to him the preferable course. (3) PERFORATION. The diagnosis of a perforated ulcer, on the other hand, falls quite within the province of the surgeon. Rapid reflection and immediate treatment are indispensable. Cases operated on within the first twelve hours usually recover ; after the first twenty-four hours the mortality is 75 per cent. SURGICAL DISEASES OF THE STOMACH 297 If a person — remarkably enough it generally happens in a man — suddenly experiences severe pain like the thrust of a dagger in the epigastrium, followed by rigidity of the abdominal muscles, local pain on pressure, acceleration of pulse and occasionally a rise in temperature, we should think of a perforated ulcer, although the patient may not have manifested any signs of gastric ulcer previously. The perforation is often, but not always, associated with collapse, from which the patient may temporarily recover before the classical symptoms of peritonitis set in. In such cases, even the delay of half a day ''for the purpose of better observation," means to abandon the patient to almost certain death. If we first see the case at a later stage there is either general peritonitis, the origin of which cannot be traced, or there may be the condition termed by Lennander peripheral peritonitis. After perforation the gastric contents flow towards the anterior surface, preferably under the liver towards the right lumbar region, thence into the true pelvis, and the peritonitis eventually ascends along the left side, without always affecting the convolutions of the small intestine, which are covered by omentum. This peripheral form remains longer accessible to surgical treatment than the central form. If we find the patient, as is usuall}^ the case on the second or third day, in a condition of cyanosis with a tympanitic abdomen, cold extremities, and a thread-like pulse, it is always questionable whether operation is worth while. It may only shorten the patient's life by a few hours and redound but little to the credit of our art. The rare exceptions, when the perforation is minute and a cure ensues without operation because the stomach is empty, constitute, of course, no argument against the above. I have had this expe- rience in a case where operation was refused. We must not risk the patient's life on such an uncertain hazard. We must now deal briefly with some details. In most cases the previous history permits of the diagnosis of gastric ulcer, or at any rate suggests it, but not always. If premonitory symptoms have preceded the perforation, the diagnosis becomes much easier. But as a rule there are none. The very suddenness and great violence of the pain in tJie gastric region are, however, of themselves symptoms of the greatest significance, and the patient is well able to distinguish them from ordinary gastralgia. In certain cases the perforation is preceded by perigastric symptoms. In one of my cases the patient neglected these warnings, so that they proved of no service to him. If they occur in a case wherein an ulcer has already been diagnosed, they, at any rate, give due notice of the possibility of the threatening danger, and if perfora- tion actually occurs, operation can take place all the more readily. The initial pain is never absent, but it may be less severe than 298 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA usual if the perforation does not exceed a pin point in size, as sometimes happens. The pain often radiates into the back, especially between the scapulae, or into the left shoulder and left arm, just as the pain of biliary disease radiates into the right shoulder. The distribution of the pain which occurs later on, is of less value for diagnostic purposes. It depends upon the direction taken by the flow of the gastric contents, and is situated towards the lower abdominal region, either on the right or left. This explains why perforation of the stomach has so often been taken for disease of the female pelvic organs. The same applies to the pain on pressure. I have found this to be most pronounced, twenty hours after perfora- tion, in the left lower abdominal region. Pulse, tenipevattire 3.nd respiration behave as in any other perforation of a viscus. The pulse is slightly accelerated, but may remain so full, strong, and quiet for the first few hours, probably through vagus stimulation, that the inexperienced may entirely dispose of the idea of perforation. A normal temperature does not exclude perforation, but, on the other hand, a rise in temperature shows that the case is not an ordinarv stomach ache. Respiration is hurried, shallow and thoracic. It is an error to suppose that vomiting does not occur ; on the contrary it is frequently present. The most important local signs are : — (i) Extensive reflex rigidity, especially in the upper abdominal region, but generally over the whole abdomen, both sides being equally involved. The degree and extent of the reflex rigidity distinguish acute perforation of the stomach from all other conditions which enter into the differential diagnosis. Those who devote their attention to this sign will not usually find any difficulty in the diagnosis. (2) The presence of gas in the free abdominal cavity. The remarks already made in connection with laceration of the intestine apply here also : liver dulness is usually present, and there is no escape of gas in most cases; but if gas is present, it may limit itself to a movable collection at the uppermost region of the abdomen, revealing itself by a localized metallic note. (3) Friction murmur, and soft friction appreciable by the hand over the gastric area. This sign is rare, but if present is of great value. (4) Rapidlv increasing dulness in the flanks, especially on the right. Important as it is to diagnose a perforated gastric ulcer early, nevertheless we must not make this diagnosis just because the patient happens to be a girl at an age when gastric ulcer is common. We may easily be misled by acute intoxicatious, especially as a reliable history is not often obtainable in these cases. SURGICAL DISEASES OF THE STOMACH 299 Symptoms of a perforated gastric ulcer in a pregnant girl always suggest poisoning — a circumstance not exactly creditable to the "stronger sex." There is hardly any disease of the abdomen which has not been confused with perforated gastric ulcer, especially cJiolecvsfifis, pan- creatitis, rupture of a pregnant tube, torsion of an ovarian tnnionr, and acute obstruction. Even acute pneumothorax has been taken for a gastric perforation. The same applies to the crises of tabes. It does not take very long to examine the reflexes, and the phvsician has a just cause for criticism if the abdomen of a tabetic is opened on four occasions for gastric crises, -as was recently reported. The foregoing remarks on rupture of a gastric ulcer hold good also for that of a duodenal ulcer. In both cases an operation is indicated. The diagnosis of duodenal ulcer can be made, at any rate with probability, from a consideration of the antecedent symptoms (see above). In the present age of necessary and of unnecessary gastro-entero- stomies, the presence of an operation scar in the epigastrium indicates a special type of perforated ulcer — perforation of a peptic nicer in the region of the gastro-intestinal anastomosis. This form of ulcer is one of the darkest spots in the whole of gastric surgery. (4) CICATRICIAL STENOSES. We get much more time for observation in the late effects of ulcers, i.e., in cicatricial stenosis of the pylorus, than we do in a perforated ulcer. We shall begin with a brief review of the clinical symptoms of the various degrees of stenosis. The severe cases are the easiest to recognize. Increasing emacia- tion and diminution of the amount of urine are always observed in these. Hysterical or neurasthenic vomiting may reduce the body to the state of a mere skeleton, and greatly diminish the urine,, but this form of vomiting usually comes on soon after food, in contrast to the vomiting of retention. The functional examination of the stomach in these hysterical cases will show^ varying abnormalities in the composition of the gastric juice, and indicate that there is no genuine retention. Among my most grateful patients, I reckon a young girl who had undergone dietetic treatment for many years, and finally had to be fed per rectum, or subcutaneously, on account of persistent vomiting.. Both the patient and her parents would gladly have consented tO' some curative operation. The history showed that the vomiting followed immediately upon a meal, and examination of the stomach showed that its chemical and motor functions were normal. The removal of the patient from her surroundings and the strict injunction not to vomit, worked wonders. The vomiting ceased forthwith, all 20 300 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA food was well tolerated, and the body weight increased by 12 kilos within a few weeks. The cure persisted for years. Unfortunately similar cases are often subjected to operation, either because the surgeon does not diagnose them, or because he is un- acquainted with the significance of psychical therapeutics, i.e., treat- ment by suggestion. If these measures fail, the benefit of operation is only of brief duration. The neurologist justifiably upbraids the surgeon on account of a number of avoidable gastro-enterostomies, and for displaying too much operative zeal. We may hope that the neurologist will never deserve the retort of treating patients by sug- gestion, without the previous indispensable exhaustive examination of the stomach, until it was too late for the necessary operation. No operation witlioiit previous careful investigation of the functions of the stomach, neither any psychotherapy witlwut the same precaution. The cases wherein there is no vomiting, but wherein the gastric contents are emptied into the duodenum with painful colic, are more difficult to diagnose. If the abdomen is watched for some time, at any rate in thin subjects, the stomach will be seen to rear itself up against the obstruction, so that its entire shape can be discerned through the skin. Sometimes this occurs in a regular rhythm of eighteen seconds. The fear of the pain causes these patients to reduce their food to a minimum, and therefore they become weaker and weaker, even before the outset of the vomiting. It is possible to estimate precisely, in these cases, the degree of disturbance in the motor functions and the amount of retention, by means of repeated examinations with a test breakfast. The milder cases are susceptible of improvement under appro- priate diet, but the patients are often glad enough, after a time, to obtain surgical relief. An individual can survive a great deal of inconvenience from a narrowing of the pylorus. I have seen a case of constriction of pylorus by a cicatricial band on its exterior surface, which reduced the pylorus to an external diameter of 7 to 8 mm. When the patient ■came under surgical treatment, he was in extremis, with a weight of 37 1^'g- His weight had doubled a few months after gastro- enterostomy. The main symptom of stenosis, as is evident from what has been said already, is retention of the gastric contents. This retention varies from a slight interference with the passage of the food to a complete obstruction. The well-known methods for the clinical examination of gastric motility, which enable us to detect even slight disturbances, are employed to demonstrate this stagnation of food. If the disturbance is only slight, the question as to its functional or organic origin arises — whether it is due to muscular weakness or defective innervation of the stomach, i.e., general atony, or whether it is due to spasmodic contraction of the pylorus consequent on an ulcer at that situation, or elsewhere in the body of the stomach. A SURGICAL DISEASES OF THE STOMACH 301 comparison of the physical signs with the skiagram is of great value in arriving at a decision. We must distinguish between the retention of large portions of solid food and that of liquid contents. The former condition without the latter only occurs when there is an organic change, i.e., in cases Avherein large fragments of food are detained within excavated ulcers ■or ulcerated tumours, or wherein an organic stricture permits liquids to pass, but not solid masses of any large size. If, on washing out the stomach in the morning, we find whortleberries, damson skins or pieces of orange, which were eaten the previous evening, we may conhdently assume that some organic change exists, whatever be the result of other tests. Skiagrams furnish the clearest evidence of the retention of liquid or mucilaginous contents, for they enable us to watch quietly the whole process of the emptying of the stomach, without disturbing it, by the introduction of a tube. It is, however, indispensable that the examinations should always be made in the same way, with an indifferent contrast-forming substance, and that the vehicle should always be the same. If we find that the stomach is couipkidv empty within six hours, after a carbohydrate contrast-forming meal, it follows that there is no organic obstruction, or if there be one, that it is compensated for, by increased muscular power. This increased peristalsis can be seen very well, both on the screen and on the plate. But we must be on our guard against error, for increased peristalsis occurs in tabes, and in a slighter degree in hysteria, so that these diseases must be excluded before deciding that an early stenosis exists. The delay of a few hours iu tJie euiptying of the stouiacli, without any subjective symptoms, indicates simple uiuscular weakness, and possesses no surgical importance. Delay, accompanied by colicky pains, strongly suggests pyloric spasm or some organic change. It is not always easy to differentiate between these two conditions, more especially as the two are often associated — for instance, when a local spasm supervenes upon an ulcer, which often occurs in cases of hour- glass contraction. The more persistent these derangements are, the more likely are they to be due to organic narrowing, and the less effect will atropine have on the physical condition revealed by the X-rays. If the bulk of the meal is still within the stomach after six hours, and if the viscus is not completely empty after twelve hours, organic stenosis is, at any rate, very probable. So far, the symptoms are the same, wherever the situation of the stenosis. Whereas it was hitherto assumed that a stenosis must be at the pylorus, and that any other situation was quite exceptional, more extensive surgical experience and skiagraphy have shown that ulcer- ative constriction occurs much more frequently in the body of the 302 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA stomach than was formerly reahzed — hour-glass stomach due to cicatrization of an ulcer. The s\'mptoms of stenosis are common to both situations, but there are also certain clinical differences. Let us begin with pyloric stenosis, which is the much more common form. This is recognized in the skiagram by the dilatation {a) {5) Peristaltic restlessness of the Small flat ulcer on the lesser stomach in tabes. curvature with spastic contrac- tion of the greater curvature. Hour-glass stomach, partly organic and partly spastic, in a case of ulcer of the lesser curvature. Cicatricial hour-glass stomach with deep ulcer on lesser curva- ture (Haudek's diverticulum). Cicatricial stenosis of pylorus, Loss of shadow due to cancer with extreme dilatation stomach, in its breadth. of at the lesser curvature. Fig 147.— Semi-diagrammatic illustrations of X-ray examination of the stomach. of the stomach in its breadth, in contrast to the condition in ptosis when the organ hangs down like a loose sack in the left half of the abdomen, reaching as far as the pelvis or even to the symphysis, the pylorus appearing usually just in front of the spinal column, if not to the left of it. (Compare figs, i-jo and 147.) SURGICAL DISEASES OF THE STOMACH 303 It may exceptionally happen that the entire distension of the stomach is towards the left, even in the case of pyloric stenosis. This will occur when the stomach has originally been "displaced, and the pylorus has been fixed in the middle line, or to the left of it, by perigastric adhesions. Loss of shadow due to cancer of the greater curvature. W (i Cancerous degeneration of Cancer of pylorus. Its duo- antrum pylori, with its com- denal end badly defined, in- plete absence from the shadow, stead of the normal clear definition. Cancerous hour-glass stomach Fig. 147. — Semi-diagrammatic illustrations of X-ray examination of the stomach Loss of shadow, owing to a tumour external to the stomach. Cirrhosis of the stomach, diffuse scirrhus. In this connection one may remark that the term dilataiion of the stomach ought to be discarded from the nomenclature of gastric disease. At any rate, the term is no diagnosis, although it is still employed in this sense occasionally. Dilatation of the stomach is a result of various diseases, but is not a disease of itself. If gastric dilatation is discovered, it is then necessary to determine its cause. 304 SURGICAL DISEASES OF THE ABDOMIXAL AND PELVIC VISCERA In davs gone bv, the stomach tube was indiscriminately prescribed for ail patients with dilated stomach, without any thought being devoted to the cause of the trouble : but we may hope that this era has finally terminated. Having established the diagnosis of pyloric stenosis, we are con- fronted by the question as to its innocence, as hitherto assumed, or its possible malignancy — a matter we will deal with in discussing cancer of the stomach. Extensive adhesions around the pylorus occasionally give rise ta symptoms similar to those of stenosis, although the calibre of the pylorus may be quite normal. Many surgeons have separated these adhesions with permanently successful results, but it is hardly possible to make an accurate diagnosis before the abdomen has been opened. Medio-gastric stenosis is a rare variety of post-ulcerative constric- tion, which constitutes hour-glass contraction of the stomach. The diagnosis mav often be inferred from tlic clinical condition. The case will apparently be one of pyloric stenosis, but if the epigastrium and left hvpochondrium are percussed on several occa- sions, varying notes will be elicited. On washing out the stomach,, pure water runs out after the stomach contents are emptied, and then suddenly stomach contents will again run out. From this it is- obvious that the stomach must consist of two cavities connected by a narrow channel. This can be proved by distending the stomach and noting the hour-glass form through the abdominal wall. As the inflated air passes from the cardiac to the pyloric section of the stomach, a buzzing sound is audible, which is a further confirmator}^ point. It has also been observed that liquids introduced sometimes- disappear very rapidly, as if they flowed directly into the pylorus- (Roux). Definite evidence is, however, only furnished by a properly inter- preted skiagram. Proper interpretation is required because the hour- glass stomach appears under many guises. The following are the possible varieties, with their characteristic signs : — (i) ^Momentary picture of a peristaltic wave, with an evanescent contraction of the larger or smaller curvature, circular in shape and sharplv defined; variable in position. (2) Persistent spasm in the vicinity of an organic lesion (ulcer,. old scar) on the smaller curvature. Narrow, deep, sharply-defined contraction on the larger curvature always found in the same position (fig. 147, h). (3) Constriction from without by perigastric bands. The con- striction is also narrow and sharply defined, the stomach sometimes appearing to be divided into two. Cannot be accurately diagnosed before operation. (4) Constriction by a round band from the liver, embracing the stomach. The constriction is sharply defined, but not of a very extreme degree. No clinical significance. SURGICAL DISEASES OF THE STOMACH 305 (^) Constriction bv cicatrized ulcers — true hour-glass stomach. The picture often resembles the condition in No. 2 ; but there is also an incurving of the lesser curvature. As a rule, however, the stenosed portion is stretched out to some extent, and possesses infundibuliform processes on both sides, forming the correct shape of an hour-glass. Haudek's diverticulum is often seen on the lesser curvature, at its narrowest portion or near it (fig. 147, d). (6) Constriction of the stomach by a ring-shaped carcinoma. The constriction is not well defined, or may be irregularly sinuous. Xos. 2 and 5 are often associated, so that an organic narrowing^, which in itself may be insignificant, will appear on the skiagram as a complete subdivision of the stomach shadow, owing to a simultaneous spastic contraction. It follows from the foregoing that the interpretation of a skiagram of the stomach is no easy matter ; at any rate, it is no easier than the clinical methods of gastric examination, hitherto in vogue. Neverthe- less skiagraphy has already become an indispensable adjunct of the examination, in most cases. Pyloric stenosis of infants still remains an unexplained disease. Some authorities regard it simply as a spasmodic contraction, others as a genuine hypertrophy of the pyloric wall. Probably both con- ditions occur. It is, however, established that operation ought to be undertaken if the infant vomits all food, without bringing up any bile, and if the rigidity of the stomach can be appreciated. The necessity to save life outweighs all theoretical considerations. D.— CANCER OF THE STOMACH. Gastric patients are divisible into two classes : (i) Those who have suffered with their stomachs for years, some patients will say that they have always suffered ; and (2) those who declare that they have previously enjoyed the digestive powers of an ostrich, and whose symptoms are of ver}- recent date. We will first consider the latter class. If there be nothing wrong with the other viscera and indications of biliary disease are absent, if the symptoms cannot be explained by some non-surgical condition such as nephritis, nor by recent or chronic poisoning, such as alcohol and tobacco, and if in addition the patient has begun to lose flesh, we are justified in thmking of cancer, and our whole examination must be directed towards settling this point. The gradual and unexplained onset of gastric symptoms in a patient, hitherto free from indigestion, is a most significant feature of this disease. Chronic dyspeptics are also divisible into two classes. The one class always adheres to a " diet," which is sometimes prescribed by an authority ; at other times is merely the formula of some nature- cure, but at intervals there is considerable indulgence in the pleasures 306 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA of the table. These patients often get alarmed after reading some popular article on medicine and consult a surgeon, in fear of cancer, although they are not really any worse than they have always been. Even these patients must be carefully examined, because they are just as susceptible to cancer as others. As a rule, nothing will be found, and unless we can convince them that they ought to feed like other people, we shall have to leave them to resume their own dietetic ways. The other class of patients consists of those who have a history pointing to ulcer ; they may be suffering from severe haemorrhages or other symptoms previously described, which indicate that they have an old unhealed ulcer, or that they may be subjects of a recent ulcer. But we must not lightly dismiss cancer in these cases, because this disease is apt to develop on the base of an old ulcer, or even on its scar. Cancer must be suspected if the symptoms have lately assumed a new aspect, and if the general condition, which had pre- viously been unaltered for years, has become worse during the last few weeks or months. We have no accurate information as to the frequency of the change of a chronic ulcer or its scar into cancer. Many of the facts hitherto advanced, do not stand criticism, and my surgical and pathological experience seems to indicate that the frequency of this occurrence has been exaggerated. Owing to the diversity of the symptoms which they present, it is necessary to distinguish between growtJis at tJie cardia, groivths at the pylorus and cancer of the hodv of the stomach itself, the last usually originating on the lesser curvature. As the symptoms of cancer of the cardia resemble those of oesophageal cancer, we have discussed them in connection with the latter. Before entering into details of the various forms, we shall point out some general diagnostic signs of cancer of the stomach. The practitioner usually demands three signs for the diagnosis of cancer of the stomach : viz., a tumour, haemorrhages, and chemical derangement, sometimes also cancerous cachexia. This kind of diagnosis is, however, a relic of the time when a patient with cancer was inevitably doomed, so that there was no hurry for the diagnosis. But an enormous change has occurred in the position within the last twenty years, and the cure of the patient now turns upon early diagnosis. We must, therefore, study the possibility and method of attaining an early diagnosis. We must first discuss the signihcance of the above-mentioned symptoms, because at least one of them is usually present when the patient consults the doctor. We begin with the question of tumour, and must at once say that if one is found it is not an unconditional evidence for cancer, nor is the absence of a tumour the slightest evidence against cancer. SURGICAL DISEASES OF THE STOMACH 307 A gastric ulcer may, in many ways, resemble a tumoui". An inflamed and indurated pylorus may feel like a movable tumour, whose size is increased by the functional hypertrophy of the adjoining musculature. The tumour is wider towards the left than towards the right, just as in an early pyloric cancer. In other cases the ulcerated segment of the stomach is adherent to the liver, omentum or mtestine, and forms a tumour which is only slightly movable, but which is free from the abdominal wall. On rare occasions, it happens that an ulcer on the anterior surface of the stomach, which is on the point of perfora- tion, contracts adhesions to the abdominal wall and leads to inflam- matory infiltration thereof. The superficial situation of this swelling is easily recognized, because it cannot be moved independently of the abdominal wall, nor does it move independently of it during respiration. If the swelling persists for any length of time it may cause phlegmonous inflammation of the abdominal wall, spontaneous perforation and the development of a gastric fistula. On the other hand, a tumour may be absent in cases which are otherwise obviously cancer, from the clinical standpoint. This occurs in : — (i) Flat cancers, chiefly situated on the posterior wall of the stomach. (2) Cancers which are covered over by the liver, especially frequent at the lesser curvature. (3) Small contracting pyloric cancers, even when the pylorus is accessible to palpation. (4) Soft polypoid cancers, which do not infiltrate the abdominal wall. It follows, therefore, that we must not delay our diagnosis of cancer until the appearance of a tumour. But there is no justification for the apparent paradox, that all palpable cancers of the stomach are too late for radical operation. As a matter of fact, some of the largest growths, i.e., those of the cauliflower variety, have the best prognosis. Before concluding that a tumour is absent, it is essential that we should have searched for it properly. If the patient is very fat, or if the reflex rigidity of the recti is very great, an anaesthetic is required. In other cases, repeated examinations without anaesthesia after empty- ing the stomach and bowels, must be undertaken, before arriving at a positive conclusion. The patient should lie fully relaxed in a horizontal position. The examiner sits at his side and feels with gentle pressui'e along both sides of the spinal column, from above downwards. If the abdominal integuments are soft and not too firm we should ordinarily be able to feel the larger curvature, sometimes also the pylorus, and even the lesser curvature, but this depends upon the degree of ptosis of the stomach. An indurated pylorus will usually appear as a transverse movable hard pad, which recedes from the palpating finger with a 308 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA sudden jerk, just as the normal structure. In the case of thin patients with ptosis one must avoid being confused by the pancreas, which can sometimes be palpated throughout its whole length. Confusion is more likely to occur when there is chronic pancreatitis or cancer of the head of the pancreas. We do not always find the growth situated where we usually suppose the stomach to be. In cases of ptosis, the whole stomach, including the pylorus, may be in the left half of the abdomen, so- that cancer in a stomach thus displaced will be encountered on the left side, occasionally even as low down as the pelvis. On palpating such a tumour, its connection with the stomach will be suggested by the ease with which it can be pushed over to the right, and by the fact that it can be displaced over an extent which corresponds to the segment of a circle around the normal position of the pylorus, A more striking evidence of its connection with the stomach is afforded by its displacement towards the right, when that viscus is- distended with gas. If we are in doubt whether the tumour is connected with the stomach or with the transverse colon, we must endeavour to trace the latter from the hepatic flexure, by palpation. If we are able to- feel the transverse colon, in its entire extent, as separate from the tumour, obviously it cannot be connected with the bowel, and there- fore probably arises from the stomach. If the tumour is on the left side, we must palpate both the ascending and descending limb of the splenic flexure, in order to be sure that it is not connected with the bowel. For the sake of completeness, it should be mentioned that a tumour originating in the kidney or its fatty capsule may simulate a tumour of the stomach. In such a case, the skiagram would show the stomach displaced and compressed. There is not much to say about haimorrhage. It merely indicates the existence of some ulceration. Every tyro knows that acute- arterial haemorrhage points to a simple ulcer, and that coffee-grounds vomit points to cancer. But exceptions occur in both directions. Sometimes there is no haemorrhage visible to the naked eye ; and to- wait for coffee-grounds vomit would mean to miss more than half the cases of gastric cancer. Early diagnosis depends in great measure on the repeated microscopical and micro-chemical examination of the syphoned-ofT stomach contents, for traces of blood which are otherwise invisible. If such traces are regularly present, we may be confident that there is at any rate some ulceration within the stomach. Traces of blood in the stools would lead to the same conclusion, with the reservation that the blood may be coming from some lower site in the digestive canal, especially the duodenum^ The examination of the cheiiiical conditions of the stomach often SURGICAL DISEASES OF THE STOMACH 309 furnishts further evidence, and the following four statements summarize the information hitherto established on the subject : — (i) Free hydrochloric acid very soon disappears in most cases of cancer, but on the other hand the absence of the free acid or even a deficiency of the combined acid is in no sense an evidence of cancer. (In those cases wherein it is assumed that cancer has become engrafted upon an ulcer, the free hydrochloric acid may persist for a considerable time). (2) The presence of a definite and intense lactic acid reaction indicates a stenosis caused by cancer ; but on the other hand the absence of lactic acid is not an argument against cancer. (3) Even if there be no definite lactic acid reaction, the presence of numerous long bacilli (lactic acid bacilli) strongly suggests cancer. (4) The increase of hydrochloric acid, or decrease of the hydro- chloric acid deficiency when the quantity of the test meal for ulcer is raised, contra-indicates cancer. (Gluzinski and Kocher.) We now come to the fourth of the above-mentioned signs — the cancerous cachexia. Controversy has been raging around this subject for some decades, but it is quite clear now that much of what was attributed to cachexia is really due to the functional disturbance of vital organs, to repeated haemorrhages, to ulceration of the cancer and septic absorption. All these factors are especially active in cancer of the stomach. Nevertheless, recent haematological research has shown that thei'e is something real in the old conception of cancerous cachexia. The peculiar sallow, waxy appearance of many cancerous- patients, which strikes the experienced observer forthwith, the early depression of cardiac force, indicated by the rapid soft pulse, corres- pond to blood changes which are imperfectly understood, but which can be estimated by certain qualities of the serum, such as the increase of its antitryptic index. A definite increase of this index, to about double the normal, is a strong evidence of cancer, in the absence of any other cause (advanced tubercle, parenchymatous goitre, Graves's disease). Unfortunately the determination of this index is much toO' complicated a process for the use of the general practitioner, and the same applies to all the other serological tests for cancer which have been investigated within the last few years. There is no one single reliable sign of cancer. The diagnosis must be based on the combination of the various signs. The assist- ance which may be derived from skiagraphy will be referred to when discussing the special forms of cancer. There can be no doubt about the nature of the disease, if circum- scribed nodules can be felt in the liver, if free fluid is detected within the abdomen, or if hard glands are found in the supra-clavicular fossce — as first described by Troisier and Virchow. 3IO SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA (1) CANCER OF THE BODY OF THE STOMACH. The favourite position is at the lesser curvature. Cancer does occur on the anterior and posterior surface, as also on the greater ■curvature, but very much more rarely. All cancers of the body of "the stomach characteristically manifest themselves by a prolonged period of indefinite indigestion, until the increasing anaemia, the size of the tumour, and secondary malignant peritonitis indicate the nature and situation of the disease. Occasionally, the growth per- forates into the colon, with the appearance of symptoms, which are obviously due to a fistula between the stomach and large intestine. These cancers are concealed beneath the liver and they often cannot be felt, but the persistent tension of the abdominal integu- ments in the epigastrium and its indefinite resistance eventually suggest organic disease and then it is usually too late for operation. They do not, as a rule, give rise to distinct symptoms until they invade the pylorus. Most of the too-late diagnoses — whether due to the neglect of the patient or of the practitioner — fall within this group, and tragically enough this fate fell, a few years ago, to the lot ■of a surgeon who had distinguished himself by his work on the early operation for gastric cancer. As we shall soon see, these cancers could be demonstrated by skiagrams before they give rise to clinical symptoms ; but in the absence of symptoms there are no indications of illness, and therefore advice is not sought. The anatomical peculiarities and the clinical details of these cancers permit of their division into the following four varieties : — ■ (i) Superficial cancer, "rodent ulcer of the stomach," can only be felt in the late stages. The skiagrams are characterized by a mere faintness of the shadow in the region of the cancerous infiltration, rather than by circular areas where there is real loss of shadow. (2) Protuberant Broken-doivn Cancer witli Deep Ulceration in the Centre. — This is the most frequent variety of cancer of the body of the stomach, and is situated astride of the lesser curvature, like a saddle. Unless concealed by the liver, it can be felt earlier than the flat cancer. It appears in the skiagram as a well-defined, roundish area, from which the shadow is absent. As such light areas may also be due to remains of food not derived from the bismuth meal, it is necessary to confirm the result by repeated examination. Mistakes may also arise, from tumours outside the stomach pressing thereon (fig. 147, /). This shows how important it is to interpret the skiagram, in relation to the existing clinical signs, for the diagnosis of gastric ■disease based upon X-rays alone is not of great value. (3) The polypoid form of gastric cancer is also recognized by areas of loss of shadow. Its consistence may allow of its easy palpation, or it may be so soft that it cannot be felt through the stomach wall, even when the abdomen is opened. These forms are liable to bleed SURGICAL DISEASES OF THE STOMACH 311 freely, and they are clinically characterized by anaemia. These are the cases which are often regarded for months as pernicious anaemia, until a careful examination reveals the diagnosis. Every case of pernicious anaemia ought to be subjected to an exhaustive examina- tion of the stomach, and a skiagram should be taken. In one of our cases, the diagnosis was established by a piece of tissue obtained by washing out the stomach ; in another case, a girl, aged 24, a tumour could actually be felt. (4) The clinical signs of diffuse cancerous cirrJiosis of the stomach (Brinton's cirrhosis, linite plastique of French authors) depend upon the fact that the organ has become converted into a rigid tube of small capacity (pocket-flask stomach). Vomiting immediately after a meal is, therefore, the chief symptom, which is liable to suggest the regurgitation due to a low oesophageal cancer, or to a carcinoma of the cardia. A tube can be introduced into the stomach quite easily,, but the viscus cannot be distended nor can any large amount of fluid be retained. If the growth can be felt distinctly, it appears as a difluse or cylindrical resistance in the upper part of the epigastrium. This diffuse contraction of the stomach is recognized on the skiagram as a narrowing of the shadow. As a rule, the change affects the uppermost portion of the stomach last, and then the shadow of the stomach has a funnel-shaped appearance. (2) CANCER OF THE PYLORUS. The symptoms of pyloric cancer are much more definite, and it is therefore easier to establish an early diagnosis. The principal symptoms are due to mechanical obstruction, just as in cicatricial stenosis at the pylorus. The same trend of manifestations occurs in both conditions : (i) Pciinful gastric peristalsis, often visible tJi rough the ahdouiinal ivall (fig. 148) ; (2) retention wliicli can he deuioustrated by the stomach tube, and (3) retention vomiting. We must not delay our diagnosis until these signs are fully developed. Epigastric pressure, from which a patient has hitherto been free, coming on after meals, or colicky pains — even if only slight — in the gastric region, occurring periodically during digestion,, are symptoms demanding careful examination, which will usually show, after the use of the stomach tube, that the food remains in th& stomach too long. As a rule, there is no vomiting at all, in this stage. A skiagram, which is indispensable when these clinical symptoms are present, usually shows the following points : — The impression taken immediately after the bismuth meal shows a normal outline ; at any rate, the dilatation in the transverse diameter,, which is so significant of post-ulcerative stenosis, is absent. At most,, the region of the antrum pylori may appear somewhat distant. On the other hand, we may be struck by the presence of deep peristaltic waves, in one impression or the other. It is especially noticeable that the stomach shadow is not well marked in the pyloric region.. 312 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA The stomach looks as if it had been cut off transversel}^ and its boundary hne presents irregularities which remind one of the areas of missing shadow which occur in cancer of the body of the stomach. We must be on our guard against deception also here. A dis- tended gall-bladder, probably with inflammatory adhesions to the pylorus, may extinguish the shadow in the pyloric region. This is especially likely to happen through remains of food not derived from the bismuth meal. It is, therefore, imperative to confirm any apparently pathological condition by a second examination, in the right lateral posture, if necessary. Fig. 148. — Pyloric stenosis due to cancer. Attack of gastric rigidity. (Stomach not artificially distended.) Sometimes, a tapering or conical process of the stomach shadow indicates the path by which the food makes its way through the cancerous masses. If examinations are made after six, twelve, or twenty-four hours, the stomach is generally found partially full, thus confirming the clinical evidence of retention. The longer the disease has lasted the greater is the food residue, the wider is the stomach shadow and the nearer does the picture approximate that of post-ulcerative stenosis of the pylorus. But whereas in the latter the boundary line of the SURGICAL DISEASES OF THE BILIARY PASSAGES 313 stomach shadow is sharply defined, in cancer we ahiiost always find, in all its stages, that the shadow is cut across towards the pylorus, or at any rate that its border is mdefinite and irregularly wavy. ^ Cancer of the stomach often begins on the lesser curvature, but is not recognizable until it invades the pylorus and constricts it. If we cannot diagnose it from the history and the results of palpation, it can often be detected on the skiagram by the loss of shadow extending considerably towards the left. CHAPTER XLI. SURGICAL DISEASES OF THE BILIARY PASSAGES. Notwithstanding the better appreciation of the nature of gall-stone disease, which we have gained during the last twenty years, there still remain some practitioners in whose minds the ideas of "jaundice" and "gall-stones" are indissolubly connected. We still hear the assertion " there are no gall-stones because the patient has no jaundice." Jaundice is a symptom which may occur in gall-stone disease, but is not essential thereto, and is moreover present in many other diseases. If a patient informs us that his liver is affected, or if we have the impression that he is so suffering, our first thoughts should be of the *' medical " diseases— simple biliary catarrh, the various forms of hepatic cirrhosis, and acnte yelloiv atrophv of the liver. If a patient with indigestion but without pain, becomes yellow but otherwise remains well, we must diagnose catarrlial jaundice. But if the general condition is profoundly affected, and the temperature is high, the disease is infective jaundice, which may also occur in the epidemic form. This also constitutes the rare malady known as Weil's disease. If a high degree of jaundice is associated with sym- ptoms of severe general illness and rapid loss of strength, we should assume either acute yelloiv atropliy of the liver, as a result of poisoning (phosphorus, arseniuretted hydrogen) or some form of septic infection. A certain amount of jaundice, without any profound anatomical changes in the liver, often exists in acute septic conditions, especially in septic peritonitis, and all experienced observers are acquainted with the terrible dirty greenish look — due to the yellow of the jaundice combined with the blue of the cyanosis — of patients who have suc- cumbed to this disease. A patient who gets about for years, with 314 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA more or less jaundice, but without any particular pain, but who com- plains occasionally of slight feverish symptoms and a general deterior- ation of his health, must be suspected of suffering from Jivpciirophic cirrliosis of the liver — which is mereh^ a chronic infection of the organ with acute exacerbations. The jaundice of Banti's disease should be mentioned here, in. which condition the enlargement of the liver is associated with great splenic hypertrophy. Secondary and tertiary syphilis may also pro- duce jaundice. The above comprise all the usual conditions which may suggest forms of gall-stone disease. But if the patient's " liver trouble " does- not appear to fit in an}' of these categories, we are justified in conclud- ing, by exclusion, that the case is probably one for surgical treatment. We should accordingly think of gall-stones, malignant growth, abscess of the liver and hydatid cyst. We have just included Banti's disease among purely medical diseases, but this is not quite accurate, for good results have followed extirpation of the spleen in this condition. The difficulty consists in the fact that our conception of the disease is not definite, either from the clinical or etiological standpoint. The condition is pro- bably a composite one. Furthur experience is necessary to clear up the matter. We may now apph^ our diagnostic reflections to a few concrete cases. (1) GALL-STONE COLIC. In one group of cases, pain is the predominant feature. The patient is seized, at rare or frequent intervals, with severe pain in the upper part of the abdomen or more definitely in the gall- bladder region. Nothing but morphia suffices to relieve the pain which, however, does not last more than a few hours, or at most, a day. There is usually no rise in temperature, nor is there, as a rule, any jaundice, so that the patient, and often the doctor,, diagnoses " colic." But gastric colic is really yerv different to gall- stone colic, both in its onset and in its nature. Pains arising in the stomach generall}' radiate to the left and towards the back ; biliaiy colic radiates towards the right, even as far as the right shoulder. If gastric pain is caused by an ulcer, it is increased on taking solid food. If caused by hyperacidity, food relieves the pain. In both cases the pain comes on almost regularly at definite hours of the- day or night. The pain in an acute attack of gall-stones, so-called biliary colic, is quite independent of food and it occurs at irregular interyals of months or years. This also differentiates it from the pain of duodenal ulcer, which is situated on the right side and comes on at the completion of gastric digestion. This is termed *' hunger pain." SURGICAL DISEASES OF THE BILIARY PASSAGES 315 After an attack of gall-stones it sometimes happens that somewhat less severe but more persistent or periodical pains remain. These are apt to cause confusion. They indicate that stones are still present, or that the attacks have led to advanced anatomical changes. In other cases there are no attacks at all ; the disease is only betrayed by certain indefinite digestive troubles, the origin of which may, however, be suspected from the pain fulness on deep pressure over the region of the gall-bladder. From this condition, it is only one step to the cases of gall-stones wherein the symptoms are quite latent — constituting 95 per cent, of the whole. This explains the impossibility of making a diagnosis in so many of the cases. We may now return to the attack of colic itself. This may be mistaken for any acute painful seizure in the upper abdomen, viz., for pain caused by hernia of the epigasiriiiiu or innbilicus, renal colic, and the severe conditions to be described in the following section. Biliary colic may be distinguished from renal colic, even in the cases where there is no palpable swelling to assist in localization, by the position of the reflex muscular rigidity. If we press simultaneously in front of and behind the painful region, in a case of renal colic, the lumbar muscles will become rigid, whereas in a case of biliary colic, it is the right rectus which becomes rigid. It has been stated that in gall-stone disease there is a particu- larly characteristic painful spot close to the right side of the spine below the twelfth rib ; but one must use this diagnostic point with discrimination. In order to explain the mild attacks of gall-stone disease, on an anatoinical basis, we must assume that the stones are incar- cerated in the gall-bladder, cystic duct or common bile duct, and that the degree of surrounding inflammation is very slight indeed, passing off very i-apidly after having attained its height within a few hours of onset. Unless recuri-ences are very frequent, surgical aid is unnecessary. We will discuss the position, of the stone in connection with other forms of cholelithiasis ; but it is usually very difficult to localize it in mild attacks. The discovery of the stone in the stools after the attack often shows that the pains are due to the extrusion of the calculus. Some patients are able to exhibit a stone for each attack. There is no jaundice in these slight attacks because the obstruction of the common duct is too brief. The attacks of pain caused by adjacent adhesions are sometimes indistinguishable from mild biliary colic. These attacks may occur whether the stone has passed naturally or has been removed by the surgeon. It is often important to be able to decide whether attacks of pain of which a patient has complained were really due to gall- stones. Two practical rules are applicable in this connection. The patient is able to go to his doctor for very many attacks of pain, but the doctor is obliged to come to the patient for biliary colic. 21 3l6 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA An anodyne prescription suffices for ordinary pain, but a hypodermic injection of morphia is indispensable in the pain of gall-stones. Exceptions are rare. (2) ACUTE CHOLECYSTITIS. The following case raises somewhat different problems of differential diagnosis, in regard to acute biliary colic. A patient is suddenly seized with symptoms of pyrexia and severe pain in the right side of the abdomen. He vomits on one or more occasions, indicating peritoneal irritation. The colour of the skin is normal, the pulse is good, the abdominal muscles, especially on the right side, are tense or become so, as soon as they are touched, and we think of appendicitis, because of its frequency or perhaps because it is in fashion. On careful examination, it will, however, be found that the centre of the painful area and the rigid musculature is not situated in the line joining the anterior superior spine and the umbilicus, or below it, as is the rule in appendicitis, but higher up in the region of the gall-bladder. Percussion probably shows that the liver dulness projects below its normal limits, even extending as far as the level of the umbilicus. If palpation is possible, despite the muscular rigidity, an area of resistance, with its lower border circular in shape, will be felt, connected with the liver. If this be the physical condition found, there can be no doubt that the case is one of acute cholecystitis, and if the pyrexia persists for many days it is certainly of a suppurative character. The position of the pain and the pyrexia often suffice for the diagnosis, without it being possible to demonstrate the typical lobular or tongue-shaped area of resistance. In such case we may assume that a contracted gall- bladder, concealed under the liver, has become inflamed, and we will generally obtain an old history of gall-stones, in confirmation of this assumption. A recent perforation of a gastric or duodenal ulcer might suggest acute cholecystitis. But in perforation, the reflex muscular rigidity very quickly affects the whole abdomen, and generalized peritonitis soon sets in if the case is neglected, symptoms which only occur in cholecystitis if an infected gall-bladder perforates into the free abdominal cavity. Pancreatitis and pancreatic hcBuwrrhage should also be mentioned in this connection. If the gall-bladder and appendix were invariably in their normal positions, differential diagnosis would be very easy. This is, how- ever, not the case. Sometimes the gall-bladder reaches as far as the ileo-cjecal region, whether the liver be movable or not. But much more frequently, the appendix is high and directed outwards. SURGICAL DISEASES OF THE BILIARY PASSAGES 317 At other times its position is in close proximity to the gall-bladder (fig. 143, //) especially when there is a " mesenterium commune ileo- caecale." I once saw it, at an early operation, strung up by a lateral band of connective tissue, close to the gall-bladder behind the liver. These abnormalities in the position of gall-bladder and appendix have led to many errors in diagnosis. The following is an instance : — A female, aged 40, was operated on by an experienced surgeon for a " perityphlitic abscess," and she subsequently had a persistent fistula in the ileo-caecal region. Two years later she was admitted to hospital, suffering from acute hemiplegia. She died in a few days, and the autopsy showed that the fistula, which opened at the upper part of the inguinal region, led into the gall-bladder, which contained a large stone. The cystic duct was closed. The hemiplegia was the result of a cerebral abscess, in which were found diplococci similar to those in the gall-bladder. Neither the surgeon nor the physician was fortunate in the diagnosis of this case, although they were both experienced observers. When the inflammatory process occurs above the line joining the anterior superior spine to the umbilicus, we should think of appendi- citis if the pain or resistance reach far towards the side, and if the lumbar muscles respond to pressure, by contraction ; but any in- flammatory process internal to the external border of the rectus must be ascribed to the gall-bladder. If jaundice supervenes in addition, the beginner will immediately decide in favour of gall-stones. This is usually a good guess, because the extension of the inflammatory swelling from the gall-bladder to the common duct often leads to a mild temporary jaundice. But, on the other hand, we often find a certain amount of jaundice in appendicitis, not necessarily in the severest cases. If the appendix lies near the gall-bladder, so that the biliary passages are secondarily involved in the inflammation, the jaundice may become very pronounced. A young man was brought into the hospital with a high temperature, severe jaundice, and abdominal resistance reaching outwards from the lateral border of the rectus, immediately adjoining the liver, and extending as far as the crest of the ilium. Despite the jaundice a diagnosis of appendicitis was made, based upon the lateral position of the resistance. This was confirmed at the operation. A rule to the following effect often enables a correct diagnosis to be made, when the painful spot is situated just on the border line : if the dulness reaches as far as the flank, the case is appendicitis, but if an intestinal note can be elicited externally to the painful area, cholecystitis is present. It is important to make a correct diagnosis. Early operation, within the first twenty-four hours, should be proposed in appendicitis; but in cholecystitis it is better to wait until the severity or the dura- tion of the symptoms demand interference. If the acute stage has 3l8 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA passed over without any interference, the appendix should be removed after two or three months, if the disease was appendicitis; but, on the other hand, operation should be avoided if gall-stones have become completely latent. If we still remain in doubt after taking all physical signs into consideration, we must be guided by the rule that appendi- citis is more probable the younger the patient, and gall-stones the older he is. Nevertheless I have twice seen girls, aged i8, sent in for appendicitis, but who were really suffering from cholecystitis. A special form in which 1 cholecystitis may manifest itself should be referred to. Just as cases of gall-bladder inflammation come to the surgeon with the diagnosis of appendicitis, so do others present themselves which have been diagnosed as "ileus." Indeed cholecysti- tis may at its beginning or during its progress, cause adhesions between the in- testine and gall - bladder, kinking or inflammatory in- filtration of the intestinal wall, extensive, serous or sero - purulent peritonitis, which may either produce mechanical obstruction, or the toxic symptoms of an obstruction. A correct dia- gnosis can only be made from the previous history of the patient, and the presence of pain and resistance, or at pressure, in the region of the Left. Fig. 149. b. Calcium fig- iSo> 5-) Right. — fl, Bismuth shadow in duodenum, carbonate gall - stones. (See also least of a localized gall-bladder. area of pain on (3) GANGRENOUS CHOLECYSTITIS. In the forms of gall-bladder inflammation so far described, the disease has been limited to the gall-bladder and its immediate vicinity. But if the clinical aspect is much more severe and septic symptoms develop rapidly, or if an increased resistance follows upon a very acute stage, we should suspect gangrenous inflaniniafion of the gall-bladder, with extensive participation of the peritoneum. A man, aged 65, was suffering from severe inflammatory symptoms SURGICAL DISEASES OF THE BILIARY PASSAGES 319 ^ U B - S O ri J- o c „ c •" i2 '2 '^^ ^ ^ 1> o ^o 3 ii .„ -— :5 5 ?i-^ 03 ,Sfl ^ c 13 OS .5 c 1 1 1 ^ 1 ii . 'S ii >- S ■_3 -c 1) .- c — .5 u :2 , tubercular or other ulceration to displacements of the large intestine and inflammatory processes in its vicinitv. It may also be due to toxic causes, such as alcohol, tobacco and mercury, and also to bacterial poisons. The latter circumstance explains the erroneous conception of muco-membranous colitis, as the result of an intestinal infection. The main surgical interest of this disease concerns its diagnosis. The practitioner must recognize it as a disease in itself, which, COLITIS AND FUXCTIOXAL DISTURBANCES OF LARGE INTESTINE 343 especially in women, is capable of mimicking all possible painful affections of the abdominal cavity, and which makes neurasthenics fearfully apprehensive of cancer, but he must also appreciate the important fact that this disease may be a concomitant manifestation of genuine cancer. It also has surgical interest from the point of view of treatment, because attempts have been, and are still bein<> made to cure the very severe forms of the disease bv procedures, varying from a simple caecostomy to extensive resections of the bowel, as no prospect of recovery is offered by medical treatment, including baths, diet, electricity or psycho-therapy. It is sometimes quite impossible to restore the intestinal reflex actions to a normal condition, in a neuropathic individual, ni whom all reflexes are out of gear. The prognosis is most favourable in those cases wherein we have been able to cure some causative disease, such as cholelithiasis, a malady of the female genitalia, or appendicitis. In regard to this last, however, our prognosis must be guarded, as we shall see later on. The connection between appendicitis and muco-membranous colitis does not always turn out as we expect, and the colitis mav continue despite the removal of a diseased appendix. The entire large intestine does not invariably exhibit this abnormal reaction, nor are all the three previously mentioned forms of functional disturbance fully pronounced. As a rule, only the motor, and to some extent, the sensory disturbances are in evidence, while the secretory derangements are either absent or not striking. The con- dition is then essentially one of painful constipation. This leads to the question of the loccilizafioii of flic fuiiciional deraugcuienf, which mav be solved by X-ray examination. If a meal, consisting of 200 grm. of carbohydrate porridge and 80 grm. of barium sulphate, is given to a normal individual, the whole of it will be found in the caecum, ascending colon and to some extent in the beginning of the transverse colon, after six to eicrht hours. The ascending colon is empty, or nearly so, after twelve to eighteen hours, and the contents are seen or are visible in the lower section of the large intestine. The whole intestinal canal is emptv after twenty-four to thirty hours. If digestion in the large intestine is slow, the delay may be distributed over the whole oi the large intestine, or it may occur exclusively in that section wherein the faeces remain longest in order to become inspissated, namely in the first portion as far as the level of the gall-bladder (Stierlin's asxending type of constipation). The delay may also occur in the last section of the large intestine (sigmoido and proctogenic constipation). In our experience the ascending type of constipation gives rise to most subjective symptoms. This is due to the fact that the intestinal contents in this position are still semi-liquid and are more prone to cause fermentation with the development of gases than the more or less dry faeces retained in the sigmoid, or lower down. 344 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA All this prepares us for the conception of a clinical picture, which has been described in France for the last fifteen years under the terms of typlilocolite or iyphlite ptosiqiie. It has only generally been recog- nized in Germany quite recently as caxiiiii mobile (Wilms), typhliklasic, typhlatoiiie, &c. In the year 1897, shortly after the appendicitis rage set in, there was a great tendency to ascribe all ills in the ileo-caecal region to the appendix, and the old idea of stercoral typhlitis was entirely discarded. At this time, however, Dieulafoy, who was himself an advocate for early operation in real appendicitis, pointed out that there were attacks of pain in the ileo-caecal region which had nothing to do with the appendix, but which signified the localization of the muco- membranous colitis in the caecum. Although names and theories have undergone much change since then, or rather have been consider- ably multiplied, no real advance has been made upon the position defined by Dieulafoy. The established facts, as far as they possess diagnostic importance, may be summarized as follows : — There are many persons, mainly females, who complain of their caecal region, but who never get real attacks of appendicitis, lasting days or weeks, with the development of resistance or peritoneal exudation. The so-called "attack" usually resolves itself into a severe seizure of pain about the caecum, which only lasts a very few hours and has generally disappeared by the time the doctor arrives. But if the patient can be examined during the attack, it will be found that tenderness exists in the ileo-caecal region on pressure, but that there is no muscular rigidity. Indeed, a structure like an elastic cushion may be felt, and sometimes this vanishes under the hands of the examiner ; but if it can be carefully palpated it will be recognized as the distended caecum. Exceptionally, the temperature may be somewhat raised, and patients with active reflexes are liable to vomit. Sometimes the attack terminates in looseness of the bowels, at other times in diarrhoea. Then the tenderness on pressure also disappears ; no localized pain remains over the appendix for a few days, as is the case even after a mild appendicitis. On the other hand, we do find, as Dieulafoy has pointed out, painful, contracted portions of the large intestine, indicating a state of abnormal irritability or chronic colitis, and, occasionally, the onset of mucous discharge confirms the diagnosis. The caecum can often be felt to be movable and capable of being displaced hither and thither. A skiagraphic examination of intestinal function will show that the contents are unduly delayed in the caecum — i.e., constipation of the ascending type. Many of these cases have been submitted to operation, some COLITIS AND FUNCTIONAL DISTURBANCES OF LARGE INTESTINE 345 under the mistaken diagnosis of appendicitis; others were diagnosed correctly and were operated on, because the disease was interfering with the nutrition of the patients and their ability to do their work. The anatomical conditions found consist of a large c?ecum extend- ing low down, a normal appendix, remains of inflammatory adhesions on the caecum itself, and the so-called peri-colonic veil (which is merely the stretched mesenteric attachment caused by the tilting of the caecum) on the ascending colon, reaching as far as the hepatic flexure. These changes do not, however, explain all the symptoms, even if we include the kinking of the small intestine in front of Bauhin's valve, as recently described by Lane. At least every tenth person has an abnormally movable caecum, and very frequently adhesions and kinks produce no symptoms at all. Delay of the faeces in the caecum also occurs without symptoms. We must, therefore, revert to our original view that functional causes play the chief role in all these troubles of the large intestine. A normally innervated large intestine overcomes all possible difficulties, and even resists the effects of abnormal conditions of nutrition and life gener- ally. But if the innervation of the bowel departs from the physio- logical standard, it reacts towards abnormalities in the mode of life and slight mechanical difficulties, by simple constipation or by more or less definite symptoms of muco-membranous colitis. We are now in a position to state what we mean by the rather inappropriate expression, chronic appendicitis. Logically, the term should only be applied to that form of appendicitis in which the appendix does not recover from its inflamed condition. This is especially the case with tubercular appendicitis, but this condition requires no new name. It also occurs in very many ordinary attacks of appendicitis, wherein the complete subsidence of tlie inflamma- tory symptoms is prevented by faecal concretions, stenoses, adhesions, and kinks. In some cases the owner of the appendix is unconscious of this chronic irritation ; in other cases he suffers frequent but sHght pains, reflex disturbances of the intestinal function, and even from muco-membranous colitis. Other patients only experience an indefinite discomfort in the right side of the abdomen. As most appendices which have suffered from several attacks remain in a state of chronic irritability, there is no object in separating them clinically from those cases in which this irritation becomes more pronounced than usual. This constitutes one class. The other class has nothing at all to do with the appendix. It embraces those cases which were formerly justifiably termed ster- coral typhlitis, and consists of localized ulcerative colitis, localized functional disturbances of the large intestine in their various forms, such as '' typhlo-colite," caecal distension, &c., either of mechanical 346 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA or functional origin. It is obvious that these cases ought not to be called chronic appendicitis. We would not have gone into this matter so much in detail were it not that it possesses great practical importance. When may the practitioner be satisfied with the assumption that the case is one of mere functiona!" disturbance of the Ccecum, and therefore abstain from operation during the first twenty hours ? He is justified in this course if the attacks are frequent and of short duration (only a few hours), if there is mucous discharge and a pronounced neuropathic history, and if the actual attack subsides within a few hours. This affords adequate time for observation, so as not to miss the opportunity of early operation if the case is one of genuine appendicitis. In this connection it must be emphasized tliat pulse and temperature are in no way decisive, because we have seen cases of appendicitis with pus formation wherein the pulse has not exceeded 100 per minute and the temperature has not been above gg'S- A. leucocyte count is of some value, because a definite leucocytosis indicates appendicitis, but if the leucocytes are normal in amount it cannot be regarded as an argument against the disease. If the patient has not recovered at the end of the first twenty-four hours it is our duty to propose operation. It is to be hoped that the recently acquired knowledge regarding the caecum and the ascending colon will not increase the mortality from appendicitis throu£ih neglect of oneration. CHAPTER XLVII. INTESTINAL OBSTRUCTION. One of the most grateful tasks which can fall to the lot of the surgeon is to relieve a maladv which is popularly recognized to be attended with great suft'ering. Early diagnosis and an accurate appreciation of the moment to interfere, are, however, essential for this purpose. Cases of intestinal obstruction exemplify better than any other condition how dangerous it is to wait for the fully developed clinical picture before arriving at a decision. To pursue this course is to sacrifice the life of the patient to refinement in diagnosis, excellent thougli the motive be. There is no object in being able to proclaim at the autopsy that we had correctly diagnosed INTESTINAL OBSTRUCTION 347 the situation and nature of the obstruction. Our main object must be to recognize when surgical rehef should be afforded, although we may not always know the precise position and character of the obstruction. This is no encouragement, however, to laxity in diagnosis. On the contrary, careful observation, tlioroiigh examina- tion, and a consideration of all signs are indispensable, but this must be done rapidlv, and we must decide rapidly, if our reflections are to be of any use to the patient. In practice it is necessary to distinguish two great groups of intes- tinal obstructions : (1) A complete form which comes on snddenly; and (2) a form which comes on gradually and which is incomplete while it is developing into chronic obstruction. We will deal first with the latter, in which the process can be followed more leisurely in all its details. I.— STENOSIS OF GRADUAL DEVELOPMENT. (Chronic Intestinal Obstruction.) A.— SYMPTOMS. Colic, i.e., the painful contraction of a portion of the intestine, is the first symptom of narrowing in its lumen. But colic is of such frequent occurrence that it does not signify very much by itself. But if pains of the same type regularly recur in the same area of the intestine they definitely point to a local trouble in the shape of a local obstruction of the intestine. This, however, is not sufficient for a diagnosis. Such pains may be present in colitis of any origin. In order to confirm such a condition it is necessary that there should be abnormal dilatation and visible or palpable contractions of the bowel above the site of obstruction. The dilatation is recognized by the repeated occurrence of a highly tympanitic or metalHc note, occasionally by the metallic sound of the peristalsis at the same site, and by spontaneous crepitant noises. Abnormal contraction is recog- nized by the periodical hardening of the bowel, which is very different to the contraction of the intestine in colitis. In the latter case, the bowel, which contracts when it is empty or contains a little faeces, feels like a firm band (" corde colique" of the French), whereas the liardened intestine — either the large or small — above an obstruction gives one the impression of an elastic tumour. That we are dealing with rigid intestine is quite clear from the tympanitic note on percussion, and from the periodical onset and disappearance of resistance. If we are fortunate enough to detect a buzzing sound at this spot as the resistance disappears, there can be no further doubt about the existence of a constriction. This applies not only when 23 348 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA one coil of intestine hardens and relaxes with a heaving movement, but even when a whole segment of bowel shares in this process — when, as sometimes happens, as many as four parallel tumid coils are present (fig. 152). It is often necessary to wait and watch for some considerable time at the patient's bedside in order to witness these phenomena, if they cannot be elicited by palpation of the bowel. As the illness progresses and the com.pensatory hypertrophy of the intes- tinal muscle is no longer able to overcome the obstruction, com- pensatory disturbance occurs, which declares itself by persistent abdominal distension, leading to complete intestinal paralysis. But this distension is by no means a sine qua iioii for the diagnosis of stenosis of the bowel, as beginners often imagine. We have, for instance, seen a case of ileo-caecal stenosis which was too narrow to admit a cherry-stone, and, nevertheless, the abdomen was quite flat, or even depressed. Fig. 152. — Rigid contraction of bowel, through obstruction of small intestine by a fibro-sarcoma. The above-described symptoms are most pronounced in stenosis of the small intestine. The hardening in the targe intestine is often very indefinite, which accounts for so many late diagnoses. This hardening can very frequently still be detected in stenosis of the ascending colon or hepatic flexure, but then it also involves the lowest coils of the small intestine after Bauhin's valve has been thrown out of action. One sign, which we meet with in acute complete obstruction, is almost completely absent in incomplete cases, i.e., vomiting. It occurs first when the obstruction becomes temporarily or persistently complete, and the higher up the obstruction is, the earlier it takes place. The condition of the stools affords important information, but not quite so much as is generally supposed. One often hears the verdict — there is no obstruction because the patient has normal stools ; or, on the other hand, that there is obstruction because the faeces are in little masses, looking like sheep's faeces. The one IXTESTIXAL OBSTRUCTION 349 conclusion is as erroneous as the other. The stools form themselves slowly in the large intestine from the transverse colon onwards. If the obstruction is in its upper part, where the faecal contents are normally liquid, there is nothing to prevent the normal formation of faeces below the obstruction. The patient, therefore, continues to have regular well-formed stools— often up to the moment when complete obstruction comes on. Even if the stenosis is in the neighbour- hood of the splenic flexure the f^ces may still be formed normally. But when changes in the stools ensue as a result of more deeply situated stenoses of the large intestine they take the form neither of sheep's faeces nor of, " tape," but of alternate complete retention • — still euphemistically called constipation — and the evacuation of pulpy, soft faeces. This means that the intestinal contents above the stricture are not solid, "inspissated," but are pulpy or putty-like ; the narrower the stricture the more liquid they are. If in a case of obstinate constipation we meet with freces of the shape of balls, even very small balls, there is no occasion for anxiety, for we may safely assume that this is due to mere sluggishness of the bowel, which leads to abnormal inspissation of the intestinal contents, in contrast to what occurs in stenosis. In a case of mine, the medical attendant justly suspected cancer, on account of persistent diarrhoea, the patient being an old man. The tumour was not palpable from the abdomen, but I discovered it at once on bi-manual recto-abdominal examination. It was situated below the sigmoid. The so-called ''tape-like" faeces occur when they are of clayey consistence, and have squeezed themselves through a constriction near the anus, within reach of the finger — but never higher up. Tenesmus is always present in these cases (see "Difficulties in Defaeca- tion "). In every case of ^^constipation " we must ascertain its duration. If it has existed for years there can be nothing seriously wrong ; but . if it has only been present for a few months in a person who had not been constipated previousl}', it is a serious symptom and requires careful examination. A man, aged 50, consulted his medical attendant because of recent constipation. He found nothing in the abdomen and prescribed fruit. The patient continued to eat fruit with the greatest diligence for four months, and, eventually, came with cancer of the rectum, situated so high up that it was hardly operable. The conclusions to be derived from stools mixed with blood are only relative. If blood is present in a case already suspected of cancer, the suspicion is thereby strengthened. But we must not forget, that any ulcerative colitis may be accompanied by the passage of blood. Blood may also be present_ in muco-membranous colitis. In these cases the haemorrhage is seldom profuse, but the masses of 350 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA mucus contain within them specks of blood which lead to a correct diagnosis. The rectal mucous membrane sometimes bleeds when there are neither ulcers nor internal piles, the only change being one of hyperaemia. An infcruiixtnrc wiiJi pus indicates a deep ulcerative process in the lower part of the large intestine, such as may occur with a large excavating cancer or d^'Senteric ulcers. If the cancer is situated higher up, the pus is so intimately mixed with the stools that it is no longer separately recognizable. Any considerable evacuation of pus per rectum signifies that an abscess has broken into the bowel. The significance of intermixture ivith iniicus is not very great, because this occurs whenever the large intestine is irritated, in idiopathic colitis, as well as in colitis which follows tubercle or cancer. We must be verv careful in drawing any diagnostic conclusions from the effect on the genera! condition, because if the compensa- tion is satisfactory, nutrition does not at first suffer. If the attacks of colic are frequent, the patient instinctively diminishes the amount of his food, and therefore emaciates, even if there is no persistent con- stipation. The question of emaciation is not decided by the amount of fat which the patient retains, but by the amount which he has lost. It is enough to pinch up a fold of skin, especially over the abdomen or thigh, to show us what was there before. If the relative obstruc- tion has persisted for some time, there will always be a certain amount of cachexia. B.— THE POSITION OF THE STENOSIS. Palpation very often settles the question of position. We may be quite clear about the site of the stenosis if w^e feel a tumour in the region of the large intestine, or if we observe above it the previously described symptoms of hardening of the bowel, metallic note, &c. But it is quite another matter if we can feel nothing in the quiet stage, and if the hardening of the bowel and the colicky pains do not enable us to localize the trouble. In such circumstances we must endeavour to decide by means of systematic examination and logical deduction. But we must first realize what will be stated later on when discussing the localization in acute cases, that the symptoms in chronic obstruction are not pronounced from the start, because the obstruction is only incomplete. We shall subsequently refer to the importance of the skiagram in diagnosing the locality of the obstruction. One important peculiarity, which may give rise to error, should also be mentioned. Wherever the obstruction may be in the large intestine, e.g., in the sigmoid, the maximum dilatation of the bowel IXTESTIXAL OBSTRUCTIOX JD- will not be immediately above it, but will always be in the caecum, as long as Bauhin's valve is in working order. The explanation, which can be inferred both experimentally and mathematicallv, is due to the double factor that in the ascending colon and caecum the diameter of the bowel is greater, but the thickness of its wall is less than in the lower parts of the large intestine. This also explains why the most numerous and the deepest ulcers, which follow the dilatation, are to be found in the caecum and ascending colon, even if the obstruction is at the lower part of the sigmoid. !■!: A veritable ulcerative tvphlitis or peri-typhlitis may arise in this way, and lead the practitioner to look for the obstruction at the valve, where it is not situated. But the onset of peri-caecal inflammation in the course of the illness will actually make the expert think of the possibility of a deeper origin. If acute perforation occurs in a case of intestinal cancer, we must accordingly not look for it just above the obstruction, but in the beginning of the large intestine. I have seen a dilatation ulcer burst in this position in an old woman, in whom a peri-metritis had constricted the rectum. C— FORM AND CAUSE OF THE STENOSIS. Giridiuil obstruction of the lumen of the bowel is the result of concentric narrowing, through disease of the intestinal wall, or of external pressure. (i) Concentric uarvoiviiig occurs especially in cancer, tubercle, syphilis of the bowel, which is much rarer, and finally in non-specific cicatricial stenosis. The differential diagnosis between cancer and tubercle is de- termined by the age of the patient and by the localization of the stenosis. Tubercle may occur at any age, bat the multiple form of intestinal tubercle which so often causes constriction has been especially observed in young people, whereas ileo-Ccecal tuberculosis occurs both in the young and old. Tubercular stenosis may also occur in the further course of the large intestine, but not often. The behaviour of carcinoma is different. Cancer of the small intestine certainly occurs among young people, but it is a rare condition. Most intestinal cancers are to be found in the large intestine after the age of 30, the upper portion being affected at the earlier age-period, and the sigmoid usually after 50. The condition found on palpation also has its significance. If a chronic obstruction in the small intestine is distinctly palpable, it is most likely to be carcinoma, because a tubercular stricture very easily escapes the palpating finger. But both carcinoma and tubercle are equally easily palpable over the ileo-caecal valve. The latter is less sharplv circumscribed than the former. In cases of tubercle, intestinal symptoms will already have been 35 2 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA present for two or more years, periods of aggravation alternating witli occasional longer periods of improvement. In cases of cancer, the patient will previously have enjoyed good health, but from the moment symptoms appear they continue to become progressively worse. There may be remissions, and occasional improvement in the general condition, but of very short duration, and despite the brief time during which the malady has existed, the emaciation is very striking. Exceptionally, cancerous stenosis may drag on for years before a definite clinical diagnosis can be made. If X-rays are not decisive, an exploratory laparotomy is preferable to indefinite waiting. It should also be mentioned that in cases of ileo-cyecal tuberculosis, a mixed infection often causes acute attacks of peri- typhlitis, which are at first mistaken for ordinary appendicitis. I have encountered large abscesses with stinking pus in such cases. The same may happen in cancer, but much more rarely than in tubercle. Carcinomala in the rest of the large intestine as far as the splenic flexure, are easily felt, especially as they usually give rise to definite tumours, early in their course. The splenic flexure itself is not easily accessible to palpation, and it is necessary to get the patient gradually accustomed to the deep palpation which is required. The same applies to the he- patic flexure, especially in men. Cancer of the sigmoid cannot often be felt, because this part of the bowel so fre- quently lies in the true pelvis, and because the growth is usually very small. The bowel looks as if it has been tied round th a piece of string (fig. 153), and not as if it is affected by a growth. Bi-manual examination, under an ansesthetic, per rectum and abdominally, is often indispensable. If the obstruction is not found higher up, recto-sigmoidoscopy must not be neglected, be- cause this is the only method which reveals the condition of the lowest 10 to 12 inches of the large intestine. Cancer of the rectum, even if situated low down, may cause extreme narrowing of its lumen and produce symptoms resembling ileus. But the history of these cases shows that the chief complaint refers to tenesmus, so that to mistake a rectal cancer for one higher up is hardly conceivable, if a history is at all obtainable, and if a rectal examination has been performed, w'hich ought never to be omitted in any case of obstruction. Pure cicatricial constrictions are much rarer than the cancerous or tubercular variety. They should only be thought of when the Fig. 153. — Cancer of the sigmoid in the shape of a constricting ring. Wit INTESTINAL OBSTRUCTION 353 history definitely suggests the possibihty. Although strictures pro- duced by typhoid and dysenteric ulcers do not possess the importance previously ascribed to them, we do know now that injuries of various kinds may lead to stenosis. For instance, coiitnsion of the bowel may cause an infiltration in its wall, and this may lead to a temporary disturbance m its lumen, but it very rarely results in a permanent or in an increasing stenosis. The fearing ojf of a piece of mesentery, or what amounts to the same thing, thrombosis of the mesenteric vessels, is a much more serious matter. The interference with the circulation injures the mucous membrane, and by its destruction, leads to a cicatricial stricture, even if the nutritive conditions are adequate for the other layers of the intestine. A circular stenosis more often follows the replacement of a strangnlated hernia, whether performed by the bloodless or open method. We will discuss this incident in connection with stran- gulated hernia. For the sake of completeness we must mention syphilitic strictures, which, however, are always situated in the rectum and therefore cannot be confused with strictures higher up. Sarcomata and innocent tumours rarely cause obstruction of gradual onset, but they may cause more or less complete ob- struction through volvulus or intussusception. (2) We now turn to chronic ileus caused by tumonrs pressing on tlie bowel from tlie ontsidc. The actual obstruction may depend upon one of three conditions — (i) on direct compression, (2) fixation of the bowel by adhesions, (3) infiltration into the wall of the bowel. The first condition is the rarest. As long as the bowel remains movable it can usually find some position in which its function can be maintained. Therefore it is that chronic ileus so rarely occurs in the most extensive mnocent tumours as long as they are not affected by inflammatory irritation. Even in cases where there is not much room for dilatation of the bowel away from the tumour — as in a fibro-myoma fixed in the true pelvis — the tumour and intestine do not usually interfere with one another. A retroflexed pregnant uterus is an exception to this rule, because of its unrestrained growth- But in the case of a malignant tumour which fixes itself to the adjacent bowel and prevents its dilatation, chronic obstruction from the pressure is very likely to occur, even if the growth has a com- paratively small circumference. This occurs in carcinoma of the kidney and ovary, in large cancers of the litems, and in sarcomata in various positions of the abdomen. The symptoms of chronic obstruction in inflammatory processes are milder and always more transitory. In these cases the bowel is simultaneously compressed, fixed and infiltrated, the latter con- 354 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA dition interfering to some extent with its normal peristalsis. This variety of obstruction is most prevalent in connection with abscesses and band formation after perl-inetritis, appendicitis, peri-ueplirifis and tubercular peritonitis. Hitherto we have been assuming that chronic obstruction is, despite brief interruptions, a slowly progressive malady, wherein the leisurely development of symptoms leaves adequate time for examina- tion and reflection, but wherein the symptoms never cease completely. This is true for most cases, at least in a certain stage, but not for all cases, and especially not for the beginning of the disease. Chronic ileus maybe intermittent, although the cause of the disease continues unchanged Periods of colicky pain and bowel hardening may alternate with times when the patient feels nothing abnormal. This depends upon the compensatory state of the intestinal musculature and possibly upon destructive changes within the stricture. In such cases, the medical attendant, who is called when the patient feels ill, makes a correct diagnosis and advises operation. But as he improves the patient declines to entertain the idea of operation, and he consults, for the persisting " dyspepsia," a more cheerful physician, who treats the case in the intermediate stage and perceives nothing seriously wrong, and reassures the patient in good faith. But the catastrophe is not long delayed ; the patient is brouglit on to the operating table in extremis, too late for him and for the reputation of surgery. The less significant the symptoms are during a quiet interval, the more weight must be attached to the history. If the unequivocal signs of a stenosis have only once been reliably observed, i.e., localized colic, probably vomiting, circumscribed hardening of the bowel and the characteristic auscultation sounds, the case must be considered serious, even if all symptoms have temporarily disappeared. Chronic obstruction is not always progressive. If it is caused by a moderate amount of scar tissue, e.g., after a strangulated hernia or an injury, it is quite possible that the symptoms may gradually abate and finally disappear completely. This is even more likely to occur in cases wherein the lumen of the bowel is interfered with by inflammatory processes. These cases constitute a fair proportion of instances of intestinal obstruction which recover without operation, in addition to cases of volvulus and intussusception to be discussed later on. Much has been expected from X-ray examination in the diagnosis of intestinal obstruction, but not all the anticipations have been realized hitherto. The basis of the examination is a bismuth meal, just as in the case of the functional derangements of the large intestine, discussed in the previous chapter. Narrowing of the small intestine is usually the result of tubercular INTESTINAL OBSTRUCTION 355 stenosis. The narrowing is recognized by the stagnation of the bismuth meal in front of the stenosis. The smaH intestme should normally be quite empty four to six hours after a bismuth meal of Normal large intestine six to ten hours after bismuth meal. Normal large intestine twenty to twenty-four hours after bismuth meal. Large intestine after twenty-four hours in a case of spastic contraction of tranverse colon. Large intestine in case ot tubercle of caecum and ascending colon. (Absence of shadow in diseased areas.) Stagnation of faeces in cae- cum and ascending colon in a case of cancer ot sigmoid. (/) Loss of shadow in cancer of transverse colon (x). Stag- nation of fasces in caecum. (Taken after twenty-four hours.) Fig. 154. — Semi-diagrammatic illustrations of skiagraphy of large intestine. 200 grm. of porridge, at least if this is not soon followed by another larger ordinary meal, which would tend to delay the expulsion of the bismuth meal from the stomach. 356 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA The following facts must be taken into consideration in regard to the large intestine : — {a) The higher the position of the stenosis, and therefore the more hquid the faeces are, the narrower must be the stenosis in order to render it visible on the skiagram. {h) If the stenosis is situated very low down, the stagnation does not occur just in front of it, but in the caecum, as we have just seen. Constrictions of the descending colon and sigmoid are mainly in- dicated by an abnormally filled caecum and ascending colon, this fulness persisting longer than usual. The same picture is also seen in constipation of the ascending type. We should, therefore, not suspect or assume the presence of an anatomical narrowing unless repeated skiagrams show a stagnation of intestinal contents lower down in the large intestine, and always in the same place. Our suspicion will be confirmed if the faecal masses always preserve the same shape at this spot. There may be a funnel-shaped gap in the shadow, indicating a narrow track in the bowel, or the loss of shadow may be at the side. Repeated examinations are indis- pensable, because such pictures may be the result of pure accident. In doubtful cases this test may be controlled by iiijectiiig 80 to 100 grm. of bismuth carbonate, or double this amount of barium sulphate, in i-g- or even 2 pints of very thin mucilage of starch. But as such a mucilage trickles through most constrictions, they are not always clearly demonstrated by this method. Attempts have therefore been made to follow the injection on the screen, and the results have been better. The temporary stagnation of the material injected has rendered it possible to localize the stenosis in a few cases. (Haenisch.) Skiagraphy renders great assistance in the diagnosis of intestinal disorder, and may be able to localize the disease when other methods fail, but as we have already said in connection with the stomach, it ought only to be employed for purposes of diagnosis in conjunction with other clinical aids. Hirschsprung's disease occupies a special position in the study of intestinal obstruction. The disease occurs in children — mostly in little boys — and is characterized by slight symptoms of obstruction combined with extreme distension of the large intestine by faecal masses. The blocked bowel is quite easily visible through the skin of the emaciated patient. On making a rectal examination masses of clay-like faeces are at once encountered, not only filling the ampulla but dilating it very considerably. The cleaning out of the bowel with the finger, spoons, and similar means, may occupy may hours. Apart from the exceptional cases wherein the large bowel is un- usually long and convoluted, or wherein the valve formation is abnormal, this disease is not due to anatomical changes, but merely INTESTINAL OBSTRUCTION 357 to a purely functional disorder of defaecation. The little patients neglect their bowels either because of some accidental pain — fissure of anus — or because of some reflex disturbance, which would be called "sluggishness" in older patients. The habit of constipation is thus formed, if this may justly be termed a habit. Unless the mother notices this condition, the faeces collect first in the rectum, then fill up the sigmoid and finally extend beyond. After a certain stage has been reached, spontaneous evacuation is impossible, owing to fiyper-distension of the bowel and sometimes also to some second- ary valve mechanism. If assistance is not i-endered, these children finally succumb to marasmus or symptoms similar to obstruction. The widely dilated coils of intestine are easily recognizable in a skiagram, with or without a bismutii meal. II.— ACUTE INTESTINAL OBSTRUCTION. A.— SYMPTOMS. Acute intestinal obstruction differs from the chronic form in the suddenness of its onset and the completeness of the stoppage. It manifests, within the course of a fevv hours or of a day, the incidents Fig. 155. — Hirschsprung's disease. which take weeks or months to develop in chronic cases, and shows more besides. In addition to the essential symptoms of intermittent colicky pains and localized hardening of the bowel, there occurs the important and regular sign of vomiting, which in chronic cases is only met with during an acute exacerbation. The general condition deterio- rates rapidly owing to the lack of fluid intake and to the absorption of toxins. The urine diminishes in amount and contains indican ; the pulse, which at first is quiet and full, soon becomes rapid and small ; 358 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA the breathing, which at first is only hurried during the actual colic, becomes rapid and shallow as meteorism increases, and the patient dies in a few days of hunger and thirst, unless peritonitis has ended the scene more quickly. The diagnosis is often rendered difficult, because the symptoms of obstruction mav be masked by those of the initial shock, which mani- fests itself bv accelerated pulse and collapse. In a very severe case these symptoms merge almost uninterruptedly into the paralytic mani- festations of the terminal stage, so that the pure signs of intestinal obstruction are not observed at all. In such a case the diagnosis may rest between acute perforative peritonitis and obstruction. Perforation of a gastric or diiodeiiai nicer, with its disastrous symptoms, must be thought of in this connection, as also any condition which causes sudden shock and reflex intestinal paralysis, e.g., pancreatic Jicemorrliage and inflaniniation, torsion of an ovarian or onierdal tnnionr, embolism of the mesenteric arteries, tnhal abortion, or ruptured tnbe, and even tabetic crises. Repeated percussion and auscultation afford the best aid to diagnosis. If we repeatedly hear at anv one place a metallic note, splashing or ringing noises, or, exceptionally, a stenotic murmur, and if the abdomen appears to be asymmetrical, with a localized area of the intestine, despite its tym- panitic note, more resistant than its surroundings, we ought especially to think of ileus. But, on the other hand, the prevalence of dead silence from the beginning in an equally distended bowel most pro- bably points to peritonitis. B.— THE POSITION OF THE OBSTRUCTION. The diagnosis of the seat of obstruction is comparatively easy when it is either high or low ; but difficult or impossible when it is in the mid-portions of the intestine. The most important indications are given in the accompanying table, and it is only necessary to add a few general observations. The peristaltic movements in the small intestine are much more active than in the large intestine. But no conclusion can be drawn from the degree of meteorism, because it may be just as pronounced when the obstruction is low down in the small intestine, as when situated in the large bowel. "Meteorism in the flanks" (''cadre cohque "), ostensibly a sign of obstruction in the large intestine, is more of a theoretical condition, because only the upper and middle portions of the bowel distend to any great extent — from the cjecum to the trans- verse colon — so that the frame is only half formed. If the distension proceeds further onwards, and the sigmoid is well developed, it will involve the mid-portion of the lower abdomen, but will not form a IXTESTIXAL OBSTRUCTIOX 359 frame. But we may consider it established that a high tympanitic note in the right hmibar region points with great probabiUty to obstructioii of the hir""e boweL (a) Obsiriiction at cardia. — Abdomen flat, regurgitation of food by cupfuls, mixed with blood and mucus, often alternating with vomiting. Cancer, rarely cardio-spasm. {b) Pyloric obstruction. — Epigastrium distended, rest of abdomen flat. Vomiting, by the dishful, of food taken days before, mixed with gastric juice and often with mucus, blood and coffee grounds. No bile. Stenosis after ulcer. Cancer. (c) Ditodeno-jejiinal obstruc- tion. — Abdomen as in c. Splash- ing sounds to the right of umbili- cus (lower part of duodenum). Biliary vomiting, not faecal. Arterio-mesenteric intestinal ob- struction, Treitz's hernia, tuber- cular band. {d) Obstruction at upper part of small intestine. — Meteorism, if present, moderate, central or diffuse. Vomiting biliar}-, rather faecal, powerful peristalsis. Bands, volvulus, tubercle, tumours, intus- susception, internal hernia. (e) Obstructioii at loiver part 0/ small intestine. Meteorism, if present, general. Faecal vomit- ing, powerful peristalsis (Causes as in d.) (y) Obstmction at ileo-ccecal valve. — -As in e, but condition usually palpable in right pelvic cavity. Intussusception, volvulus, cancer, tubercle. (g) Obstruction of large intes- tine at hepatic flexure. Meteor- ism if present, general. Caecum and ascending colon distended. Active peristalsis occasionally. Faecal vomiting. Possible to in- ject li to 2 litres of fluid into rec- tum. If obstruction incomplete, stools are formed. Condition generally palpable. Cancer, tu- bercle very rarely. (A) Obstruction of large intes- tine at splenic Jlexure. — Meteor- ism as above, but transverse colon also somewhat distended. Injec- tions of I to ij litres possible. If obstruction incomplete, stools generally forme'l. Palpation more often negative than in g. Cancer, tubercle very rarely, or syphilis. (?) Obstruction at sigmoid. — Meteorism as above, main disten- sion of colon at caecum. Slight peristalsis. Injection of \ to \ litre possible, seldom more. If obstruc- tion incomplete, diarrhoea alter- nates with constipation. Palpa- tion often negative owing to sirall- ness of growth, but sigmoidoscopy and bi-manual e.xamination under chloroform advisable. Volvulus, cancer. (li) Obstruction in upper pari of rectum. — Meteorism as above. Constipation alternating with diarrhoea, or always thin evacua- tions. Exceptionally ribbon- shaped. Tenesmus occasionally. Cause detected by rectal or combined examination, tumours and inflammation within true pelvis. (/) Ob'ttriiction in ampulla.— Tenesmus, fluid or ribbon-shaped stools. Causes : Cancer, syphilis. Can be felt and sometimes seen. Fig. 156. — Diagram of the typical positions of intestinal obstruction. Cancer, syphilis, Obstruction high up leads to many mistakes in diagnosis, because flatus and stools still pass and the abdomen remains flat, even if the obstruction is long persistent. These cases often suggest cerebral, 360 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA urasmic or even hysterical vomiting, gastric crises or the onset of peritonitis. The last, however, can be excluded by the absence of any local irritative symptoms, uraemia by the condition of the urine, cerebral or tabetic vomiting by the absence of any other cerebral or spinal cord symptom. The obstinacy of the vomiting, the rapid decrease of urine and the cessation of the passage of stools and flatus within a few days will finally convince those wiio cannot conceive of intestinal obstruction without a drum-like abdomen. We cannot expect much elucidation from X-rays in cases of com- plete intestinal obstruction. There is no time for an examination of the intestinal movements, because immediate operation is, as a rule, necessary. It is quite conceivable, however, that X-rays may be use- ful in subacute forms, to localize the obstruction accurately, when it is situated high up. Similarly in cases of obstruction low down, in the large intestine, a skiagram may be valuable after a bismuth injection, more especially as this delays the operation less than an examination of the intestinal movements. Besides this, a bismuth meal is liable to be vomited, and the site of the stagnation of the test material is not the position of the obstruction. But a skiagram taken after an injection has not only a theoretical interest, in complete obstruction of the large intestine — the time is too precious for theoretical examinations in such cases — but possesses the great practical value of indicating the correct position for operative interference. C— THE GENERAL VARIETIES OF ACUTE OBSTRUCTION. Before discussing the detailed causes of acute obstruction, we will glance at the different forms in which it may appear. This considera- tion will often facilitate accurate diagnosis. The following are the main varieties : — (i) Obstruction passing from ail I iiconipleie Chronic into a Teinporarily Complete — apparently Acute, Stage. — Cancerous and tubercular disease constitute the chief examples of this group. If an elderly patient who has been suffering for several months from colic and increasing dis- tension, has passed neither stools nor flatus for two days, but vomits bowls full of brown foetid material, it is highly probable that he has a constricting carcinoma of the colon, particularly of the sigmoid. If a younger man with tubercular antecedents and a history of months' or years' suffering from colic, shows signs of complete obstruction, he probably has a tubercular stricture in the small intestine or at Bauhin's valve. Many cases of obstruction during the course of tubercle or cancer of the peritoneum should be included in this group. In both, the apparently sudden onset of complete obstruction will always have been preceded by some abdominal discomfort, especially INTESTINAL OBSTRUCTION 361 colic and loss of appetite, which shows that the event has long been in preparation. (2) Intcfinittent Obstruction.- — This term applies to all cases wherein sudden attacks of transitory obstruction alternate with intervals of complete freedom of a variable duration, sometimes even of years. There is no permanent narrowing in these cases, but a temporary obstruction of the lumen of the bow^el repeatedly occurs, caused by some existing abnormality, which becomes latent at intervals, or by some anatomical change. This variety is mostly exemplified in torsion of the sigmoid, or more rarely by an abnormally movable ileo-cascal segment of the bowel, or, still more rarely, of the small intestine. Obstruction by omental or cicatricial bands, by abnormalities con- nected with Meckel's diverticulum, strangulation of internal hernia, kinking produced by tubercular adhesions, as well as arterio- mesenteric intestinal obstruction, may belong to the same group. (3) Sudden and nnanticipated Onset of Acute Obstruction. — This group includes the rare cases of sudden obstruction by cancer in apparently healthy individuals without any pathological antecedents. But the more carefully the history is taken, the more frequently some indication of previous disease will be found, if only some dyspepsia, slight pain, irregularity of the bowels, or unexplained wasting. Obstruction may also occur suddenly in tubercle, before any diagnosis of intestinal disease has been made. All the enumerated causes of intermittent obstruction come into consideration again if a first attack is under observation. Finally, there are cases in which, as a rule, one attack only occurs, e.g., intestinal obstruction from gall-stones. D.— CAUSES OF ACUTE INTESTINAL ;OBSTRUCTION. We now propose to consider whether any given case can be referred to one of the classical forms on the evidence of history and physical symptoms, and for this purpose we will briefly discuss the most important of these forms, begin nmg with those to wdiich the history provides the clearest clues. (1) Obstruction due to Bands and Kinks. If the patient has had an abdominal operation, however long ago, we shall rarely err if we diagnose obstruction by a band. Bands, which result from operative procedures are more dangerous, because they are usually more circumscribed than those which arise spon- taneously after inflammation. Nevertheless, the latter may also produce obstruction by bands, 6'.^., after appendicitis, cholecystitis, inflammation of the female genital organs, and tubercular peritonitis. 362 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA The last may produce adherent omental bands in the true pelvis. The adhesions, which occur after ulceration of the large intestine, pericolic cords and bands, are flatter, and therefore are more liable to give rise to chronic obstruction. If signs of obstruction in the upper part of the small intestine occur in an emaciated individual, the subject of lateral curvature or Pott's disease, we should think of aiicrio-uiesenteric intestinal ohstriic- tioii, i.e., kinking of the small intestine at the duodenal boundary by the root of the mesentery. A duodenum with a very low-lying situation is necessary, or at any rate is a favourable condition for the causation of this form of intestinal obstruction. The knee-elbow position removes the obstruction and confirms the diagnosis. The classical picture of arterio-mesenteric intestinal obstruction was seen in a girl, aged 13, the subject of disease of the cervical spine and compensatory lordosis in the lumbar region. The stomach and the duodenum, which, as the operation showed, reached considerabh^ to the right, were greatly distended, and gave evidence of splashing on auscultation. The stomach was tympanitic and the duodenum yielded a metallic note. The cervical disease prev^ented the use of the knee-elbow position for the purpose of treatment, and the fact of tuberculosis did not, of course, exclude obstruction by a band. Laparotomy was, therefore, performed, and I found the whole of the small intestine deeply in the true pelvis. The kink was situated at the junction of the duodenum with the jejunum. The latter became .^lled with gas as soon as it w-as lifted up. It is an open question whether one should include here the duodenal obstruction which has been observed after laparotomy, especially in the upper portion of the abdomen. This condition depends upon atony of the gastric musculature, which sometimes occurs after operations on the abdominal cavity, and is analogous to atony of the rectum. It is a condition which certainly occurs in the slight infections which are overcome by the peritoneum in a few days. In other cases the peritoneum possesses an idiosyncrasy towards blood. The greatest degree of rectal atony which I have seen occurred in a case of post-operative haemorrhage, which was bacterio- logically sterile. (2) Obstruction by Gall-stones. If pain on pressure over the gall-bladder occurs siniultaneonsly with symptoms of acute intestinal obstruction, the case is probably one of acute cholecystitis. This disease frequently produces tem- porary signs of obstruction, either as a reflex process or by extension of the inflammation to the transverse colon or small intestine. If an attack of gall-stones Jias occiiryed previously the obstruction is most likely to be due to a gall-stone rather than to the so-called " bride-pericolique." The entrance, even of a large gall-stone into the small intestine, usually takes place bv a process of suppuration INTESTINAL OBSTRUCTION 363 without any striking symptoms, and the last attack of gall-stones observed by the patient may have occurred long previously. Some support for the diagnosis of " gall-stone obstruction " is afforded by feeling a firm and somewliat tender swelling in Douglas's pouch on vaginal or rectal examination. Most of these gall-stones remain tixed in the lower portion of the small intestine, and the coil con- taining the stone is dragged down into the cavity of the true pelvis. It might be thought that gall-stone obstruction ought to be included in the chronic variety, owing to the length of time the stone remains within the bowel. This is true for some cases, wherein the symptoms are very protracted and remittent, and the stone eventually departs spontaneously. But in most cases the symptoms come on very acutely, and we often find that signs of peritonitis super- vene at the same time, or at any rate very soon afterwards. If the stone is in a healthy coil of intestine, it will allow flatus to pass by it. But if it remains for any length of time, the intestinal wall becomes irritated and draws itself lightly over the stone, which then allows nothing to pass by it. At the same time a pressure ulcer develops, so that the intestinal wall becomes inflamed and infiltrated, and instead of grasping it by active contraction, becomes stiff by infiltration, and embraces the stone tightly but passively. At this moment the " attack of gall-stone obstruction " often begins. The inflammation rapidly involves the serous membrane, so that local peritonitis occurs early. If we make the diagnosis of gall-stone obstruction in such a case on the evidence of the clinical history, we must not hesitate to operate iininediately, on the assumption that most gall-stones pass through the bowel by themselves. The actual symptoms, indeed, show that the stone, in such a case, will not do so. The following is an illustrative case : — A man, aged about 50, who had suffered from a severe attack of gall-stones one year previous!}^, was suddenly seized at night, without any warning, with abdominal pain and vomiting. Twelve hours later, the pulse was already rapid, the abdomen tender and slightly distended, and contained some free fluid. The vomiting continued. The diagnosis wavered between obstruction by a band, or by a gall-stone, combined with severe peritoneal irritation and slight effusion. Opera- tion was done at once, and a gall-stone was found in the lower portion of the small intestine, in firm contact with the inflamed and infiltrated bowel. A pressure ulcer had already perforated, and the abdomen contained sero-purulent fluid. The operation, however, was unable to restrain the advance of the peritonitis. (3) Intussusception. Exceptionally, a positive indication is supplied by the age of the patient. This is true of intussusception in so far as it occurs in infants, who very rarely suffer from anv other form of obstruction. The symptoms vary with the degree of disturbance of the circulation in the invaginated portion, and they range from the very severest type, 24 364 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA with rapid death from peritonitis, to chronic intussusception of many months' duration. The beginning of the disease is usually marked by the passage of blood-stained, fruit-juice-like fluid with the stools,, and the intussusception can, as a rule, be felt, on careful examination, as a sausage-shaped swelling, close to the spinal column. The intus- susception rarely reaches so far as to be felt in the rectum, like the vaginal portion of the cervix, or be mistaken for a prolapse of the rectum. Intussusceptions which are not of the ileo-c^ecal varietv are, as a rule, caused by Meckel's diverticuUun or innocent tnniours of the bowel. In both cases the upper portion of the intestine with the tumour, or with the inverted diverticulum, is dragged into the lower portion. I once saw the characteristic etiologv well exemplified in a little boy ; the lower portion of intestine was fixed bv tubercular mesenteric glands, the upper, forming the intussusception, was, however, free. This corresponds to the condition at the ileo-cjecal valve, where the inore movable portion of the intestine becomes mverted into a less movable portion. We have mentioned the passage of blood-stained liquid as an important sign of intussusception. The same symptom occurs in infarction of the bowel, caused by blocking of a blood-vessel, which is usually accompanied by the symptoms of sudden intestinal obstruc- tion. The simultaneous vomiting of blood-stained material points to infarction. (4) Volvulus. There is a geographical indication which points to volvulus as the diagnosis of the form of intestinal obstruction. In most countries, neither the student nor surgeon sees manv instances of this condition, but in Russia, especiallv in the Baltic Provinces, volvulus is the most frequent variety of obstruction brought mto hospital. Gruber states that this is due to the greater length of the Russian intestine ; others attribute it to the abundant dietarv of potatoes. I know many places where the potato is a great favourite, but where volvulus is almost unknown. Gruber's view is also stoutlv contested. Indeed, volvulus is more likely to be due to congenital or acquired abnormalities in the mesentery, which permit a more extensive move- ment of some parts of the intestine, than to the length of the bowel in metres. To allow of the twisting of the bowel the mesentery requires a certain amount of hidependence, which is given it by a long mesenterv with a narrow attachment. Such a condition is only normal in the sigmoid, and it can be increased by the greater develop- ment of this coil or by the abnormal approximation of its lower extremity. Sometimes the ileo-caecal portion is provided with so profuse a mesentery that it occasionally twists about on its long axis. Finally, the whole of the siiuill intestine, either itself or with the large ■intestine, may possess such a narrowly attached mesentery that the whole bowel is capable of twisting in its entirety. I saw an instance IXTESTIXAL OBSTRUCTIOX 365 of this ill Kocher's wards, in a young man in whom the torsion occurred after an enormous meal of cherries, including the stones. The occurrence of torsion in a single coil of small intestine, pre- supposes a condition in which it has been subjected to traction for a considerable time, such as long detention in a hernial sac, or the pull of an intestinal tumour. The diagnosis of volvulus of the sigmoid is verv easy. In this condition the whole abdomen is occupied by an enormously dis- tended coil, with its head in the upper part, and with its more or less parallel limbs, which can be distinctlv felt, and even seen. Con- firmation is afforded by the impermeability of the sigmoid to an injection of water. An ilco-ccecal volvnlns may be diagnosed if, instead of a long and distended coil, we find that a roundish tvm- panitic tumour has suddenly formed, with a seizure of vomiting, and that an injection of water can be successfully given. Volvulus of the ccliolc siNdll intestine yields the symptoms of duodeno-jejunal obstruction, plus meteorism. The symptoms of volvulus of the small and large intestine together are about the same, but it is impossible to inject any large quantity of water into the rectum. It is not possible to differentiate volvulus of a single coil of small intestine from obstruction bv a band, and from strangulation into a peritoneal pouch. It is equally impossible to detect clinically the nodnles which are to be found in the vicinity of a volvulus, and which depend upon the presence of Meckel's diverticulum and the bands of connective tissue arising from it. The foregoing remarks apply to volvulus which has caused com- plete obstruction and a torsion of 360°. If the obstruction is in- complete (torsion of 180' to 270^), the symptoms are less severe, and often disappear spontaneously. For instance, 1 once saw the desired evacuation of flatus occur after a long journev, at the verv moment when everything was about to be expedited for an operation. In all these cases, however, the diagnosis is only a matter of pure probabilitv, (5) Strangulation of Internal Hernias. Strangulation into a congenital peritoneal pouch is one of the rare causes of intestinal obstruction ; but sometimes this diagnosis is suggested by the demonstration of a localized distension. But before we think of an internal hernia, we must exclude strangnlation of an cxterncd liernia, which is not always so easy to do as it mav appear, especially in cases of pro-peritoneal and inter- muscular inguinal herniae — hernia; of the obturator foramen, lumbar, and gluteal herniae. I recall a case which occurred when I was an assistant. A young woman was sent into the surgical ward after suffering from obstruc- 24A 366 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA tion for several clavs. She had ah'eady been examined for hernia. but none had been detected. Nevertheless a slight resistance at the apex of the internal inguinal ring pointed to strangulation of an interstitial hernia ; and at the operation it was found that the contents of the hernia were alread_y gangrenous at the constricting ring. An error in connection with an obturator hernia is more pardon- able. In a tvpical case, however, the pain or deep pressure below Poupart's ligament, and the neuralgia of the obturator nerve — probablv called old rheumatism by the patient — allows the diagnosis to be made with the greatest probability. But, on the other hand, not every hernia which may accidentally be present, even if irreducible, must be credited with the causation of intestinal obstruction. If the hernia is not tense, and if there is no pain on pressure over its neck, it has nothing to do with the obstruction, even if old adhesions have rendered it irreducible. If a hernia has been reduced previously to the occurrence of obstruction, the neighbourhood of the ring must be examined. Anv in-drawing of the tissues, or indefinite resistance, or pain on deep pressure points to reduction en masse; but if the hernial ring is normal, it indicates that the obstruction has some other origin. There are three particularly important forms of internal hernias : [a) Hernia at the Foramen of Winslow. When strangulated, this causes a tumour behind the stomach. It has often been operated on, but has not previously been diagnosed, [b) Diagnosis ought to be more possible in clnodeno-jejnnal hernia. This begins at Treitz's pouch, where the jejunum passes under the transverse colon. The pouch opens to the left of the first part of the jejunum, and is directed thence obliquely upwards and to the left. It may become large enough to contain the major portion, or, indeed, the whole of the small intestine.' The svmptoms of these hernia are intermittent in character: but this circumstance is common to several other forms of intestinal obstruction. The hernial tumour is situated in the epigastrium, rather towards the left. There have been cases recorded wherein strangulation has occurred in a similar pouch arising from the right of the jejunum. (c) The third typical position for internal hernice is in the appendix region. Of the various pouches described by anatomists only two possess surgical importance, viz., the ileo-appendicular, which is situated betw'een the appendix and the end of the small intestine under the region of Bauhin's valve ; and the refro-ccBcal, which runs laterally from the appendix behind the caecum. In both forms a hernial swelling is found in the ileo-caecal region, and if no other cause for the inte>tinal obstruction is evident, it is fair to assume that one of these varieties of hernia is responsible. INTESTINAL OBSTRUCTION 367 We shall not mention any of the rarer forms of internal hernia^ for it is quite impossible to diagnose them clinically. This applies to strangulation in openings of the mesentery, omentum, or broad ligament. Diaphragmatic hernise are seldom suspected before operation, unless a previous injury to the diaphragm has suggested its proba- bility. A tympanitic note or dulness over the left lower lobe and marked dysphagia might arouse suspicion. These hernise are either on the left side, or in a space in the diaphragmatic attachment to both sides of the sternum (Alorgagni's space). An X-ray examination after a bismuth meal furnishes the best means of diagnosis. (6) Spastic Obstruction. Spastic contractions of the intestine, without any evident cause, sometimes occur after abdominal operations, and if thev persist for any length of time lead to symptoms of intestinal obstruction, i.e., spastic obstruction. The following is a typical case : — A young, healthy man came to the hospital with symptoms of obstruction high up in the small intestine and a temperature of 99"6'"' F. The family history suggested tubercle. It was remarkab e that his general condition remained comparatively good, despite the continuance of the obstruction. Operation showed that a coil 15 cm. in length, in the upper part of the small intestine, had contracted to a thin band. When the spasm relaxed all symptoms vanished. It is possible that atropine might have been effective here^ and permitted the making of a diagnosis. As a rule, no diagnosis is made until the abdomen is opened ; spastic conditions of the large intes- tine are more frequent, but less serious. Persistent vomiting must not be confused with spastic obstruction, because hysteria may imitate intestinal obstruction. But in that condition the physical signs do not correspond with the general severity of the symptoms arranged bv the patient. If it is pretended that solid faeces are vomited, this must baffle even those who easily believe what they are told, because lumps of faeces are not vomited by anti-peristalsis. They get into the vomit in a much simpler wav. Relapses have been observed in cases wdierein the first " exhibition " was successful. A thorough course of psychical treatment is required to prevent these relapses. 368 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA CHAPTER XLVIII. TUMOURS AND SWELLINGS IN THE ABDOMINAL PARIETES. The superficial situation of a tumour or swelling indicates that it is in the abdominal wall and not in the abdominal cavity. But in very thin people a genuine intra-abdominal tumour may appear to be quite superficial. It is, therefore, necessary to make the abdominal muscles contract. If the tumour then disappears, it must be situated within the abdominal cavity, or, at any rate, under the abdominal muscles. If however, the tumour can slill be felt, and at the same time becomes immovable, it is obviously connected with the muscles or fascia?. Should the muscular contraction make no difference at all, the tumour is situated either within the skin or subcutaneously. Fig. 157. — Chronic abscess in epigastrium. In order to obtain a correct idea amid all the various possibilities, it is very important to note whether the tumour is in a position "typical" of these pathological changes, i.e., in the middle line, in the inguinal region, in the lumbar region, or whether it has appeared at some other point. (1) THE UPPER ABDOMINAL REGION. A swelling in the epigastric region may, apart from exceptional rarities, be one of three things ; viz., (i) an epigastric abscess ; (2) subcutaneous lipoma, or (3) an epigastric hernia. If the swelling is acute, and presents the appearance of a firm infiltration, which, after a little while, begins to soften in the centre TUMOURS AND SWELLINGS IN THE ABDOMINAL PARIETES 369 and fluctuate, there is no difficulty in recognizing an epigastric abscess. The chronic form, in which the skin remains unchanged for a considerable time, may easily give rise to doubt. But even in these cases the wide base of the swelling (fig. 157), and the fluctuation which is rarely absent, suffice to indicate an abscess. The source of infection is often a gastric ulcer which has become adherent to the abdominal wall, and which has protruded after suppuration. Theoretically, one would imagine that these abscesses contain gas, and that their incision would lead to the formation of a gastric fistula. But, as a matter of fact, this is not always the case, for the collection of pus may have no connection with the interior of the stomach, and may heal up without delay. Figure 157 represents such a case. The cause — - gastric ulcer — was only suspected ; it was not strictly demonstrated. In other cases, the swelling may be an ab- scess due to tubercle of the ribs or sternum. Rarely it may be a bur- rowing abscess making its way through the ab- dominal muscles. Subcutaneous lipo- mata differ in no re- spect from lipomata in other situations. The accompanying illustration (fig, 158) shows that they may attain an ordinary size. They are distinguished from epigastric hernias and from sub- serous lipomata, by their free mobility over the sheath of the rectus. Epigastric herniae and subserous lipomata are, however, much more frequent. In order to appreciate their origin we must realize that a large amount of fat is contained in the upper triangular area of peritoneum which has its apex at the umbilicus. The first stage in the develop- ment of a hernia is the protrusion of a lobule of fat through an oval slit, which is always situated transversely in the fibrous tissue of the linea alba. If this lobule continues to grow after it has become free, 24B Fig. 158. — Subcutaneous lipoma of the epigastrium. 370 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA it develops into an ordinary subserous lipoma (fig. i59rt). As it grows it usually pulls up some peritoneum into the slit, so that it obtains a pedicle of peritoneum, which, however, contains no abdominal viscus within it (fig. 1596). If this peritoneal protrusion in front of the slit in the aponeurosis develops mto a hernial sac, into which omentum or bowel finds its way, the case is one of epigastric fatty hernia (fig 159, c). If, finally, the hernial development is greater than the fatty proliferation, the case is one of ordinary epigastric hernia (fig. 159, ^); The differential diagnosis, in these conditions, depends to a great extent on the question of reducibility. If, despite patient and gentle pressure, the swelling cannot be reduced at all, and if we are told that Fig. 159. — Epigastric hernia and subserous lipoma. (i) Skin. (2) Rectus sheath. (3) Subserous fat. (4) Peritoneum. (a) Subserous lipoma, after breaking through sheath of rectus. (i) ,, ,, with some peritoneum pulled up into fascial slit. (c) „ „ with a hernial sac containing some protruded omentum. (Epigastric fatty hernia.) {if) Pure epigastric hernia, without lipoma. the circumference of the tumour is always the same, the case is one of pure subserous lipoma, an illustration of which is given in fig. i6o. If the tumour becomes large under the influence of abdominal pressure, but always permits of partial reduction, it is most probably a hernia, but the possibility of subserous lipoma cannot be entirely excluded. As far as their external appearance is concerned, they both look like the swelling depicted in fig. i6o. The hernia seldom attains the size illustrated in fig. i6i. A mass of omentum adherent to a hernia may resemble a lipoma, as the thickness of the abdominal wall does not usually permit of differentiating between omentum and a lipoma. TUMOURS AXD SWELLINGS IX THE ABDOMINAL PARIETES 371 If the diagnosis of epigastric hernia were always made in time, it would prevent many so- called "dyspeptics" wast- ing years on treatment for indigestion, when a simple surgical measure could at once restore them to health. The " dyspepsia " is caused by the pull on the perito- neum, or on the omen- tum firmly grasped within the hernial sac. But, on the other hand, one must not overlook a cancer of the stomach, because there happens to be an epigastric hernia present. Both the abdominal wall and the stomach must be investigated. I have, several times, seen the ligamentnm teres of the liver in this hernia, a circumstance which, as Graser remarks, is not without its influence on the symptoms com- plained of. (2) THE UMBILICAL REGION. If we find that a newly-born infant has a swelling in the um- bilical region, generally with a broad base, and but rarely pedun- culated, in which the intestinal contents — usually the liver and bowel — can be seen through a veil- like membrane, the case is clearly one of hernia of the umbilical cord (fig. 163). It is quite impossible to mistake this for any other condition, and therefore need not detain us. If the umbilicus projects in a semi-globular form and eventually in a conical or cylindrical shape, in Fig. 160. — Subserous lipoma in epigastrium. Fig. 161. — Large epigastric hernia. 372 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA a shrieking little cliild, only one diagnosis is possible, that of umbilical hernia. If an adult, generally over forty, presents a tumour, varying in size from a pea to a man's head, in the same region, the same diagnosis applies, if the swelling is, at least partially, reducible. The principal diagnostic interest in these cases, is not so much concerned Fig. 162. — Multilocular umbilical hernia in cirrhosis of the liver. with the nature of the trouble, as with certain of its accompanying symptoms. If the contents are reducible, either the granular feel or the gurgling sound will indicate omentum or intestine. But in some umbilical herniae it is impossible to demonstrate the one or the other. The contents are easily displaced by pressure, but neither the reduc- tion nor the refilling is accomplished with a jerk, which suggests TUMOURS AND SWELLIXGS IX THE AliDO.MINAL PAKIETES 37: that the contents must be fluid. On careful examination, free fluid "^vill also be found in the abdominal cavity, and the liver may exhibit signs of cirrhosis, or some cause for the ascites may be discovered in the heart or kidnevs (fig. 162). In large old-standing cases of umbilical hernia (fig. 162) it can be seen, even externallv, that they consist of separate loculi. Some of these may be reducible while others are not. It sometimes happens that a hard and tender swelling arises in one of these loculi, while the rest of the hernia still remains reducible. The most likely explanation of this occurrence is the strangulation of intestine or omentimi in one of the loculi. But other causes are conceiv.ible. For instance, in the case of an old woman, whom I suspected of such partial strangulation, the localized inflammatory symptoms were really caused by a tubercular Fig. 163. — Hernia of the umbilical cord in an infant. peritonitis which had involved tlie hernial sac. This might verv well occur also with cancerous peritonitis. On another occasion I witnessed a peritonitis, which arose from the suppuration of an ovarian cyst, involve a large omental hernia and form a circumscribed abscess. An inflamed gall-bladder, and even the appendix has been found in an umbilical hernia. If the tumour presenting at the umbilicus is not reducible at any stage we must ascertain whether it fluctuates, or, at any rate, whether it feels elastic, in which circumstances it mav be one of the various cysts occurring in this region, especially a dermoid or epidermoid. If the cyst is situated in or beneath the abdominal wall, opposite the bladder, it is probably connected with the urachus ; if directly behind the umbilicus, with the vitelline duct. Solid timioiirs are u-uallv secondar/ and represent metastases or direct extensions of cancer within the ribdominal cavity. If, how- 374 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA ever, such a causation can be excluded, they must, apart from rare exceptions, be regarded as primary cancers or sarcomata if they grow rapidly, and as fibromata if their growth is slow. The primary cancers start from the skin and appear as ulcers with hard margin and base, or as cauliflower-like papillomata. Cancer of the umbilicus mav also arise from intestinal cpitheliuni, which has become displaced into the umbilical scar. Finally, the epithelium of the iiradius may undergo cancerous degeneration. We should think of this origin, if the cancerous tumour stretches downward from the umbilicus towards the bladder. The snb-nnihilical abscess may also be mentioned. This occupies a triangular area with its base upwards under the umbilicus and behind the recti. The pus organisms reach this space from the viscera of the lower abdominal cavity, or from the abdommal integuments. The course of this abscess is either chronic or acute, depending upon the nature of the organism — tubercle bacillus, staphylococcus, colon bacillus, &c. (3) INGUINAL REGION. Owing to the presence of the spermatic cord, the round ligament, and the vaginal process of peritoneum, the inguinal region is the seat of many kinds of swelling, which we shall meet with later on. For the moment we are only concerned with the leading features of diagnosis in this region. We must first ascertain whether the swelling can be reduced, or whether its contents can be displaced. If so, the case must be either a hernia, a bilocular or communicating hydrocele, or a burrowing abscess. If an intestinal note is found over the swelling, or if it feels granular or lumpylike omentum, there is no doubt about it being a hernia. The same applies, if its reduction is accomplished in a sudden manner. But if it is only displaced gradually and the swelling corresponds accurately to the direction of the inguinal canal, we must think of one of the forms of hydrocele just mentioned. If the swelling is more laterally situated and can only be incompletely dis- placed, and if, in addition, it is painful on pressure, we should think of a bun-owing abscess and search for confirmation in the vertebral column. Finally, if the swelling is reducible, but feels neither like intestine nor omentum, but like a smooth roundish body, the case is one of an inguinal testicle or a prolapsed ovary. If, however, the swelling is irreducible, but is soft or tensely elastic in consistence, we must think, according to its position, either of an enclosed hydrocele in the inguinal canal, or of a burrowing abscess which admits of no displacement. In this connection it is worth mentioning that there a so such a condition as a hydrocele in the female. TUMOURS AND SWELLINGS LN THE ABDOMINAL PARIETES )75 A solid tumour is more probably an inguinal gland, especially if it is subcutaneous, of the shape of a bean, and multiple. The ex- amination of the appropriate lymphatic district will show whether its origin is due to cancer, hard or soft chancre, or merely a simple herpes genitalis. Should no such origin be discoverable, there arises the question of tubercle or Ivniphadeuonia, for the latter occasionally starts in the inguinal region. We have already discussed the differential diagnosis HI the chapter on Tumours of the Neck. If the swelling consists of a large uniform tumour which has grown rapidly and soon becomes immovable, it must be regarded as a sarcoma. If its size increases but slowly, it must be regarded as a fibroma of the abdominal wall. A movable, spindle-shaped or cylindri- cal, hard tumour in the ingumal canal of a woman is most probably a fibro- myoma of the round ligament. (4) LUMBAR REGION. A swelling which appears in the lum- bar region during an abdominal strain is a lumbar hernia, whether it is spon- taneously reducible or only by pressure. There are two sites for hernial pro- trusion in the lumbar region. One is at the outer border of the quadratus lumborum, just imder the tweh'th rib (Gryrjfeldt), the other is at Petit's triangle, the three sides of which are formed by the iliac crest, the external abdom- inal oblique, and the latissimus dorsi. Congenital lacunae in the muscles seem, however, to be of more importance. In certain rare cases of infantile paralysis the muscular atrophy may affect the muscles in front of the quadratus lumborum, which become paralysed and atrophic over a dehnite limited extent. The border of the paralysed area is so sharp that it imparts the same sensation as the boundaries of a genuine hernial ring. Pig. 164 depicts such a case; one of the first in which this paralvsis was shown to be the cause of the pseudo-hernia. A lumbar swelling, which is onlv partially reducible after steady pressure, is either a burrowing abscess or a tubercular perinephritic abscess, which has burst through, behind. An examination of the urine will differentiate between these two possibihties. If the tumour Fig. 164. — Pseudo-hernia in the lumbar region, due to localized muscular paralysis. 3/6 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA is soft, but quite irreducible, with a perfectly smooth surface, and a more or less distinct fluctuation, it is a cold abscess with the origin just mentioned, or it may have started in one of the lower ribs. If it has a lobulated structure, and its situation is definitely sub- cutaneous, it must be regarded as a lipoma. (5) SWELLINGS AND TUMOURS IN ATYPICAL POSITIONS. If a swelling is not in one of the usual typical positions, but still possesses the features of a hernia, we are bound to assume a traumatic origin for it. Such trauma is almost always a laparotomy wound, which at once reveals itself by the scar. It is much more rare Fig. 165. — Tuberculosis of the abdominal wall. for such localized destruction of the abdominal wall to be due to accidental injuries or inflammatory processes. The very rare abdominal hernia which appears at the outer border of the rectus muscle, in the vicinity of the linea semicircularis, should be distinguished from other abdominal hernia because of its rather typical occurrence. Irreducible tumours, connected with the skin and suhcutaneoiis fissile, are lipomata, more rarely soft fibromata, occasionally also naevi which have become sarcomatous. (See under "Tumours of the Back," Chapter XXXI.) If they are more deeply situated and ABDOMINAL SINUSES 377 are connected with the luuscular layer of the abdominal ivall, they may be either fibromata of the abdominal integument, which have been previously mentioned, or tubercle of the muscle, which not infrequently attacks the abdominal muscles. The female sex, and a spindle-shaped, sharply defined, uniformly hard tumour are points in favour of a fibroma ; but an irregular shape, partial softening, slight mobility and relaxation of the abdominal integuments are points in favour of tubercle (fig. 165). If a hard fibrous tumour appear in the operation area months, or even years, after an abdominal operation — e.g., the radical opeiation for hernia — we shall probably find a few threads of silk floating about in a little deeply situated pus, or embedded in granulations, as first shown by Schloffer. Experience shows that a hard, board-like swelling in the ileo-caecal region, which gradually reddens the skin and eventually produces sinuses, is most probably actinomycosis, originating in the caecum. Every localized inflammatory swelling of the abdominal wall should be referred to infection breaking through from the intestine, but it is more likely to be tubercle or cancer than actinomycosis, except in the ileo-caecal region. CHAPTER XLIX. ABDOMINAL SINUSES. A SINUS may arise anywhere in the abdominal wall, as the result of an abscess or a malignant growth breaking through. There is, however, nothing typical about such an occurrence. We will, there- fore, confine ourselves here to sinuses whose position and charac- teristics are of diagnostic significance. Most sinuses originate at the umbilicus, the point at which most abdominal organs meet in their embryological history, and which is the weakest spot in the abdominal wall, as far as later morbid processes are concerned. (1) Congenital umbilical sinuses may be connected through a patent vitelline duct with the small intestine, or through a patent urachus with the bladder. The distinction is quite easy, because in the former cases fjecal matter escapes from the sinus, in the latter, urine. It is somewhat more difficult to account for a third umbilical sinus, which discharges neither fasces nor urine, but a thin mucoid fluid. This variety leads either into a piece of urachus, 378 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA which is open at the umbilicus but is closed towards the bladder, or into a piece of vitelline duct, closed towards the intestine. As far as observations have gone hitherto, the latter is the more frequent termination. These incomplete vitelline sinuses discharge a peculiar acid secretion like the gastric juice, and were formerly regarded as gastric fistulas. The secretion sometimes causes digestion of the skin, and ulcerates the area surrounding the sinus. (2) We diagnose an acquired umbilical sinus from the nature of the secretion, and thus differentiate pure suppurating fistulae, biliary fistulae, faecal fistulas, and urinary fistulae. (a) Suppurating fistuhe usually result from an intra-abdominal inflammatory process, which has burst through the abdominal wall at the umbilicus, i.e., its weakest spot. As a rule it occurs in peritonitis which has become chronic (pneumococcus infection, fig. 142). A localized tubercular peritonitis may exceptionally burst through at the umbilicus. Rupture of a suppurating hydatid or ovarian cyst may be mentioned as a very rare cause of suppurating fistula at the umbilicus. Empvema of the gall-bladder may occasionally open at the umbilicus and cause a suppurating fistula, as long as the cystic duct remains closed. Finally, the sub-umbilical abscess at the back of the abdominal wall, previously referred to, may escape through the umbilicus. A carefully passed probe will attain a certain depth in all these forms of umbilical sinus. But if, after several attempts, the probe does not reach beyond the umbilicus, the case is probably one of an umbilical concretion enclosed in a cutaneous pouch, or a ruptured sebaceous cyst or dermoid of the umbilicus, or, finally, a very small sub-umbilical abscess. If the microscopic examination of the secre- tion reveals chiefly detritus and epithelial cells, one of the first three possibilities should be thought of, but its accurate differentiation cannot be made out until the sinus is laid open. If the secretion is entirely purulent we should think of sub-umbilical abscess. (b) Biliary fistulcv arise in the manner previously indicated if the cystic duct regains its patency after rupture of the empyema of the gall-bladder. (c) Gastric and intestinal fistnlce, which are easily recognizable by the character of their secretion, are caused by rupture of an ulcer. In the case of the stomach, this is either a simple gastric ulcer or cancer ; in the case of the intestine, it may be due to cancer or tubercle, but it may also be the consequence of a strangulated gangrenous umbilical hernia. The latter origin would at once be clear from the history. {d) Urinary fistula; may arise through extension of cystitis into EXTERNAL INGUINAL HERNIA 379 a persistent urachus, with eventual rupture at the umbihcus. In other cases they may be due to the rupture of a phlegmon of the abdominal wall caused by infiltration of urine. Typical sinuses are also found in the inguinal region arising from a strangulated hernia, or through rupture of a burrowing abscess. The character of the discharge from the sinus (intestinal contents or pus) and the previous history will lead to a correct conclusion. In addition, a sinus situated very much at the side points to a burrowing abscess. But if the sinus is in a more central position, either between both recti or at the outer border of one of them, there may arise a question of tubercle of the pubic bone, or of osteomyelitis with a sequestrum. Finally, urinary fistula3 after strictures may occasionally wander into the lower abdominal region. We shall not discuss ectopia vesicae, because this malformation cannot be mistaken for anything else. CHAPTER L. EXTERNAL INGUINAL HERNIA. Although abdominal hernias are matters of daily occurrence, and the more common forms are correctly diagnosed by the public as well as by the profession, nevertheless there are some points worth referring to, even in this region. We begin with some observations on the subject of a "tendency to hernia," an expression which to many people conveys no clear conception. A tendency to liernia implies certain anatomical condilions, ivliicli may lead to tlie development of liernia zvlien- the inira-abdominal pres- sure is raised, i.e., even to the slightest temporary entrance of any of ttie abdominal viscera into a process of peritonenm. A tendency to hernia may involve either the peritoneum or the muscular wall of the abdomen, or both. In the former case the hernial sac is small, very narrow and con- genital, being due to the imperfect obliteration of the processus vaginalis of tiie peritoneum. The sac is too narrow to admit any of the abdominal contents (fig. i66, a). The development of the muscles and aponeurosis may be quite normal. In the latter case the primary change consists of a congenital or acquired weakness of muscles and fascial, combined w-ith abnormal width of the canal. Every act of coughing presses the peritoneum, which is quite closed in the normal manner, against the unresisting internal inguinal ring, and causes it to bulge therein in a conical form (Kocher) (fig. i66, b). 25 380 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA Finally, both conditions, patent processus vaginalis and weak abdominal walls, may occur together. The first variety of "tendency to hernia" cannot be demonstrated clinically as long as it is really only a "tendency." In the second variety of tendency the finger introduced into the inguinal canal meets with the well-known impulse. This also applies to the com- bined variety, in which the "tendency" rapidly develops into a complete hernia. There is no doubt that the congenital tendency to hernia, in the form depicted in fig. 166, is of more importance than the acquired form, but this is no justification for throwing any doubt upon the occurrence of the latter. After these preliminary remarks we now turn to simple inguinal hernia, dealing first with the form which manifests nothing abnormal externall}^ (1) DIAGNOSIS IN THE ABSENCE OF A HERNIAL SWELLING. To examine a patient for hernia, when there is nothing visible externally, we place him in a standing posture, with his legs some- what separated, and direct him to cough or press, while we see whether any bulging occurs. If the whole region above Poupart's ligament becomes pushed forward in a diffuse manner, without any visceral projection, we term the condition " soft groin," i.e., a congenital or acquired weakness of the abdominal wall. But if, on feeling both groins simultaneously, we appreciate a definitely circumscribed impulse on one side we may conclude that a hernia is beginning. Then we invaginate the scrotal skin into the ingumal canal with the index finger, and press again. In normal conditions this manoeuvre causes the posterior superior limit of the inguinal canal to become more tense owing to contraction of the internal oblique ; but if there is any tendency to hernia a soft bulging forwards of the posterior wall of the canal will be felt. If any of the intestinal contents have entered the canal it is no longer a matter of tendency to hernia, but of a hernia actually begun. It is advisable to let the patient lie down before making any further examination into the direction and range of the inguinal canal. If the abdominal contents remain within the canal after the abdominal pressure has been relaxed, but do not emerge from the external ring on subsequent coughing, the case is one of intestinal, or, better, of inter-muscular hernia. It sometimes happens that we are unable to secure any exit of intestine at the first examination^ although a hernia is present. In such cases we may derive some assistance from carefully feeling the EXTERNAL INGUINAL HERNIA 381 spermatic cord. If it is definitely thickened on one side, and if it is possible to demonstrate the presence of a narrow transverse pad, we may assume the existence of a hernial sac. This narrow pad represents the ring-shaped thickening which is often observed in older hernias, and which had been situated previously at the internal inguinal ring. If this examination is inconclusive, it is necessary Fig. 166. — Relations between external inguinal hernia and the abdominal wall. (1) Peritoneum. (2) Spermatic cord. (3) Muscular layer (especially internal oblique). (4) Aponeurosis of external oblique. (5) Skin. {a) Congenital tendency to hernia. (/)) Acquired tendency to hernia with weak muscles. (c) Fully developed inguinal scrotal hernia. (rf) Pro-peritoneal hernia. (e) Intermuscular hernia (interstitial). (/") Intermuscular bi-locular hernia. (^) Subcutaneous hernia. to repeat the examination by making a patient lift a heavy weight, with his legs outspread and his body bent backwards. It is not easy to demonstrate the presence of an inguinal hernia in females if it does not happen to be down at the time of examination. The narrowness of the inguinal canal does not allow of the intro- 25A 382 SURGICAL DISEASES OF THE ABDOMIXAI. AND PELVIC VISCERA duction of the finger, as in the case of a male. It no impulse is seen or felt on coughing, we must endeavour to feel the hernial ^ac, which can be done more easily than in bovs or men, because the round ligament in females disturbs us less than the spermatic coi'd m males. We place the index fingers on each side, median to the external inguinal ring over the pubic bone and move the skin over the latter, upwards and downwards, comparing the two sides. If a hernial sac is present, there is felt, not so much a thickening of tissue as fine friction caused by the gliding of one serous surface on the other. If this sign can be demonstrated at repeated examinations, we may be quite secure in our diagnosis of inguinal hernia. Fig. 167. — External inguinal hernia (at external abdominal ring;. Fig. 168. — External inguinal hernia, extending into the labium. This simple examination will sometimes explain severe attacks of abdominal pain which have been attributed to appendicitis, movable kidnev, and other possibilities before the di-xovery of the hernia. (2) DIAGNOSIS OF INGUINAL HERNIAL SWELLINGS. If an abnormal -welling bulges forward in the inguinal region, the examination is a much -nnpler matter. If the swelling can be dis- placed backwards, and probably also yields an intestinal note on percussion, it is an interparietal intestinal hernia. If it is irreducible EXTERNAL INGUINAL HERNIA 3«3 but yields a definite intestinal note, the diagnosis is the same. If the swelling, whether reducible or not, feels like a soft granular mass, it is an interparietal omental hernia. But if, on the other hand, we define clearly a smooth, roundish bodv, it must be an inguinal testicle in a male, an ovarian hernia in a female. Every now and then, such a swelling is a testicle, although the patient has a plait and bears a girl's name. A pseudo - hennaphrodite is proclaimed by a somewhat enlarged clitoris (fig. 169), but possessing both testicles and a vagina, the patient is too much of a male to be a woman, and too much of a female to be a man. It is fortunate if this state of affairs is discovered before marriage is contracted. Some of these pseudo- hermaphrodites celebrate the dis- covery of their sex by indulgence in tobacco and alcohol ; others, de- spite their testicles, retain the sen- sitiveness of the female and remain true to their frocks. Fig. 169. — Genitalia of a male pseudo- hermaphrodite, wiih a vagina, and with testicles in a hernial sac. Fig. 170.— External inguinal hernia with a divided Fig. 171.— Bilateral burrowing abscess due to spii sac (one portion being labial, the other intermuscular, caries, filling and emptying separately). 25B 384 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA The detection of an inguinal testicle does not, of course, exclude a hernia ; indeed it renders the presence of a hernia very probable. These herniae may be divided into three main forms, according to their position : — • (i) Pro-peritoneal hernia, situated immediately under the parietal serous membrane (fig. 166, d). (2) Inter-niusciilar hernia, in the area of the muscular abdominal \vall, generally between the internal oblique muscle and the apo- neurosis of the external oblique. (Interstitial hernia in a narrow sense; subaponeurotic hernia.) (Fig. 166, e and/, and fig. 174.) (3) Subcutaneous hernia, between the aponeurosis of the external oblique and the skin (inguino-superficial hernia, sub-fascial hernia). (Fig. 166, g, and fig. 174.) Fig. 172. — Right-sided burrowing abscess, admitted into hospital as " hernia.' All these herniae may occur in the form of herniae with divided sacs, which unite into one hernial sac in the scrotum or labium. They all occur, but much more rarely, in the female sex, both in the simple form or with divided sacs (fig. 170). In males they are often associated with a retained inguinal testicle. If the hernial sac is of the subdivided variety the testicle is often found lying in the upper interparietal portion. As far as the clinical diagnosis of these various forms is concerned, tlie pro-peritoneal variety is, as a rule, detected first when it becomes strangulated. The symptoms are those of internal strangulation, and a roundish resistance can be felt deep down behind the internal EXTERNAL IXGUIXAL HERXIA 3^0 inguinal ring. The diagnosis of tlie intennuscnlar and the much rarer snbcntaneons varieties, has ah-eady been referred to in common ; but their differentiation is of some interest. For this purpose, the patient is directed to sit up without supporting himself by his arms. If the aponeurosis of the external oblique then becomes tense over the hernia, the latter is intermuscular (fig. 174) ; in other cases it is sub- cutaneous (fig. 175). In this illustration the laxity of the hernia indicates its subcutaneous position at the first glance. The following case is typical of a hernia with a divided sac : — I operated on a man, aged 68, for what was apparently an ordinary scrotal hernia, without opening the inguinal canal, but I excised the sac as high up as possible. All went well until the patient stated, three weeks subsequently, that the hernia had returned. As a matter of facr, protrusion of the intestine could be seen above the internal inguinal ring, when the patient coughed. A second operation revealed Fig. 173. — Hydrocele ot spermatic cord. an intermuscular hernial sac running laterally under the aponeurosis of tiie external oblique. It was quite as large as its scrotal off- shoot, which had been removed three weeks previously, but was overlooked at the operation, because it had not been felt at the previous examination. Simple as the diagnosis of interparietal hernia would appear to be from the foregoing remarks, nevertheless mistakes do occur. Femoral herni^e, with processes extending over Poupart's ligament, are especially liable to be mistaken for inguinal hernins and vice versa (figs. 186 and 187). But it is not only with other hernijc that confusion arises, but 386 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA also with other diseases. Thus trusses have been ordered for bur- rowing abscesses, and not by quacks only, for medical practitioners sometimes neglect to make an examination from mis- placed motives of delicacy, or conduct it so indifferent- ly that it is quite useless. Such errors are easily avoided by careful exam- ination. As a rule, a spinal abscess shows fluctuation ; a hernia does not. It is true that the pus can some- times be displaced, but this only occurs gradually after steady pressure, and not suddenly with a gurgle, as in the case of the intestine. When the pressure is re- laxed the swelling gradually returns without any strain- ing, whereas a hernia re- quires some change of Fig. 174. — Intermuscular inguinal hernia, under the aponeurosis of the external oblique. Fig. 175. — Subcutaneous inguinal hernia (H. inguino Fig. 176. — External inguinal hernia, just come through superficialis) situated under the skin. the external ring. EXTERNAL INGUINAL HERNIA 387 posture or the straining of abdominal pressure before it makes its re-appearance. Finally, most burrowing abscesses are situated more laterally than inguinal herniae usually are (figs. 171 and 172). Fig. 177. — Diagrammatic representation of the relations between the vaginal process of peritoneum, in congenital and acquired hernia; and in hydrocele. (a) Normal obliteration of the process, i (i) Partial patency of the process. Funicular hernia, (c) Complete patency of the process. Te=;ticular hernia. ((^) ,, ,, „ ,, with narrow neck, communicating hydrocele. (e) Patency in centre of process. Funicular hyf^rocele. (yO Patency at lower part. Testicular hj'drocele. (?•) Outgrowth of 7^ upwards. Biloculat hydrocele. (/?) Combination of t? and X Funicular and testicular hydrocele. (0 Combination of /' and /. Funicular hernia and testicular hydrocele, (/t) Acquired funicular hernia. (0 ,, , ,, ,, reaching as far as the testicle, and imitating (c) congenital testicular hernia. (ot) Combination of _/" and i: Acquired funicular hernia, and congenital or acquired testicular hydrocele. (3) DIAGNOSIS OF LABIAL AND SCROTAL HERNI/E. A swelling situated within the scrotum or labium can only be a hernia if it has a pedicle running in the inguinal canal. If this be not the case (fig. 178), there is no hernia. If, however, there be such a pedicle, we must see whether the swelling is reducible (fig. 179). If the swelling can be displaced backwards, possibly with a buzzing or gurgling sound, the case is one of hernia. If the reduction is slow and requires steady pressure, the condition is usually one of communicating hydrocele, and only rarely a bilocular hydrocele with the second sac in the abdomen. 388 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA A varicocele is apparently reducible, but the filling up of the swelling like a handful of earthworms, when the patient stands, and its immediate relaxation when he lies down, without, however, any of its contents actually receding, ought to exclude the possibility of any confusion. If the swelling has a pedicle, but is irreducible, the case may be one of testicular hydrocele reaching as far as the inguinal canal. Such a swelling is, however, uniformly tense and elastic, is dull on percussion, and generally translucent, whereas an irreducible, unstrangulated intestinal hernia is not translucent, is of more lax consistence, and usually gives the intestinal note on percussion. A strangulated hernia is indeed also tense like a hydrocele, but it has Fig. 178. — Testicular hydrocele. Fig. 179. — Bilateral external scrotal inguinal hernia. a smaller and very tender pedicle, and, moreover, is always attended by symptoms of intestinal obstruction. But the following case will indicate how error can arise. A young man sought advice for a classical pear-shaped irreducible testicular hydrocele, with a narrow neck in the inguinal canal. He stated that he had felt, two months ago, just before the appearance of the hvdrocele, a sudden pain in the left hypogastrium. We attached no iniportance to this, and adhered to the diagnosis. At the operation, a hydrocele was indeed discovered, but it had a narrow offshoot m the inguinal canal, containing a small adherent plug of omentum. The patient, therefore, had a small strangulated omental hernia in a congenital sac, and the fluid was really hernial in character. The EXTERNAL INGUINAL HERNIA 389 pain in the hypochondriuni was due to the dragging of the omentum at the moment of strangulation. If we had paid more regard to the history, an accurate diagnosis could have been made. An irreducible granular or lobulated scrotal swelling which possesses a pedicle may be one of three things : (i) Omental hernia; (2) hernial sac, with much peri-hernial fat ; or (3) a lipoma of the spermatic cord. Unaltered omentum in a hernial sac feels more finely granular than a lipoma of the spermatic cord. But this dis- tinction is a very delicate one, and can only be appreciated by very experienced fingers. The history is really of more value in this connection. If the patient states that the size of the swelling is very Fig. 180. — Varicocele with atrophy of testicle. Fig. 181. — Left-sided hydrocele and external inguinal hernia. variable, we should think of hernia, as also if he frequently complains of pain during digestion. The not infrequent cases wherein a small lipoma of the spermatic cord is present with a hernia are hardly capable of being diagnosed. It is of diagnostic importance to know that mguinal hernia and lipoma of the spermatic cord are sometimes accompanied by obstinate spermatic cord neuralgia, the cause of which remains obscure until the hernia or the lipoma appears. Diffuse extension of peri-hernial fat is rarely found in external inguinal herniae, but it is quite general in internal inguinal herniae and in femoral herniae. 390 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA CHAPTER LI. INTERNAL OR DIRECT INGUINAL HERNIA. There is usually no difficulty in distinguishing an internal direct intjuinal hernia from an external indirect hernia, if one bears in mind that in the former the hernial ring leads directly into the abdominal cavity, and does not run through the inguinal canal. This form is frequently bilateral, and does not descend into the testicle, but remains above the root of the penis after giving rise to a pronounced trans- verse fold in this region (fig. 183). In contrast to the external variety, internal hernia usually occurs in the middle-aged and the old, and almost always in males. On coughing a semi -glob- ular swelling appears, which is more sharply defined laterally than in the case of an external inguinal hernia. Xo importance should be attached to the clinical demonstration of the po- sition of the deep epi- gastric artery. It runs upward, along the inner side of an external hernia, and along the outer side of an internal hernia. \"aluable as this sign may be at the operation, when a case is doubtful, it is, as a rule, im- possible to palpate the artery before operation. \i:t In addition to the cases which fit in the above scheme, there are two varieties of inguinal hernia which may present some diffi- culties in diagnosis : — (1) External inguinal hernias of old standing, wherein the canal has lost its obliquity, and the hernial ring opens directly into the abdominal cavity just as in the case of an internal hernia, but the hernial sac has not descended into the scrotum. The gradual protrusion of the swelling towards the side may, in these circum- stances, be the onlv sign pointing to an external hernia. (2) Internal inguinal herniae which descend to a small extent into the scrotum — a condition noted by Berger, and one which we have Fig. 182. -Internal inguinal hernia on the right, and external hernia on the left. IXTERXAL OR DIRECT IXGUIXAL HERXIA )9I occasionally observed — and which are easily mistaken for external herniae. Difficulty in diagnosis will be encountered if it is not possible, on examining the hernia after reduction, in a recumbent posture, with one finger in the canal and the other introduced directiv into the ring, to demonstrate that there is still a biidge of tissue between the two fingers. The question which arises occasionally in connection with a direct hernia, as to whether it is more of a lipoma or more of a hernia, is unimportant, because it is quite a relative matter. All internal inguinal hernias have a more or less extensive fatty layer within the sac, and the personal equations come in in deciding where ;i hernia ceases and a lipoma begins. A final word concerning hernia of the bladder. This mav occur either in an exter- nal or an internal inguinal hernia, but more frequent- ly in the latter. It will be understood that one cannot speak of hernia of the bladder, when a piece of this organ is dragged up into the ring during the course of a radical operation on the hernia. A portion of the bladder must be part of the regular contents of the hernia — • not necessarily of the hernial sac, because the bladder often extrudes itself, extraperitoneally, along the side of the sac, to the ring. Disturbance of micturition would jus- tify the suspicion of a hernia of the bladder, whether it be difficulty in emptying the organ, or frequent tenesmus. The suspicion would be confirmed if it were observed that these disturbances coincided with fulness of the hernia. It is possible to demonstrate in such cases that when the bladder is very full there is fluctuation in the hernia and dulness over it on percussion, signs which disappear after the bladder is emptied. In some circumstances the catheter is required to emptv the bladder, because internal inguinal hernias happen to be most frequent in patients wilh enlarged prostates. Fig. i8j. — Bilateral internal inguinal hernia. 392 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA CHAPTER LII, FEMORAL HERNIA. There are not many swellings which can be mistaken for femoral liernia. Errors may, however, possibly arise in connection with hernial protrusion of the saphenous vein, enlarged glands, lipomata, burrowing abscesses in the crural ring, and, finally, inguinal herniae. We will consider these in order. The not infrequent protrusions of the saphenous vein, if visible, glimmer with a blue colour through the skin, the slightest pressure suffices to make them vanish, but they retui'n as soon as the pres- sure is relaxed. They react with mathematical, or rather with physiological, precision to every variation in venous pressure, such as is caused bv coughing, vomiting, &c., and even to the normal breathing, in a recumbent position. These signs are so clear that confusion would apparentlv seem impossible, but as a matter of fact errors have arisen. Burrowing abscesses do not, as a rule, break through the spaces transmittmg the vessels, but more laterally through a muscular interspace ; they are frequently multilocular, and are displaced on gradual pressure, yielding a sen- sation of elastic resistance. They fill up again as soon as the pressure is relaxed, without any abdominal straining or change in the posture of the patient. But even in the cases wherein these abscesses appear towards the middle line, as in fig. 185, the other signs are so definite, that an error is hardly possible after careful examination. Enlarged glands may present more difficulties. The entrance of the infection is usually found somewhere on the leg or foot. The chief characteristic of enlarged glands, even when chronic, is their sharp limitation at the femoral ring, whereas a hernia always possesses Fig. 184. — Bulging of the femoral region through varicose swelling of internal saphenous veiTi. FEMORAL HERXIA a pediclt which runs under Poupart's hganient, and which is compres- sible against the pubic bone. The rare subserous lipomata are also, strictly speaking, pedunculated, but the pedicle cannot be felt like the neck of a hernia. The absence of a palpable process into the abdo- men, combined with the absence of any variation in volume and symptoms of hernial protrusion, would suggest a lipoma, behind which there may be a small pouch of peritoneum, although it may never have contained any intestine or omentum. It is very significant of femoral hernias that a verv small hernial sac is often surrounded bv a large amount of fatty tissue, which grows into a lipomatoid structure. Superficial lipomata also occur in this region, either as isolated growths, or as a partial manifestation of a general lipomatosis (fig. iS8). G. 1S5. — Crural burrowing abscess from spinal caries. Fig. 186. — Crural hernia in female. Its relation to Poupart's ligament, x — x. If the swelling has a definite pedicle which becomes lost under Poupart's ligament, the diagnosis of hernia can hardly be mistaken. But if there is no intestinal note, the case is either one of peri-hernial lipoma, just mentioned, or an omental hernia. The differentiation depends less upon the phvsical condition found on palpation, than upon the presence or absence of svmptoms of omental dragging, as ah'eady indicated in the case of inguinal hernia?. The question, is, however, one of indifi'erence, because if treatment is called for, operation must be undertaken in either case. If a pedunculated swelling feels definitely elastic, there must be a collection of fluid in an old obliterated hernial sac. If attacks of sudden 394 SURGICAL DISEASES OF THE ABDO-AIIXAL AND PELVIC VISCERA abdominal pain, without intestinal obstruction, have preceded the onset of a tense hernial swelling, it is obvious that a small piece of peritoneum has been strangulated in the ring and has led to the development of hernial fluid. Having determined that the swelling is a hernia, the question still remains as to whether it is really a femoral hernia. If the tumour is clearlv below Poupart's ligament, the matter is settled ; but if it is riding on the ligament the solution is not so clear. It may be an inouinal hernia which has wandered downward, or it mav be a femoral hernia which has grown upwards ffigs. 189 and 190). The differ- entiation is not difiicult, if we are able to reduce the hernia. We base our decision on the position in which it recedes, and by feeling the Fig. 187. — Femoral hernia in a male. Fig. 188 — .Symmetrical lipomata in crural regioi ring. It is, however, otherwise, if the hernia is irreducible, whether it be strangulated or not. Incorrect diagnoses are very frequent in such cases, and as a rule a femoral hernia is taken to be an inguinal hernia. As Poupart's ligament cannot be clearly defined because it is overlain by the hernia, and because it is obscured by fat in elderly women, Malgaigne's line has been adopted to indicate its position, i.e., the line joining the spine of the pubis with the anterior superior spine of the ilium (fig. t86). Everything above this line is to be ascribed to inguinal hernia, and below it, to femoral hernia. But this criterion is not always reliable. More importance is to be attached to the position FEMORAL HERNIA 395 and direction of the neck of the hernia, which can generally be felt on careful palpation, and which is recognizable, w-hen strangulated, by its size and tenderness on pressure. If it runs vertically and is capable of being moved from side to side on the crest of the pubes, or if it appears to run deeply down when the hernia is displaced upwards, the case is one of femoral hernia. If it runs outwards and upwards, or directly outwards, the case is one of inguinal hernia. This sign enables a definite diagnosis to be made in such a case as fig. 190, although the major portion of the hernial swelling was above Poupart's ligament. If there is a historv of hernia, but we find nothing at our first ex- amination, we must care- fully compare the two sides for slight tissue thickening, or for fine friction, as already men- tioned in connection with inguinal hernia. We must especially observe w'hether the area of the fossa ovalis is fuller on one side than on the other. In this wav we may sometimes discover the explanation for inex- plicable abdominal pains, even if the patient denies any hernial protrusion. I have already mentioned that I once removed an appendix because of the history and the diagnosis of the family practitioner, and then, later on, recognized that the pains which continued were really due to a small concealed femoral hernia on the right side. There are a few abnonnalities in connection with femoral hernia, which are generally only discovered at the operation, but which might be recognized, or at least suspected, on careful examination. For instance, the hernial sac may pierce into the muscle under the fascia of the pecf incus, and thus resemble an obturator hernia — a rare condition only occurring in women and designated after Cloquet. The hernia may descend under the large vessels, or it may appear to their outer side in the opening through which they run, or it mav leave the abdominal cavity through a muscular interspace. This latter 26 Fig. 189. — Bilocular femoral hernia encroaching above Poupart's ligament. 39^ SURGICAL DISEASES OF THE ABDO.MIXAL AND PELVIC VISCERA form, the so-called Hesselbach's hernia, has been recognized before operation by means of its broad base and its lateral position. Finally, we find here, as in inguinal hernia, a pro-peritoneal form, which does not come through the abdominal wall. \ \ Fig. 190. — Strangulated femoral hernia projecting above Poupart's ligament. CHAPTER LIII. TRAUMATIC HERNItE. The surgeon will occasionally be confronted with the question as to whether the hernia which he has demonstrated has arisen through an "accident." The terra is usually meant to include any sudden strain, which does not come within the patient's ordinary occupation, or one within his occupation, if it has overtaxed his strength. Most of these cases are accounted for by the sudden strain of abdominal pressure, with the body in disadvantageous posture. The story of the Zouave trumpeter is typical of this. As he was blowing for the attack at Malakoff, he fell into a hole, and got up with a hernia. We have to take into consideration both direct and indirect trauma. Neither form can cause a hernia in persons hitherto per- fectly normal. But indirect trauma — rarely direct — may convert a TRAUMATIC HERNIA 397 tendency to hernia into actual hernia, i.e., the stretching of the pre- existing small hernial sac and the consequent dragging of the parietal peritoneum may determine the entrance of some intestine or omentum into the sac. This process is, as a rule, so painful, that it prevents any furlher bodily exertion, and the patient feels bound to seek medical advice. These two conditions are usually associated in the evidence of a " traumatic hernia," though there are exceptions varying with the occupation and energy of the workman. A hernia which has arisen in this manner is small — at most the size of a hen's egg — the sac is thin, and not palpable ; the hernial ring is generally small but it may be of medium size. The intestine does not always protrude when the patient assumes the erect posture, but once having protruded it does not always return when he lies down. The hernia is only slightly movable, without, as has been asserted, necessarily being strangulated. There should be no traces of a truss on the skin. The consideration of these circumstances enables us to decide whether the hernia could possibly be traumatic, i.e., whether it could have arisen from sudden strain. As a rule, nothing more definite can be said, unless the patient happens to have been examined shortly before, specially for hernia. However reasonable the claim of the workman for compensation may be, for the genuine traumatic change of his " tendency to hernia " into an actual hernia — for in- stance, a radical cure by operation, without any money payment — nevertheless the practitioner should be extremely cautious in coun- tenancing the fashion of making a profit out of these too easily assumed cases of traumatic hernia. The extent to which these attempts may go is illustrated by the fact that even gonorrhoeal epididymitis and inguinal buboes after soft chancres have been represented as "traumatic hernia." Most so-called traumatic hernias are of the external variety ; but all forms have been at times ascribed to injury. We may, however, discard the possibility, in internal inguinal hernije and umbilical hernise, and should be very sceptical with femoral herniae. An epigastric hernia is much more likely to be due, in some considerable degree, to trauma. 398 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA CHAPTER LIV. STRANGULATED HERNIA. It is most important to observe that strangulation must not be confused with irredncibility, for it is only one special variety of irreducible herniae. Both intestine and omentum may be irreducible without being strangulated ; the cause usually is the presence of adhesions. Moreover, the omentum within the sac may develop so much, entirely of its own accord, that it is unable any longer to slip back through the hernial ring, even if no adhesions exist. A special form of irredncibility is found in connection with certain herni?e of the caecum and ascending colon, and also of the sigmoid and descending colon. In these cases, not only does the intestine, which is covered by peritoneum, leave the abdominal cavity, but also its extraperitoneal site of attachment, and, in consequence of the slipping down of this surface of attachment into the area of the hernia, the intestine loses all its tendency to return within the abdomen. It may be mentioned incidentally that it is obvious that the hernia has no sac on this surface. There are also those enormous herniae which are met with less frequently than formerly, which, apart from adhesions, are irreducible, because the abdomen no longer contains enough space to receive them. Petit aptly said that these herniae " have lost their right of domicile." The subjective sym.ptoms of a non-strangulated but irreducible hernia are not, as a rule, any more severe than those of a free hernia. But dragging pains are often present ; though they manifest themselves in the upper part of the abdomen rather than in the hernial region. Local pain usually arises if the patient maltreats the hernia with a truss. Strangulation is a form of irredncibility which arises suddenly, and is attended by constriction of the pedicle, fixity of the presenting intestine, with disturbance of the circulation in the contents of the sac. A number of questions require answering in this connection. (1) Is the Case really one of Hernia? This is no superfluous question. Every surgeon has had infants referred to him with the diagnosis of strangulated hernia, when the case has been one of acutely arising hydrocele in an infant. The distinction is really not difficult. The tense hydrocele swelling is, as a rule, definitely limited above, and does not run into the inguinal canal. The infant passes motions and flatus and does not vomit. STRANGULATED HERNIA 399 at any rate persistently. It takes the breast or bottle, again, after a short interval, an indulgence which an infant with a strangulated hernia never enjoys. It certainly cries, because the rapidly increas- ing effusion is a source of discomfort, but it does not appear to suffer severely. If one has made certain of the diagnosis, by careful examination, the swelling may be tapped quite safely and the anxious parents be convinced of the accuracy of the diagnosis. Besides the hydrocele of young children, there are complications connected with an inguiual testicle which may resemble strangulated hernia, namely, twisting of the pedicle oi the testicle and its strangulation. This error is all the more accountable because most inguinal testicles are associated with herniae, and the patient will therefore give a history of hernia. Formerly, inflammation and strangulation of the inguinal testicle were the only recognized morbid conditions thereof, but since the time of Nicoladoni it has been agreed that torsion of the abnor- mally pediculated testicle is the usual affection, and the possibility of strangulation has been somewhat neglected. But that it exists appears from the following case : — A patient who had a left-sided hernia, which, however, had not come out of the inguinal canal since his fourteenth year, felt a severe pain in the left inguinal region, on lifting a heavy weight. A tender swelling, which looked like a strangulated hernia at first sight, appeared. But the emptiness of the left half of the scrotum and the patency of the intestine enabled a correct diagnosis to be made, and the operation showed that the inguinal testicle had slipped down to the narrow external inguinal ring and had been conducted externally under the skin. The kinking of the spermatic vessels at the external abdominal ring, and their dragging, owing to the abnormal position of the testicle, had led to the formation of a considerable infarct. In this case the diagnosis could only lie between torsion and strangula- tion with subcutaneous displacement. The subcutaneous position of the testicle contra-indicated simple torsion. If a testicle within the inguinal canal becomes twisted, it remains ^^'ithin the canal. The symptoms of the more frequent condition of torsion are as follow : sudden severe pain and the appearance of a tumour. In addition, there are often reflex symptoms which suggest strangulated hernia, viz., severe abdominal pains, temporary obstruction to the passage of motions and flatus, and even collapse. In the inguinal region, there will be found a tender swelling, like a strangulated hernia. The empty scrotum and the return of the passage of motions and flatus after the cessation of the original reflex symptoms, usually enable a diagnosis to be made. But as it is impossible, at the beginning, to distinguish, with absolute certainty, between a twisted testicle in the inguinal canal and a strangulated interparietal hernia, and as surgical intervention is urgent in either case, it is bad practice to wait until the diagnosis is established by signs of intestinal gangrene ; but treatment 400 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA must at once be undertaken, to save the structure which is in trouble, whether it be intestine or testicle. A boy, aged i year, suddenly developed a tense swelling about the size of an almond in the right inguinal region, and therewith had pain, with signs of general malaise. The right testicle was absent from the scrotum, and the left one had only incompletely descended. There were three possibilities : (i) strangulated hernia ; (2) acute hydrocele in the inguinal canal ; and (3) torsion of a testicle. All these three circumstances were favoured by the presence of an inguinal testicle. The absence of persistent vomiting, the softness of the abdomen, and especially the passage of motions, were points against a strangulated hernia. Flatus was retained, but nothing definite could be inferred from this. The marked disturbance of the general condition showed that it could not be a mere hydrocele. Torsion of the testicle remained, therefore, as the most probable diagnosis, and this was confirmed by the operation, which was per- formed forthwith. The little patient repeated the whole procedure, a year later, on the other side. The same considerations should guide us in the case of torsion of a testicle, which is in the scrotiun. There is, of course, no emptiness of the scrotum, as a diagnostic sign in such a case. There are some circumstances in which we may hesitate as to the diagnosis between a strangulated hernia and a mass of swollen glands- If there are any intestinal symptoms there cannot be any possible doubt, and it is incredible that any practitioner should order poultices to what is really a strangulated femoral hernia, in order to " ripen " the swelling. The following case will, however, show that both patient and practitioner may succumb to a series of misleading circumstances. A female, aged 50, became ill with acute cholecystitis, and suffered from very painful swelling of the gall-bladder. The initial vomiting ceased and the cholecystitis subsided somewhat. But at the same time the doctor accidentally discovered a tender swelling in the left groin. No definite pedicle could be distinguished. As there was neither vomiting nor colic, and as the abdomen was soft, and as there was an erosion on the corresponding lip of the vulva, which suggested a glandular swelling, the patient was watched for a day. The absence of the passage of flatus determined the diagnosis of strangulated hernia after the lapse of this time — but it was too late. The patient died suddenly during the preparations for operation. The autopsy showed not only a severe suppurative cholecystitis but also a strangu- lated hernia, with gangrene at the constricting ring. The strangulation evidently took place during the cholecystitis as a result of the vomit- ing, but the patient was not intelligent enough to notice it. There was no vomiting or colic because the patient was under dietetic treatment owing to the cholecystitis, and therefore the intestine was almost empty, The erosion on the vulva also contributed its share towards the error. STRANGULATED HERNIA 4OI (2) Is the Hernia Strangulated? One of the most important pieces of evidence for strangulation is afforded by the pain on pressure over the site of the constriction, usually at the hernial ring. The obstruction of the bowel, and the symptoms consequent thereon, constitute further evidence. This obstruction also occasionally occurs in Littre's hernia, which involves only the intestinal wall. Strangulation of omentum is distinguished from ordinary irreducibility thereof by the sudden onset of symptoms, the pain on pressure over the site of strangulation, and the tension of the hernia owing to the development of hernial fluid. We have mentioned an example of such strangulation of omentum in the chapter on Inguinal Hernise. There is one further possibility in connection with strangulated hernia. Formerly one heard much about inflauiination of a hernia, and strangulation was regarded as inflammation. There is nothing surprising in the fact that the sac of a strangulated hernia may inflame after a time, in consequence of infection by organisms which wander through from the bowel. The inflammation is, however, secondary in such circumstances. Primary inflammation of a hernia is, on the other hand, not frequent. The following conditions are most important : — (a) Appendicitis in a Hernial Sac. — The appendix is not infrequently found in right-sided herniae ; it has even been found on the left side and also in umbilical herni?e. It may become inflamed within the hernial sac and perforate there. Such a case is usually mistaken for a strangulated hernia, until the error is rectified at the operation. But the sequence of symptoms ought to give a correct clue. In a strangulated hernia the first symptoms are those of intestinal obstruc- tion, and then, after they have persisted for some time, comes the inflammation— the hernial phlegmon. But if appendicitis starts in a hernial sac, the inflammatory symptoms come first, and there is pyrexia. Should intestinal obstruction eventually supervene, it is a much later phenomenon. In most cases of strangulated hernia the pain on pressure is especially marked over the hernial ring ; in appendicitis, however, it is from the first in the hernia itself. {b) The involvement of the hernial sac in a General Peritonitis. — The differential diagnosis depends upon those considerations which were advanced in distinguishing between peritonitis and intestinal obstruction. The same applies to a hernia involved in the sequelai of an acnte pancreatitis. In both cases the severity of the abdominal symptoms will be very striking, considering the short duration of the supposed strangulation. (c) Tubercle of the Hernial Sac. — This is usually a consequence of general tubercular peritonitis. But it sometimes happens that this latter causes no symptoms, and the practitioner is only consulted about the disease of the hernial sac. Whereas a miliary tuberculosis of the hernial sac with fluid contents is most likely to be taken for a 402 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA hydrocele, the nodular form is easily confused with a strangulated, or at least with an irreducible, mass of omentum. If, however, one bears in mind the possibility of tubercle of the hernial sac, suspicion thereof will be aroused by the presence of isolated nodules, by the pain on pressure, and by the great hardness of the swelling. A careful examination of the abdomen may perhaps find support for the diagnosis. Abdominal pains are of less diagnostic significance, because, although they are frequent in tubercular peritonitis, they may also be caused by strangulated omentum. (d) Sutter and others have shown that metastatic inflammation of an empty hernial sac may resemble the clinical symptoms of strangulation. There are three possible events which may introduce error into the solution of the last two problems, with which we have been dealing ; first, the combination of external hernia witli internal intestinal obstruction. Let us assume the case of a patient with all the signs of intestinal obstruction, in whom we also find an irreducible hernia^ and we are inclined to ascribe to it the cause of the obstruction. If the hernial swelling is soft and not painful on pressure, the cause of the obstruction must be elsewhere ; either in another hernia, which has been overlooked, or in some disease within the abdomen itself. On the other hand, there are cases wherein we find no hernia, and are therefore inclined to attribute the intestinal obstruction to some internal cause. On inquiry we may learn that the patient has put back a hernia. Careful examination of the site occupied by the hernia may then show some slight retraction, and we may discover in the abdomen, behind the ring, an indefinite resistance, which is painful on pressure. Our diagnosis must then be that of reduction en masse. These cases are, however, becoming rarer, as fortunately violent taxis is giving way to herniotomy. It occasionally happens that an omental hernia becomes painful on pressure. Symptoms occur, at the same time, suggestive either of peritonitis or of intestinal obstruction. There may be found in the abdomen a tumour-like painful area of resistance with corresponding dulness, or even, under some circumstances, a free fluid effusion. If these symptoms occur on the right side, in a patient who has already suffered from attacks of pain in this region, the diagnosis usually made is that of appendicitis with extension of the inflammation into .the sac. This diagnosis seems all the more likely as the process is often accompanied by moderate fever. Operation, however, shows that the case is one of torsion of a large mass of omentum, the extremity of which is firmly fixed in the hernial sac— a condition with which all surgeons are familiar, but which has been specially described by Hochenegg. (3) What does the Hernia Contain? If signs of intestinal obstruction are present, we must assume that the hernia is intestinal ; if they are not present the hernia must be omental. One must be very cautious in drawing any conclusion from STRAXGULATED HERNIA 403 physical examination. A tympanitic note of course indicates an intestinal hernia. A dull note is of no significance, as small intestinal herniae are very liable to yield complete dulness on percussion. The feel of the hernia can never be relied on. The granular consistence of omentum may be concealed by hernial fluid, and, on the other hand, a small coil of intestine is often found strangulated in cases wherein an omental mass can be definitely demonstrated. If there is a small movable body in the hernial sac of a female, the case is one of a sirangiilated ovary, a condition which is not rare, even in young girls. (4) Where is the Strangulation Situated? The strangulation may be in the neck of the sac, at the hernial ring, or in the sac itself. The strangulation is especially at the neck of the sac in inguinal herniae, which usually present a ring-shaped thickenmg at the level of the internal ring. As this ring may shift as far as the peripheral end of the sac, in consequence of the constant onward movement of the peritoneum, the strangulation may occasionally occur quite close to the head of the sac. We may assume the presence of this con- dition, if the central portion of the hernial swelling is soft and painless, while the peripheral portion is tense, and tender to pressure. As a rule, a strangulation within the sac is at the level of the internal inguinal ring, and one may assert that most strangulations at this spot are strangulations within the hernial sac, because the internal ring is not itself tight enough to cause a strangulation. If the diagnosis is at all possible, it will depend upon the localization of the greatest amount of pain on pressure. Strangulation at the external ring is recognized in a similar manner, but here the strangulation is not caused so much by sac as by the fibrous elements of the inguinal ring. In cases of femoral hernia, the strangulation usually takes place at the femoral ring; in uinhilical hernia, it is due to constriction at the umbilical ring, but it may occur in one of the frequent pouches of the hernial sac. In the latter case, only one segment of the hernial swelling will be tense and painful on pressure. Finall}^, there are cases wherein the intestine is caught by a noose- like band of connective tissue arising from the hernial sac. Such a condition is first recognized at the operation. (5) What is the Condition of the Strangulated Gut? The duration of the strangulation affords important information, because the intestine usually retains its vitality for the first twenty-four hours, though the constricting furrow may become necrotic after 404 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA twelve hours. If, however, the constriction is not very tight, the intestine may recover itself, even after several days' strangulation. All depends upon the degree of circulatory disturbance, which is usually greater in small hernise than in large ones. Gangrene is therefore more probable in a small hernial swelling than when a large mass of intestine and omentum is present. The presence of omentum in the hernia permits us to make a more favourable prognosis in regard to the intestine, because the omentum serves as a protecting pillow to it in the hernial ring. As long as the hernial swelling remains movable and the skin above it can be picked up, and is neither red nor oedematous, so long is the recovery of the intestine not impossible. But if inflammatory symptoms have occurred in any degree, from simple oedema of the integument to a definite hernial phlegmon, we must expect that the intestine has been severely damaged. Although the indications are for immediate operation in all cases, nevertheless if circumstances prevent it being carried out forthwith, we may venture upon a modest attempt at taxis, if the strangulation is recent and inflammatory symptoms are absent. But if the operation can be done at once — and this is always the case nowadays, except in remote districts — one may quite conscientiously abandon taxis. Infants, however, provide an exception. Strangulated hernia is very rare during the first year of life ; at this period hernise are easily reducible and never cause gangrene. As a rule, the hernia goes back when the child is put in a bath. (6) The Questions which may Arise during the Operation. We shall not waste any words over the recognition of the various layers of the hernial coverings — a hobby-horse of the older surgeons. The layers may represent the usual coverings in recent herniae, but in old hernias they may be considerably increased in number by the growth of new layers of connective tissue. The careful operator will succeed in entering the hernial sac, tiiio if not cito, even with- out counting the layers ; but he must remember that not every space containing fluid is the hernial sac. Cystic spaces containing serous fluid often occur around the hernial sac, especially in femoral hernia, and if the hernia is strangulated the serous fluid may be mixed with blood. The decision made from the appearance of the intestine is of greater importance ; and it is necessary to consider not only the strangulated coil but also the bowel leading towards it. In order to pull it suffi- ciently forward it is necessary to widen the constriction previously, but care must be taken lest the hernial coil slips back into the abdomen unexpectedly and unperceived. If the intestine is smooth and shiny, and if definite contractibility is present in the whole of STRANGULATED HERNIA 405 the strangulated coil, including the constricted ring, we may safely reduce it, even though it may have seemed congested at first and felt somewhat thick. The bluish discoloration improves as we wait, and the thickening is preferable to the opposite condition. The intestine may be suspected if the contractions only start after long waiting, and are then very indolent. In such doubtful cases the circulation in the mesentery must be observed, and special attention must be paid to the arteries to note whether they are pulsating, and to the veins, to see whether they are thrombosed. Intestine should not be replaced if it cannot be excited to contract in every part, including even the constricted ring. Even if its consistence remains normal, or only slightly thickened, it should not be replaced. It is quite certain that if necrosis has once started it will become com- plete, in cases wherein the intestinal wall is disposed in small folds and its consistence is diminished, whether its colour be black, green, or grey. The character of the hernial fluid may prove of value in doubtful cases. A clear, odourless fluid indicates that the intestine is capable of recovery ; a turbid offensive fluid shows that necrosis has begun. Obviously, we must not allow an apparently healthy hernial fluid to reassure us, if, for instance, we find clear signs of necrosis at a constricting ring. On the other hand, the fluid may be somewhat offensive or slii^htlv turbid in cases wherein the bowel is capable of recovery. I was once called to a distant village to see an old woman with a strangulated femoral hernia. When I arrived the practitioner informed me that the symptoms of obstruction had subsided, but that the hernial swelling was increasing. The swelling felt very tense, and when it was opened a little offensive gas escaped. This led into the femoral hernial sac, which contained a very few drops of pus, and which was separated from the abdominal cavity by obviously recent adhesions. Recovery followed in a short time with- out further intestinal disturbances. The intestine which had been strangulated had returned of its own accord, leaving behind some bacteria, which did nothing more but infect the hernial sac. This case reminds us of the observations which we have already made in regard to inflammation of an empty hernial sac. (7) Questions which Arise after Reduction by the Open or Bloodless Method. A coil of intestine which has been strangulated for some hours does not always resume its functional activity forthwith. We must, therefore, not be surprised if some colic still 'persists for several hours, or for a day or two after the strangulation has been relieved. It may not be easy to obtain the passage of motions and flatus even after copious enemata. If reduction has been effected by taxis we 406 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA must not allow this fact to reassure us very easily, but should think of the possibility of a reduction en masse. An operation must be resorted to if the symptoms continue for several hours with the same severity. If herniotomy has been performed we may wait longer, but must undertake laparotomy if the symptoms increase instead of abating, especially if the pulse becomes unsatisfactory. There may be some additional intra-abdominal trouble, such as a volvulus, or kinking, owing to adhesions. The acceleration of the pulse should suggest to us that we have probably erred in deciding that the intestinal coil retained its vitality. I have seen gangrene come on in an entire coil after a skilfully performed herniotomy in a case wherein the strangulation had not existed for twelve hours. There are some cases in which everything goes well at first, but wherein the patient begins to complain again, after the lapse of several weeks, of attacks of colic, and, finally, of retentions of motions and flatus — in a word, of the symptoms of chronic intestinal obstruc- tion. If we operate we find that a ring-shaped or a channel-shaped narrow^ing exists in the place of the strangulated coil, or that the whole coil has been caked into an inextricable ball through adhe- sions. Both these conditions show that we were too optimistic in our opinion of the intestine at the time of operation. They both indicate that the mucous membrane has sloughed more or less exten- sively, and this may occur even when the serous surface appeared to be capable of living and has, as a matter of fact, retained its vitality. The only early warning of the onset of this late stenosis is offered by intestinal haemorrhage and persistent diarrhoea coming on in the first weeks after the reduction. A female, aged 60, was operated on for strangulation of an umbilical hernia, which had persisted for eighteen hours. The intes- tine appeared to be healthy and was replaced. The intestinal func- tions were normal for the first few days, but classical symptoms of chronic intestinal obstruction occurred after the second or third week. They increased so much that another operation became necessary in the seventh week. The intestine which had been strangulated had developed into an S-shaped mass, with very firm adhesions of one portion of the coil. An entero-anastamosis was performed, with complete and permanent recovery. DIFFICULTIES OF DEFALCATION 407 CHAPTER LV. DIFFICULTIES OF DEFECATION. In the popular sense this term includes several conditions of varied significance which the practitioner must separate from one another. They comprise functional derangements of the whole intestine, or, at least, of the large intestine, and also disorders which are due to some local affection of the rectum or its vicinity. We have discussed the former in the section on '' intestmal obstruction." The following are the symptoms by which rectal disease manifests itself :— (i) Simple Constipation, i.e., Difficnlty in evacuating the Feeces, but no Pain or Tenesmus. — This form of constipation is rare. It occurs in simple weakness of the rectal muscle (proctogenic constipation), with tumours of the true pelvis, which mechanically compress the rectum from without, and a fair amount of compression is required before defjecation is compromised. Retroflexion of the gravid or myomatous uterus, exudations within the true pelvis, cysts, and solid tumours may be mentioned as examples. The notorious "tape-like" faeces are sometimes found in these circumstances. We have been told by a patient with a dermoid in the pelvis that his motions were as thin as cardboard. (2) Coustipatiou associated witti Constant Tenesmus. — The evacua- tions are soft and pulp)^, or even quite liquid, and are frequently expelled in very small quantities at a time. The patient experiences an incessant desire to go to stool. This picture is most frequently encountered in cases of progressive pressure on the rectum from with- out by one of the swellings just mentioned. (3) Tenesmus, without Constipation, but until the Passage of Blood, Mucus or Sero-sanions Fluid, during the Acts of Defcecation, and in their intervals. — If a patient complains of these symptoms, and especially if his clean shirt is soiled with red or pinkish stains, we may at once assume that some ulcerative process is present, which does not lead to stenosis. It may be associated with an ulcerative colitis, extending low down, an innocent polypus, a syphilitic or tubercular lesion, or it may be due to cancer which has not yet reached the stage of stenosis — the most frequent cause. (4) Tenesmus with Constipation, Passage of Liquid, Pulpy or softly formed Feeces in small Quantities, accompanied by Blood or Scro-sanious Fluid. — This assemblage of symptoms points to an ulcerative lesion, which is also causing stenosis, i.e., to cancerous, syphilitic, or gonorrhoea! stricture. 408 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA The history affords certain indications; thus in childhood polypus is the most frequent cause ; in females from adolescence to middle age syphilis or gonorrhoea is, under certain conditions, the most probable cause ; in elderly people a villous polypus, or cancer, is most likely to be present. Exammation of the rectum must never be omitted. The trouble must never be attributed to piles, which may accidentally be present, and they should never serve as an excuse for an incomplete examination. That so many advanced cases of cancer are sent for operation with the mistaken diagnosis of rectal catarrh or haemorrhoids is due to the shyness of the patients — and often of practitioners — in the matter of rectal examination. It is quite in- telligible and praiseworthy that the practitioner who is engaged in surgery or in obstetrics should avoid contaminating his fingers unnecessarily; but nowadays a finger-stall removes the risk of con- tamination, and a rectal examination in this type of case is never " unnecessary." If we feel a soft movable structure, with a more or less long stalk, which easily escapes the finger, the case is one of polypus — a mucous polypus in children, a mucous polypus or a villous polypus in adults. If the mucous membrane appears to be softly granular over a diffuse area, or if it be studded with superficial ulcers, which are most distinctly recognizable with a rectal speculum, the condition represents an early stage of chronic gonorrhoeal or syphilitic proctitis. Flat, very painful ulcers in the vicinity of the anus suggest tubercle. We have already discussed the differential diagnosis between this condition and non-specific ulcerative colitis. If the finger defines a shell-like elevation of the mucous membrane with an overhanging, more or less firm border, and a friable, easily bleeding surface, the case is one of cancer, which has not yet encircled the bowel. If there be any doubt, such as might arise in the presence of a fiat non-pedunculated papilloma, a histological examination must be made. Such papillomata often become malig- nant. The same applies to the polypoid condition of the rectum, in which the whole rectum, and often a considerable portion of the large intestine, is invaded by numerous polypi. If the finger enters into a smooth-walled, rigid, cylindrical tube, the case is one of stricture, following gonorrhoeal or syphilitic proctitis. If, on the other hand, we feel a circular wall, into whose centre the finger can scarcely impinge, owing to the narrowness of the opening, and if the friable tissue breaks down, there can be no question that we are dealing with a ring-shaped carcinoma. If the growth is high up, we must direct the patient to bear down, or we must press the abdomen downwards with our free hand. According to Hochenegg, a remarkably wide ampulla should raise the suspicion of a cancer, DIFFICULTIES OF DEFECATION 409 situated high up, and fixing the pelvic colon. If a cancer of the lower segment of the rectum protrudes through the anus, the diagnosis is easy enough (fig. 194). Sarcoma is much more rare in this region (fig- 196). (5) Painful Defctcation. — We meet with this symptom in various conditions : — {a) If a patient tells us that he suffers from severe cutting pain in the anus after every action of the bow^els, that the pain starts immediately, and lasts for about fifteen minutes or longer, and that he postpones defaecation as long as possible on account of the pain, we may conclude that he is suffering from a fissure. On examining the anal aperture, we see one or more radiating cracks which, if care- fully separated from each other, look like defects in superficial epi- dermis, wdth a reddened base. Sometimes they are situated between small nodules of haemorrhoids of a perfectly unirritating character. [b) If, on the other hand, the pain is only occasional, and comes on in attacks lasting for a few days, the pain at first being confined to the moment of defaecation, but subsequently becoming more per- sistent, only to disappear for some time, after the loss of considerable dark blood, we may be certain that the condition is one of inflam- matory changes in haemorrhoids, i.e., thrombosis in their venous spaces. One of my patients compared the severity of the pain to toothache. Sometimes the loss of blood only occurs periodically at long intervals ; at other times the loss of blood may be constant at each action of the bowels over a protracted period — the loss being to the extent of a dessertspoonful or more. The condition found on inspection varies with the stage in which the patient happens to be. We may only find a few withered folds of skin or mucous membrane (fig. 191), or a bunch of bluish-red tense nodules, tender on pressure, or even a wdiole crown of them. If the patient is in the bleeding stage, one of these nodules will be ulcerated, and it may be possible to see a black coagulum projecting from the point whence the haemorrhage occurred. If internal hjemorrhoids became thrombosed, they prolapse very easily, and maybe strangulated by the sphincter ani, with such damage to their circulation that necrosis may follow. They look like bluish-black or brownish-black nodules, surrounded by oedematous anal skin, or by a ring of oedematous and swollen external haemorrhoids (fig. 193). Further extension of the inflammation may cause retention of the urine, abscesses, and even general septic infection. If the subjective symptoms and the haemorrhage indicate the presence of haemorrhoids, which are invisible on inspection, we must endeavour to get the rectal mucous membrane to prolapse, in order to bring internal haemorrhoids into view^ 4IO SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA We vvithou haeraor Vei" must never assume the presence of infernal haemorrhoids, t local examination, merely because there are no external rhoids. y rare cases have been recorded wherein the haemorrhoids have been situated lo to 20 cm. above the anus. The diagnosis may be suggested by haemorrhage, but it can really only be established by rectoscopy. (c) A patient who complains of occasional attacks of pain in the region of the anus, on sitting down or on defaecation — pains which in- crease for a few days and then sud- denly disappear after the evacuation of a certain amount of pus — is suffer- ing from a peri-proctitic abscess. There may be intervals of months or years between these attacks, but the patient will sometimes observe that some pus escapes even durmg these free intervals, indeed that flatus passes Fig. 191, — Relaxed haemorrhoids. despite the firm contraction of the Fig. 192. — Inflamed external heemorrhoids. Fig. 193. — Prolapsed internal bremorrhoids surrounded by external oedematous piles. sphincter. In such a case we may conclude that the abscess has been followed by an anal fistula or a rectal fistula. We shall discuss the details of the examination of these tistulae in a separate chapter. {cl) If the pain occurs before defaecation, rather than dnrl/ig this DIFFICULTIES OF DEF.i:CATIOX 411 act, and if there be, at the same time, pain on micturition, the case is one of prostatitis, probably of gonorrhoeal origin, but possibly also of a tubercular nature, (6') If the symptoms do not fit in with any clinical picture, but consist of tenesmus, blood and possibly pus in the stools, consti- pation, pains in the pelvis, we should think of a foreign body. We shall see in the next chapter, the variety of articles which have been introduced into the rectum. (6) Prolapse of ilie Anns. — Sometimes the difficulty in de- faecation consists of a prolapse of the rectal mucous membrane. The diagnosis can be made by a layman ; we have to decide whether the prolapse merely con- cerns the lowest portion of the mucous membrane — prolapsus ani — or whether the mucous membrane higher up is involved — prolapsus recti — or whether both conditions are present Fig. 194. — Cancer of the anal portion of the rectum. FlG. 195. — Prolapse of the anus and rectum. 27 Fig. 196. — Sarcoma of the anus. 412 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA (fig. 195). Our decision must be based on the size of the prolapse and upon the level at which the doubling up of the bowel is found — ■ at the anus or higher. Prolapsus ani is purely a matter of mucous membrane prolapse. In prolapsus recti, all the layers of the intestinal wall are turned in and the peritoneum may even be dragged, so that a perineal hernia may be formed — a so-called hedrocele. CHAPTER LVI. INJURIES OF THE RECTUM. Apart from lacerations of the intestine and rectum during labour, the injuries of this region are mostly due to impalement or to foreign bodies introduced for various purposes and in different ways. Impalement may be caused by falling on a garden fence, the handle of a broom, the barrel of a gun, or the leg of a chair, &c. Agricultural labourers are often impaled by falling off a haystack on to the handle of a fork. The laceration of the rectum by the horns of a bull produces a similar injury to impalement. The external wound is easily recognized in all these accidents ; diagnosis is mainly con- cerned with the question of the extent of the injury above. This may sometimes be determined by the length of the tract of blood on the impaling instrument. Some consideration should be bestowed upon the question of the possibility of a foreign body being retained in the wound. The following case, which I saw when assistant to Kocher, shows that this is not an unimportant matter. A young man, overstimulated by alcohol, climbed up to the top of three chairs standing on each other. The chairs fell over, and the leg of one of them penetrated deeply between his rectum and sacrum. But the wound seemed to be remark- ably harmless, and the rectum appeared to be uninjured. The onset of fever and of offensive discharge showed, however, that there was something wrong. Just before the demonstration of the patient in the clinic the probe touched at the level of the promontory on a peculiar structure, the meaning of which at once became clear. During the clinical demonstration the seat of the trousers in which the four seams joined together was triumphantly extracted by the forceps. The patient had changed his trousers before being brought to the hospital, otherwise the hole would have enabled us to make the diagnosis earlier. If we are certain from the length of the penetrating body that the INJURIES OF THE RECTUM 415 peritoneum has been torn, the abdomen must be opened and searched,, so as to avoid a belated diagnosis of intraperitoneal injury to the intestine, when peritonitis supervenes after a few days. Among the foreign bodies purposely introduced, one should mention especially the nozzles of enema syringes. Fatal injuries have been inflicted in this way, especially when the enema is administered into the abdominal cavity. These accidents happen, naturally, more frequently when the mucous membrane is diseased, as in cancer, than when it is healthy. In contrast to an enema syringe employed for constipation, a wood- chopper in the forest put a wedge of wood into his rectum, for diarrhoea. A colleague has informed me of a case whei'ein a man introduced a liqueur glass, in order that he might be able to witness a. festive procession, undisturbed. Sometimes foreign bodies are used for mastuibation. There is no complete account of these cases in literature, and the most unique examples of these occurrences do not exhaust all the possibilities, but in them all, the patient complains of tenesmus and hcemorrhage. We should, therefore, never neglect a rectal examination in any case wherein such symptoms come on, apparently without cause. As we cannot obtain any reliable information concerning the nature of the foreign body, we must be careful to protect the hnger with a stall, to prevent injury to it. Inspection with a speculum, which is sometimes indispensable for the diagnosis, should be left until the extraction is undertaken, as this requires anassthesia. The rectum is occasionally injured during attempts to procure abortion. I once made an autopsy on a young girl who died of peritonitis after an attempt at abortion. The posterior vaginal wall and Douglas's pouch were perforated and the rectum was impaled : The midwife who was accused set up the defence that she was much too experienced to have attempted to gain the right orihce in this- clumsv manner. 27A 414 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA CHAPTER LVIL TUMOURS AND SWELLINGS OF THE SCROTUM. When we are consulted for any scrotal swelling, we must first determine whether the swelling originates in the testicles or in the scrotum. This can only be done if it is possible to feel the testicle and its appendages quite distinctly, apart from the investing skin. But if the swelling, the testicle and the skin all form one connected mass, we must depend upon the history to tell us whether the change involved at first the scrotal contents only. iTjirfiitri m«si Fig. 197.— Acute exlravasation of urine, in a case of neglected urethral stricture. l.-SWELLINGS OP^ THE SCROTUM. A.— ACUTE SWELLINGS. If the swelling has arisen suddenly, the first point to consider is the question of contusion, which may cause a severe degree of blood extravasation. Then there is the possibility of acute inflammatory diseases, especially erysipelas, or of extravasation ofurine conse- quent upon an injury or a neglected urethral stricture, a matter of the greatest importance, because the treatment depends upon the accuracy of the diagnosis. If one meets with such a clinical picture as is illustrated in fig. 197, he must not be content with the diagnosis TUMOUKS AND SWELLINGS OF THE SCROTUM 415 of phlegmon, &c., but must at once provide for the free escape of the urine, in order to prevent his patient dying from uraemia and sepsis. B.— CHRONIC SWELLINGS. (i) If a diffuse swelhng has arisen graduahy, as a result of repeated acute inflammatory attacks, e.g., erysipelas, or as a consequence of chronic multiple urinary fistulae, the term applied to it is elephantiasis, The same name is applied to the enormous hypertrophy, which occurs in the tropics, from filarial disease. In this condition the patient is hardly able to walk, because of the appendage to his scrotum. (2) Circnuiscribed iiiiiioitrs of the scrotal skin are diagnosed accord- ing to their consistence. If they show fluctuation, are soft or tensely elastic, they may be dermoids, sebaceous cysts or cystic lymphan- giomata. The former are unilocular and non-translucent ; the last are multilocular and translucent, but are distinguished from hydrocele by their superficial situation. If the circumscribed tumour is hard, it may be either a fibroma or a sarcoma, in accordance with its rate of growth. If the scrotal tumour is of an ulcerating character, we should think instinctively of chimney-sweep's cancer or tar cancer. We should examine the history from this point of view, and note whether there be any eczema which paves the way for the cancer, or any so- called soot-warts. But if the history does not support this view^, we should remember that the scrotum may be a seat of a primary chancre, and that tertiary ulcers may resemble carcinomata. II._SWELLINGS OF THE SCROTAL CONTENTS. If the swelling is in relation with the normal contents of the scrotum, we must first ascertain whether it has a pedicle at its upper part, in other words, whether it runs into the inguinal canal. If this should be the case, the conclusions to be drawn are already discussed in the chapter on Inguinal Hernicie. In acute inflammation of the testicle and epididymis there is nearly always some infiltration of the spermatic cord, which may then resemble the pedicle of a tumour, a matter which will be referred to later on. The same applies to advanced cancer. A.— TUMOURS OF THE SPERMATIC CORD. An elastic or tense swelling in connection with the spermatic cord, quite free of the testicle and epididymis, is a funicular hydrocele, The diagnosis is absolutely certain if the swelling is, in addition, translucent. 27B 4l6 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA We have seen in Chapter LIV. that the acute hydrocele of Httle boys is often mistaken for strangulated hernia. A soft non-translucent swelling is in all probability a lipoma of the spermatic cord (p. 3^9). A hard tumour, adherent within the spermatic cord, suggests the rare form of sarcoma, which grows rapidly towards the abdominal cavity. We now proceed to deal with diseases of the testicle and epididymis, which, logically, should be considered separately. But as the apparent position of the swelling does not always correspond with its true topography, we propose to group them together in the first instance and then, later on, endeavour to distinguish between the testicle and epididymis. B.— ACUTE SWELLINGS OF THE TESTICLE AND EPIDIDYMIS. Let us assume the case of a patient who consults us for an acute painful swelling of the scrotal contents, and who tells us that it has resulted from a blow, a statement which should be taken cniii grano salis if the patient is insured against accidents. We find the testicle and epididymis fused together into a very tender oval-shaped mass. The skin of the scrotum is slightly oedematous, the spermatic cord is hard and swollen, and resembles a pedicle running into the inguinal canal, and the vas deferens cannot be felt as a separate structure. If Ave agree that an injury has been the cause, we should think of a traumatic hsematocele, i.e., an effusion of blood into the tunica vaginalis and into the cellular tissue of the scrotum. The diffuse swelling which obscures the division between testicle and epididymis and the infiltration of the spermatic cord may very well be attributed to the oedema which accompanies such an injury. Our assumption will be correct if the swelling exceeds in size the usual dimensions of a recent orchitis or epididymitis, i.e., if it is larger than a goose's egg. Sometimes confirmation may be obtained from a dark blue discoloration of the scrotum, especially on the posterior surface ; at any rate this discoloration should appear within a few days. If, how- ever, the swelling be smaller, and there be no discoloration despite the lapse of a few days since the alleged accident, our thoughts should run in another direction, although we should not entirely discard the traumatic theory. Pressure on the urethra may cause a few drops of the anticipated discharge to exude, and then further discussion is unnecessary, especiallv if the swelling mainly concerns the epididymis. The case is one of gonorrhoeal epididymitis. If we do not obtain any discharge, which sometimes ceases with the onset of the epididy- mitis, we should inquire for the date of the last attack of gonorrhoea. If this meets with a negative reply, we should make a rectal examina- TUMOURS AND SWELLINGS OF THE SCROTUM 417 tion, exerting slight pressure on the prostate, and then direct the patient to urinate. Abundant gonorrhoeal threads and small flakes of pus suffice for the diagnosis. But if these are not present, and the urine is somewhat turbid and of offensive odour, containing numerous pus-cells, micro-organisms, and probably crystals of triple- phosphate, we must abandon the idea of gonorrhoeal epididymitis. The patient has cystitis either as the result of stricture, hypertrophied prostate or tubercle, &c., and the epididymitis or orchitis has arisen owing to extension from the bladder. As these infections are fre- quently caused by trifling injuries, we should ascertain whether the patient has passed a catheter on himself or has recently had one passed. All this does not exclude the possibility that gonorrhoea may have been the original starting point of the disease. The gonorrhoea may have occurred years previously, and the infecting organism at the moment is not necessarily the gonococcus, but an ordinary pus organism such as the staphylococcus or streptococcus. We may assume inflammation of this kind if the testicle rather than the epididymis is involved. But if no source of infection is discoverable in the uro-genital apparatus there remains the possibility of metastatic orchitis. This includes the inflammation of the testicle which sometimes occurs in mumps, and occasionally after other infectious diseases such as typhoid fever. Finally, there are some very rare cases which cannot be explained, even in this manner ; the orchitis is apparently spontaneous and has no connection with any other disease. The testicle is, as a rule, alone involved in these cases, so that the}^ are easily distinguished from gonorrhoeal inflammation. If this form of swelling appears to extend beyond the testicle, it usually depends upon a slight attack of secondary hydrocele, in association therewith. In such a case there would be no sharp separation between testicle and epididymis ; but, as stated previously, they would merge into one oval-shaped swelling. In a simple orchitis the epididymis is situated above the swollen testicle like a narrow ledge. On the other hand, in a case of simple epididymitis, the uniformly enlarged epididymis lies against the testicle like the crest on a helmet. If we aie in doubt about the nature of an orchitic swelling owing to the absence of any accurate histor}^, we may resort to an explora- tory puncture, lest we overlook a purulent inflammation until it is too late to save the testicle. Before making the puncture we should warn tiie patient that his testicle may atrophy as the result of the disease, otherwise the incident which happened to us, owing to our neglect of this pre- caution, might be repeated. A young man had a testicle as large as a plum, which was very painful on pressure ; fever and pain persisted so that a puncture was made with a fine needle, but without any 4l8 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA result. The inflammation, however, subsided, and the patient was discharged. He returned in a few days looking very sad, because not only had the inflammation disappeared but the testicle also, and he blamed the exploratorv puncture for this. Indeed, there only remained a hard body, not bigger than a bean, instead of the plum- sized swelhng. We had then to ofter the explanation which we had previously neglected to do by way of prognosis, and the patient finally consoled himself with the reflection that the presence of one testicle was sufficient. It happens occasionally that, although everything points to a gonorrhoeal epididymitis, we learn that the patient has had of late more frequent calls to micturition than usual, the stream still being normal, and that he is obliged to get up one or more times during the night for this purpose. He may have noticed a fine, whitish deposit, or, exceptionally, a little blood in the urine. This usually signifies the beginning of uro-genital tuberculosis. How, then, is the acute onset of the swelling to be explained ? This may be due to an acute perforation of a tubercular focus into the tunica vaginalis, with a consequent tubercular hvdrocele. Examination would show tliat the epididymis cannot be separately defined from the testicle, and that the latter appears to be enlai-ged, and may even present fluctuation. Or it may be that the epididymitis is not purely of a tubercular nature. There may have been a nodule which the patient had not noticed, and it may have become secondarily infected, a circumstance which often happens in uro-genital tuberculosis, even if catheterization has not been practised. Examination of the urinary sediment shows mononuclear and polynuclear leucocytes, possibly a few red cells also, epithelial cells. Bacillus coU, staphylococci and streptococci. As the disease progresses an abscess will probably form in the epididymis, and spontaneous rupture finally occurs. Contusion of the testicle and the various forms of inflammation do not, however, exhaust all the possible causes of acute swelling. If the symptoms have come on very suddenly, and are accompanied by such reflex signs as vomiting, retention of flatus, if the swelling is somewhat high up and we are informed by the patient that his testicle had never completely descended, we should think of torsion of the testicle, a condition already referred to in connection with strangulated hernia. The results of this torsion are ha3morrhagic infarction and gangrene of the testicle (p. 399). The anatomical basis of this event is an abnormally developed mesentery of the testicle, Avhich permits it to hang free in the tunica vaginalis. The only condition with which it could possibly be mistaken is an embolic infarction of the testicle occurring in a patient with heart disease. TUMOURS AND SWELLINGS OF THE SCROTUM 419 C— CHRONIC SWELLINGS OF THE TESTICLE AND EPIDIDYMIS. Although we are not able to clearly distinguish the testicle from the epididymis when they are acutely swollen, this distinction is somewhat more possible in the early stages of chronic swellings. (1j Swellings of the Epididymis. If the epididymis is hard and swollen in an irregularly nodular manner, or if a hard, tender nodule is felt in an otherwise normal organ, we should immediately think of tuberculosis. We seek for confirmation of this diagnosis in the characteristic nodular or cylindrical thickening of the vas deferens, which is early recognized because the vascular elements of the cord usually feel quite normal when the tubercle is not accompanied by secondary infection, in contrast to what wc have seen in acute orchitis, gonorrhoeal epidi- dymitis, and tubercle with secondary infection. If the vas deferens is not thickened, we must look for traces of tubercle in the prostate, bladder, kidneys, as described in fuller detail in the chapter on uro- genital tuberculosis. The kidney is often the organ first affected, and the disease of the epididymis is only detected first because of its accessibility. There are three conditions with which this early stage of tuber- culous epididymitis ma}^ be confused : — (a) The reiiuiiiis of gonorrliCEal epididymitis, hard, somewhat tender, indurations in the epididymis. The distinction is made by the history and other physical findings, especially by a careful examination of the urine. (6) Syphilitic epididyiiiitis of the secondary stage, recognized by its almost painless onset and other diagnostic signs of syphilis. (c) A small cyst connected with the head of the epididymis — spermatocele. Its striking mobility, the smoothness of its surface, and its painlessness settle the diagnosis. But if we do not see the patient until a later stage of the disease, when he has an old, retracted, slightly discharging sinus, the problem is quite different. Testis and epididymis are fused together into one shapeless mass and cannot be felt separately. The principal question to decide is whether the case is one of tubercle or tertiary syphilis. A gumma attacks the testicle by preference, while tubercle starts in the epididymis. The patient may perhaps be able to inform us of the original site of the disease, iDut if he cannot do so we should diagnose a gumma when the epididymis is only slightly involved and the testicle considerably affected, especially if spontaneous pain and tenderness are but slight. If a sinus has already formed it is convenient to remember Reclus' 420 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA sign, to the effect that a syphiHtic sinus generally lies /// front and that a tubercular sinus lies behind, corresponding to the situation of the two diseases in the testicle and epididymis respectively. One must not forget, however, that if the testicle is inverted a tubercular sinus may lie forward. It is therefore necessary to observe the position of the vas deferens in the spermatic cord to see whether it is in front or behind, before drawing any conclusion from the situation of the sinus. (2) Swellings between the Testicle and Epididymis. Cystic tumours lying between the head of the epididymis and the testicle, and seated on the latter like a cap or helmet, are grouped together under the term spermatocele. When such a cyst is present it is either impossible to feel the head of the epididymis as a separate structure, or it lies, as just stated, on the spermatocele, so that the latter is tixed between it and the testicle. In order to render the diagnosis more certain an exploratory puncture may be performed, which, although generally superfluous, never does any harm if asepsis is preserved. The diagnosis is confirmed by the turbid watery appearance of the liquid, and by the presence of seminal threads visible under the microscope. (3) Swellings of the Testicle. {a) An oval or pear-shaped tumour with a smooth surface and of soft or tensely elastic consistence, indicates an accumulation of fluid in the tunica vaginalis. If it be of small extent, the epididymis can still be appreciated as a separate structure, and we may ev^en be able to feel the testicle [if the fluid is not very tense. If, however, the swelling is large and the tension greater, both testicle and epididymis only present somewhat more resistant places in the wall of the swelling. If the effusion has a thick wall, it may be quite mipossible to define them. The case is one of hydrocele or hsematocele of the testis, a serous or proliferating or haemorrhagic peri-orchitis, which may vary in size from a hen's egg to enormous proportions, if the patient waits until it is necessary to draw off the fluid by the pint. If the swelling is translucent it is a hydrocele, and puncture is then not merely an exploratory procedure, but is a therapeutic measure, at any rate of a palliative nature. If puncture of a tense translucent swelling is not followed by a flow of fluid, we should not diagnose cancer as a young practitioner once did, but rather a bad syringe. If, however, the swelling is not translucent, the diagnosis is usually proliferating peri-orchitis, i.e., a hydrocele whose wall has become thickened by connective tissue proliferation, by crest- and cone-like TUMOURS AND SWELLINGS OF THE SCROTUM 42 1 indurations, and by deposits of gradually organizing fibrin. If, on exploratory puncture, a fresh bloody fluid, or more frequently a chocolate-brown fluid, exudes, the case is one of haematocele, which we must look upon as a sub-variety of proliferating peri-orchitis, when it is not of traumatic origin. Serous peri-orchitis, as well as the proliferating and haemorrhagic forms, give rise, in different ways, to many points of differential diagnosis. A serous pcri-orcliiiis, associated with appreciable changes in the testicle and epididymis, may be secondary or symptomatic. Such effusions within the tunica vaginalis occur in herniae, tubercular epi- didymitis, and cancer of the testicle ; but they rarely become so large that the underlying disease is obscured. If we find that the upper end of a hydrocele which extends high up is very painful on pressure, and that there is probably some thickening of the spermatic cord at this spot, it is very likely that a fragment of onieninni has become strangulated in a communicating sac with a narrow neck, so that the hydrocele is another instance of the secondary form (p. 38S). In a case of proliferating peri-orchitis, our diagnostic reflections take another direction, at any rate before an exploratory puncture is done. A malignant groivtli will very frequently suggest itself ; unequal con- sistence usually indicates a tumour, although in simple proliferating peri-orchitis its wall may present soft, thin areas as well as hard ones. A rough nodular surface is clear evidence of new growth. Some tumours, however, have a perfectly smooth surface in their initial stage. As the infallible signs of a malignant growth, i.e., enlargement of the retroperitoneal glands of the same side and other metastases, are absent at the beginning, we must fall back upon the history. A simple proliferating or haemorrhagic peri-orchitis has usually existed for months, or even years, whereas a malignant tumour can only have been present at most for a few months. There is nothing absolutely conclusive in these signs, because a haematocele may develop very rapidly after an injury, and some malignant tumours grow very slowly. I once saw a malignant tumour w^hich had been under the observation of the family practitioner for many years. These are, however, exceptional cases, and the practical rule remains that the duration of haemorrhagic peri-orchitis is a matter of years, while that of cancer or sarcoma is a matter of months. After having taken all these points iuto consideration, puncture with a sufficiently strong and wide cannula is justiBable. In proliferating or haemorrhagic peri-orchitis, a serous or morbid chocolate-coloured liquid or fresh blood is obtained ; from a tumour, however, nothing is forthcoming, or at most a few drops of blood, or a plug of tumour tissue may be found in the needle. The latter is useful for histological examination. If exploratory puncture yields nothing at one spot, whereas some mucous fluid is obtained at another 422 SURGICAL DISEASES OF THE ABDOMIXAL AXD PELVIC VISCERA spot, we should diagnose a cystic adeiioiiia. If the fluid is of a Hght brown colour like cafe-an-lait, and contains epithelial cells, detritus and cholesterin crystals, the case is a dennoid, or at any rate an embryoma of similar constitution to the much more frequent ovarian dermoids, both of which may undergo cancerous degeneration The state of the testicle and epididymis is of no significance in cases of old-standing proliferating and haemorrhagic peri-orchitis, because both these structures become atrophied and absorbed in the indurated cvstic wall. If the clinical picture of proliferating or haemorrhagic peri-orchitis is combined with signs of acute local inflammation, with fever, and probablv even with rigors, we should remember that these forms of peri-orcliitis may easily become infected, and we should inquire whether there has been any therapeutic interference, such as puncture or injection of iodine. {h) The diagnosis is very much easier when there is a solid tumour, definitely connected with the testicle and independent of the epididy- mis, or when both testicle and epididymis are fused together into one uneven tumour. If neuralgic pains are present in tlie spermatic cord there is no doubt about its malignancy; but it is not always possible to tell from the clinical signs whether it is sarcoma or carcinoma, a differentiation which is not always easy, even after histological examination. A cystic adenoma or cystoma of the testicle is a very rare tumour, but we should bear it in mind if the swelling is irregularlv roundish and nodular and contains both hard and soft areas, and if the above mentioned mucous fluid is obtained on exploratory puncture. It is important to distinguish cancer and sarcoma from the swellings described by Wilms as euibryoid tumours, which are derived from all the three layers of the embryo and grow in an erratic manner. The dermoids or embryomata just mentioned are innocent tumours, but these embryoid tumours behave clinically like cancer, and can only be distinguished microscopically. A tumour of an inguinal testicle may very probably be of this nature, at any rate, such has been my experience. Tertiary syphilis of the testicle — either as a single gumma or a diffuse gummatous sclerosis — is the only disease which may lead to error in regard to moderately sized tumours limited to the testicle. If there are no metastases, and if we have no very good reason to definitely exclude tertiary syphilis, iodide of potassium should always be given. But if no result follows, operation must be undertaken, because cancer of the testicle soon gives rise to secondar}^ deposits, and therefore the organ must be removed without hesitation. A word with reference to accidents. How much attention should be paid to the assertions of insured patients that these various diseases have come on after an injury ? It is undoubted that even tumours may have a traumatic basis. Such a sequence is, however, very rare, FISTUL.9£ IN THE PERINEAL REGION 423 and it is very necessary to ascertain in every case whether there was not some morbid change present before the accident. This also apphes to tubercle. It is also a fact that tlie onset of gonorrhoea! epididymitis is favoured by injury ; but this is no justification for claiming workmen's compensation, when the testicle has only been subject to the ordinary impact it may encounter during work, and its possessor has previously provided the necessary gonococci. This would be a defiance to the aims of accident insurance. CHAPTER LVIII. FISTULA IN THE PERINEAL REGION. The perineal region, the seat of various natural apertures, is also the gathering place of various fistulae, some of which are congenital, while others only appear in later life. The principle of classification which we will adopt depends upon the site of origin of these fistulje. The period of their appearance is not a satisfactory basis for classifica- tion, because even congenital fistulae may not develop fully for many years. Neither can classification be based upon their position, because similar fistulae may have very different situations. Sometimes micro- scopic examination is required to decide the nature of the discharge from the fistula. We distinguish : — (1) DERMOID FISTUL/E. A fistula in the coccygeal area, dis- charging a small amount of secretion, which has been pre- sent for many years and which admits a probe into a short blind sac, is a dermoid fistula. The diagnosis is confirmed if on miscroscopic examination there be found not only pus, but also pavement epithelium and even hairs. The patient who had the fistula depicted in fig. 198, drew out many hairs from it, with the aid of a mirror. Fig. 198.— D = Dermoid fistula. F = Foveola coccygea. 424 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA Apart from these embryonic invaginations, there is often found in this region a depression, the foveola coccygea (fig. 198) which corre- sponds to the point of attachment of the caudal hgament to the skin. (2) FISTUL>!E IN CONNECTION WITH BONE. These are ahnost always tubercular, and usually originate in the sacrum or ileo-sacral joint ; more rarely in the coccyx or spinal column. The discharge from these fistulas is always purulent, and the probe introduced reaches down to bone. We can draw no conclusion as to the origin of these iistulae from the histological demonstration of tubercle, because many simple rectal fistulae are tubercular, and it is just from these that the differential diagnosis has to be made. Neither do negative results justify any definite conclusion, because the fistula may still be coming from bone, affected by osteo-myelitis. Even if a fistula comes from bone, we are not justified in exclud- ing the possibility of all connection with the rectum. The abscess may have opened secondarily into the rectum before appearing at the perinaeum. An unequivocal proof for its bony origin is only obtained if a skiagram shows the presence of a primary focus in the bone, or if this focus (vertebro-ileo-sacral tuberculosis) begins to manifest clinical symptoms. (3) FISTUL/E OF THE RECTUM AND ANUS. {a) Cougeuitcil Fistnkv. — These may be referred to three types, in accordance with the degree of occlusion and the sex of the patient : — (i) The anal aperture is itself reduced to the size of a narrow fistula, which opens either in the anal cleft, the scrotum or penis. (2) The anus is closed, and the ampulla is connected by a fistula with the vagina, or more frequently with the vestibulum. (3) The anus is closed, and the ampulla opens into the urethra. The state of the anal fossa and the position at which the faeces escape permit an accurate diagnosis to be made forthwith. (b) Acquired Inflaniinatory Fistulce. — These are usually the final results of peri-rectal abscesses, which open externally near the anal aperture, and generally also break through somewhere in the rectum. They cannot be recognized, as a beginner might suppose, by the escape of faeces therefrom, for they are usually much too small for this. Besides, many of them are situated entirely below the sphincter, and others, despite their name, have no opening in the rectum. A fistula which has burrowed through, and opened above the sphincter, may, however, sometimes allow flatus to pass involuntarily. Before a fistula can be designated either rectal or anal, it ought to be shown that the original inflammatory process started in the rectum or anus. FISTULA. LV THE PERINEAL REGION 425 This is not possible, as a rule, and therefore our diagnosis is even- tually made by exclusion; that is to say, a fistula in this region is either rectal or anal in the narrow sense, if we can find no other explanation for it. The portal of en- try for the infection is very varied. The infective process may have become engrafted on a fis- sure, a haemorrhoid, an accidental wound, a simple eczema, or even On a urethritis. In other cases the infection probably attacks peri - rectal tubercular glands. At other times the infection may enter through the folds of Morgagni (Chiari), or through Hermann's sinus, in which certain glands described by this observer open — this sinus itself opening into Morgagni's folds (Tavel). These fistulae are invested with pavement epi- thelium. In order to determine whither the fistula leads, the bowel must be emp- tied and the patient placed in the lith- otomy position and a moderately thick probe is passed into the fistula with one hand, while the in- dex finger of the other is in the rectum for purposes of control. If we obtain no result the examination must be repeated after the introduction of a rectal speculum. If no connection is even then visible a sausage-shaped Fig. 199.— Diagrammatic view of anal fistulse. m = Mucous membrane of rectum. r_= Muscular layer of rectum. Si = Internal sphincter. Se = External sphincter. 1 = Levator ani. J = Ischium. 1 = Incomplete submucous fistula. 2 = Incomplete subcutaneous fistula. 3 = Complete subcutaneous fistula. ^ m Fig. 200. — Diagrammatic view of anal and rectal fistulse. Anatomical details as in fig. 199. 4 = Incomplete ischio-l'ectal fistula. 5 = Complete ischio-rectal fistula. 6 = Incomplete pelvi-rectal fistula. 7 = Complete pelvi-rectal fistula. 8 = Fistula leading from tuber ischii. 426 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA roll of gauze should be gently put into the rectum as high up as possible and the external opening of the fistula injected with a few cubic centimetres of a i per cent, solution of methylene blue. If there is any connection between the fistula and the bowel there will be a blue stain on the gauze when extracted, which will also show its position. If there is no connection we must see whether the probe reaches bone, and if not, must observe whether the injected solution appears in the urethra instead of in the rectum. If all these examinations yield negative results we must still regard the fistula as a rectal fistula, although it does not open into the rectum. But, on the contrary, we must not suppose that every fistula which opens into the rectum is a rectal fistula, as we have already indicated. Both fistula from bones and from the urinary tract may form secondary connections with the rectum. A fistula which penetrates right through is called complete, one which ends blindly is called incouiplete. If it runs between the external sphincter and the skin or the mucous membrane we speak of a subcutaneous or a submucous fistula respectively. If it lies out- side the external sphincter and under the levator ani we call it ischio- rectal. If such a fistula is complete it usually opens just above the external sphincter, between it and the internal sphincter. If a fistula pierces through the levator ani it is called pelvi-rectal. If there is an internal opening to it, it will be found above the internal sphincter (fig. 200). In regard to the treatment and prognosis we are confronted with the question whether the disease is tubercular, as it is in half the cases, or whether it is not. The very appearance of the fistula may convey some meaning to the careful observer, and he will entertain a deep suspicion of tubercle if the skin is undermined and the granulations pale brown, just as he would if apical tuberculosis had been found beforehand, although the patient may have had no pre- sentiment of it. Positive proof is afforded by histological examination of the granulations, and in doubtful cases by animal inoculation. (4) URINARY FISTUL/E. These are easily recognized and easily diagnosed, because a dis- charge of urine is an unmistakable symptom, and one which the patient realizes at a very early stage. {a) We will begin with congenital nrinaryfistnlce. These obviously only occur in males and are caused by the urethra opening in the perinseum — hypospadia, scrotal is and perinealis — or in the rectum. This hypospadias merges into hermaphroditism. (6) Acquired urinary fistulae are of greater importance. We shall not refer to urogenital fistulae of females, which belong to the depart- ment of gynaecology, but shall limit ourselves to the male sex. GENERAL REMARKS ON DISEASES OF THE URINARY ORGANS 427 The first question to decide is the source of the fistula. The mode and manner of the urinary flow may be conclusive on this point. If it is constantly dripping the fistula must run into the bladder, or some previous disease must have destroyed the action of the sphincter. This form of fistula is rare. I have seen it in an old prostatic patient in whom a retroprostatic pouch had led to an extravasation of urine towards the perinaeum, and therewith to the formation of a fistula. On the other hand, if urine only exudes at the time that the patient micturates voluntarily, not, however, through the natural opening, but through more or less numerous fistulae, it follows that the urethra must be leaking between the sphincter and some obstruction peripheral to it. The spot at which the urine escapes is a matter of indifference. One finds sometimes, as a result of extensive urinary infiltration, fistulae on the scrotum, penis, perinaeum, lower abdomen, and even on the thigh, so that the patient eventually micturates as from a basin full of holes. If the distinction between fistulae from the bladder and from the urethra is once made, the etiology follows naturally. In cases of vesical fistula the obstruction must be at the neck of the bladder, and consists either of a tumour or prostatic hypertrophy. In cases of urethral fistula the obstruction must lie peripherally to the neck of the bladder, and consists of gonorrhoeal or traumatic stricture, rarely of tubercle or cancer ; but in the Tropics Bilharzia disease is frequent. The fistulae which develop after open injuries, and which concern the urethra rather than the bladder, follow no rule. The same applies to the fistulae which develop in consequence of malignant growths of the urethra or anus. CHAPTER LIX. GENERAL REMARKS ON THE SURGICAL DISEASES OF THE URINARY ORGANS. The cystoscope, catheterism of the ureters, the intravesical separa- tion of the urine, and cytoscopy, may have improved the accuracy of diagnosis of urinary disease, but it has certainly robbed it of sim- plicity, and there is a risk that the practitioner will think that urinary disease, with the exception of nephritis, cannot be diagnosed without all these accessories. This would be, however, a grave error, and the 28 428 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA exaggerated significance which was at first attributed to some of these methods is to blame. The general practitioner still sees urinary troubles in their earliest stages, and the responsibility rests upon him of recog- nizing when surgical assistance is required. Every practitioner has, or should have, a microscope at his disposal, and is conversant with the elementary methods of the chemical and bacteriological examina- tion of the urine. These two aids, in addition to careful clinical observation, permit the diagnosis to be made in most cases sufficiently early for timely surgical treatment — if this is attainable. We will not proceed to consider ready-made diagnoses like the headings of a text-book, but will take the symptoms which lead the patient to the medical attendant. These consist either of some dis- turbance in micturition or of some abnormal constitution of the urine. Then there come into consideration local symptoms in the area of the diseased organ. /i.— DISTURBANCES OF MICTURITION. Micturition may be painful (dysuria) or diijicult (retention), or, on the other hand, it may be too free (incontinence), or, finally, there may be a persistent strangury (tenesmus). Involuntary micturition, which is otherwise normal, has only rarely a surgical interest. (1) PAINFUL MICTURITION. Pain on micturition may originate either in the urethra or in the bladder and its vicinity. We distinguish the following possibilities : — (i) If the urine scalds when it passes through the nrethra, there is either some abnormality in its composition (concentrated, or chemically changed), or the urethra is inflamed. The former con- dition may be caused by indulgence m certain beers, or by taking beer to which one is not accustomed (" biertripper "). In recent urethritis it will not, as a rule, be difficult to fix the blame on the gonococcus. The observer must convince himself of the condition of the urethra by inspection, lest he treat a gouty urethritis for a gonorrhoea. The differential diagnosis is easy, because there is no discharge in the former, whereas in the latter it is always present in some form. A pain which originates in the bladder is sometimes referred to the urethra, and the patient complains of a scalding in the glans penis, when, for instance, the bladder is irritated. Pain on micturition may also arise from some localized disease of the urethra, a stone, a foreign body introduced from without, or rarely from the early onset of carcinoma, (2) Pain in the neighbourJwod of the bladder, especially at the end of micturition, indicates disease in the bladder itself or in its vicinity. GENERAL REMARKS ON DISEASES OF THE URINARY ORGANS 429 (a) Stone and tuberculosis are the principal diseases of the bladder in this connection. Tumours do not cause pain until their later stages, unless cystitis supervenes. In tuberculosis, and more especially in stone, the pain occurs chiefly at the end of micturition, remains a long time after the completion of the act, and may radiate into the urethra. In cases of stone there is the very significant circumstance that the pain and the accompanying strangury increase with bodily movements, such as riding on an uneven road. (6) When the inflammatory process is in the area adjacent to the bladder, as in the case of perimetritis or of appendicitis, &c., wherein the bladder is directly involved in an abscess wall, the pain occurs at the beginning of micturition and remains more limited to the neighbourhood of the bladder; patients with appendicitis often retain their urine for many hours to avoid this pain. The same applies, although in a less degree, to the bladder pain which often occurs in cases of tubercular peritonitis. (2) DIFFICULT MICTURITION. This is caused either by some disturbance of the mechanism or by obstruction in the passage. Whenever there is no urine passed, it is most important to show, by percussion or catheterism, that there is urine in the bladder, and that the failure of micturition is not due to suppression of urine. We have already discussed in connection with abdominal injuries the apparent anuria which occurs in laceration of the bladder. (a) Disturbances of the Mechanism of Micturition. Retention, due to disturbance of the mechanism, by an interrup- tion in the reflex arc or by cerebral inhibition, is of medical rather than of surgical interest. The surgeon often sees this form of retention after operations, due to psychical inhibition. It is not at all necessary that the operation should be on the genitals, urinary tract or their vicinity. Retention may also follow other operations, such as excision of a goitre, or radical cure of hernia. Sometimes it is only the horizontal posture which disturbs the patient ; in other cases micturition is impossible in any position. This form of retention may be compared with what is often seen in neurasthenics, who, for instance, are quite unable to micturate in the presence of another person. The retention observed in semi-comatose patients, especially in the course of meningitis, indicates functional disturbance of the reflex process. The voluntary retention in cases of painful micturition previously noted is quite of a different character. In cases of retention 430 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA due to over-distension of the bladder, the cause is paiiially due to disturbance of the mechanism of micturition, but as the chief cause is some mechanical obstruction, we shall discuss this type of retention in the latter group. Anatomical destruction of the nerve tracts is found in injuries of the spinal cord, and in compression thereof by tubercular caries or tumours. (b) Obstruction of the Urethra. The difficulty caused by mechanical obstruction of the urethra has much greater surgical importance. The following comprises a summary of the causes of such obstruction : foreign bodies and stone, inflammatory and traumatic strictures, compression of the urethra from without by a haematoma, tumour or inflammatory material, &c., and laceration of the urethra. Each one of these con- ditions possesses its own peculiarities, which, as a rule, render the diagnosis quite easy. (a) A sudden onset, accompanied by pain and possibly by the passage of blood, strongly suggests a foreign body in the iiretJira. It may be a stone from the bladder, which has lodged in the urethra^ a very probable contingency if there be a history of the passage of stones or of discomfort due to stones. But a foreign body may have been introduced from without, obstructing the urethra either by its size or by the inflammation which it provokes. History is usually silent in these cases, and nothing less than the ocular demonstration of the foreign body suffices to extort a confession. A metal catheter and a urethroscope are required for the diagnosis. The extent to which sexual perversion may go is shown by a case in our clinic, wherein the patient filled his urethra, as far as the sphincter, with plaster of paris. Stones may remain in the urethra for a considerable time without leading to obstruction. These are stones lying in diverticula and their symptoms are of a chronic nature. If the urethra is free, the cause of a sudden obstruction must be at the exit from the bladder, and then stone at the vesical neck is most probable. In certain positions such a stone may block up the neck of the bladder like a bail-valve. In most of these cases the patient \\l\\ already have discovered that he can only micturate easily in a certain posture of his body. Often, the micturition will be suddenly interrupted, or the previously powerful stream becomes- suddenly feeble. If obstruction has apparently come on suddenly at the neck of the bladder, and it remains absolutely unchanged as a complete obstruction for a day or more, we should think of enlarged prostate if the patient is an elderly man. GENERAL REMARKS ON DISEASES OF THE URINARY ORGANS 431 A careful inquiry into the history of these cases will elicit the fact that there have been symptoms of mild obstruction previously, but that the patient has not appreciated their importance. The sudden obstruction is also partially due to over-distension, and therefore to disturbance of the mechanism of micturition. (b) Subacute obstruction of tite urethra is the term applied to those cases wherein the process develops, without any warning, in the cours,e of a few days. They are usually caused by rapidly growing swellings which press on the urethra from without — in males, by abscesses of the prostate or vesiculse seminales, or peri-proctal suppuration ; in females, by some genital tumour strangulated in the true pelvis and becoming rapidly larger through circulatory disturbances, by a pregnant retroflexed uterus, or by some effusion under high pressure. (c) Gradual obstruction of tlic urethra presents quite a different clinical picture. The patient complains that for weeks or months he has had to strain during micturition, and that the stream does not reach as far as formerly. Attacks of catarrh of the mucous membrane or of over- distension of the bladder may increase the symptoms spasmodically, but the obstruction may become complete quite suddenly, and its degree never varies, as it does in cases of obstruction by stone. The causes of this gradual obstruction include stricture, new growth, stone in a urethral diverticulum, enlarged prostate, pelvic tumour, or a very chronic abscess. The age and history of the patient will suggest the selection from these causes, and local examina- tion, which we shall describe later on, will allow us to make a more definite diagnosis. (3) DEFICIENT CLOSURE OF THE BLADDER. Inability to retain the urine, incontinence, may be due to many causes, some of which are concerned with medicine, others with surgery. Disturbances of innervation are the most important of these causes. They may be of a purely psychical character and transitory in nature (fright or excitement). In other cases there may be organic paralysis of the sphincter, in which condition the incontinence is not primary, but merely the result of retention with overflow, from an over-filled bladder (paradoxical incontinence). The urine dribbles away, yet the bladder may reach as far as the umbilicus. Retention with overflow also occurs when mechanical obstruction has led to over-distension of the bladder, e.g., in enlarged prostate. Incorrect diagnosis of these various disturbances is quite fre- quent. Pure incontinence as a result of sphincter paralysis is 432 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA confused with overflow from a full bladder due to paralysis of the detrusor. The difference is, however, very obvious, because in the former case the bladder is emptv, while in the latter it is full. The constant micturition which occurs when the capacity of the bladder is very small (as in tuberculosis or stone) is sometimes mistaken for genuine incontinence. Finally, pure nervous derangements may be regarded as the result of mechanical obstruction, and a patient with masked tabes diagnosed as a case of enlarged prostate. These mis- takes can onl\^ be avoided by a complete examination of the patient. Ulcerative destruction of tJie sphincter by new growth or tubercle mav also lead to constant flow of urine. (4) VESICAL TENESMUS must not be confused with incontinence. This term is applied to all cases wherein there is increased frequency of micturition, accom- panied by abnormal sensation of irritation. The first thing which usually strikes the patient is that he is bound to get up once or more in the night, although he has not taken more than his average allowance of liquid. Then, he begins to be annoyed by frequency of micturition during the day, and, finally, strangury sets in, which prevents him from attending to his occupation. The bladder is in a constant state of contraction owing to some persistent irritation. It is unable to fill up, and the urine escapes at short intervals, although the sphincter still retains the full powers of closure. The main cause of this condition is cystitis, especially of tubercular origin, but it is sometimes due to a large stone in the bladder. In persons with extreme reflex irritability, such as is attri- buted to Rousseau, there is no relation between the physical state and the degree of vesical contraction. Even a small ulcer ma}" suffice to produce the so-called "irritable bladder." The diagnosis is based on the frequency of micturition and the diminution of the capacity of the bladder, which can be demonstrated by the injection of fluid. Whereas a normal bladder easily holds 200 to 250 c.c, an irritable bladder sometimes rebels against one-tenth of this quantity, and it is often quite impossible to inject the 80 to 100 c.c. which are required for cystoscopy, at any rate, without the aid of morphia or anaesthesia. As the various conditions which lead to the anomalies or fre- quent micturition are very liable to confusion, they may be briefly summarized once again : — Anuria. — Absence of urinary secretion, or its retention in the kidneys (the former in severe nephritis, the latter in stone in both kidneys) ; but the power of emptying the bladder is not lost. Oliguria. — Very small amount of urine secreted, without regard to the frequency of micturition {e.g., in nephritis, ileus and diarrhoea). GENERAL REMARKS ON DISEASES OF THE URINARY ORGANS 433 Polyuria. — Increased secretion of urine, without reference to the frequency of micturition {e.g., in diabetes). Pollakiuria. — Abnormalirequency of micturition, without reference to the quantity of urine. This may be the result of : — {a) Abnormal filling of the bladder, with incomplete micturition (t'.^., enlarged prostate). (6) A condition of abnormal irritability (vesical tubercle, vesical stone). (c) An abnormally large quantity of urine. 5.— ABNORMAL COMPOSITION OF THE URINE. The substances which a patient notices as abnormal constituents of his urine are pus, blood, and inorganic deposits in the form of concretions. (1) ADMIXTURE WITH PUS. The naked eye should never be relied upon for the diagnosis of pus ; it is always necessary to employ chemical examination and the microscope. This, however, does not mean that the naked eye cannot discover a good deal in a cloudy urine. The following type of case is not infrequent : A patient consults us for a condition which has been diagnosed, either by himself or by others, as cystitis. He complains of tenesmus, and in evidence of his disease he puts on the table a bottle containing whitish cloudy urine. While describing his symptoms in full detail, a sediment forms in the bottle, which the experienced observer sees at once is not pus, but carbonates and phosphates. A few drops of acid dissolve this precipitate. A microscopic examination of the deposit will reveal amorphous calcium salts, and probably also the beautiful crystals of di-calcium phosphate ; sometimes also calcium oxalate. A few general directions for the reghnen of the body and mind suffice to cure the patient of his " cystitis." If the urine is slightly cloudy, but forms no deposit even after long standing, nor clears up on the addition of acid, it is most probable that the specimen is not fresh, but has become a culture medium for bacteria. A glance with the microscope shows us swarms of bacteria but no pus cells. If the patient assures us that the somewhat cloudy and offensive urine has been passed quite recently, the probability is that the bacterial culture has developed in the urinary passages, and another examination with a catheter specimen would prove this. Pus cells are entirely absent, neither are there any clinical signs of inflammat-ory disease of the urinary passages. The case is one of " bacilluria," generally due to the Bacillus colt but sometimes to the typhoid bacillus. If there really be pus in the sediment, the urine must be examined very carefully with the naked eye. If gonorrhoeal threads or small 434 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA flakes of pus float about in it, the urethra of the patient must be examined, and, according to circumstances, the urine must again be investigated after washing out the urethra, or the three-flask test must be undertaken. If the pus only comes from the anterior urethra, or from the posterior urethra as well, leaving the bladder free, the case is gonorrhoea. If both the urethra and the bladder discharge pus, we shall rarely err if we diagnose cystitis as a complication of gonorrhoea. But if all the pus comes from the bladder, we must inquire whether there is always a sediment in the urine, or whether the cloudiness in the specimen under examination is a first appearance, or whether such cloudy specimens have been passed on previous occasions. If the urine is uniformly purulent, or at any rate if the pus contents are not subject to sudden changes, the lesion may be in the bladder, although the pus may come from the pelvis of the kidney. A single evacuation of very purulent urine, or of pure pus, indicates, either that a pyonephrosis has suddenly emptied into the bladder, or that a perivesical abscess has broken into it. Such an abscess may originate in the appendix, female sexual organs, prostate, or pelvic bones. This event will always have been preceded by symptoms which permit of the establishment of a diagnosis. The appearance of pus in the urine is only an incident in the course of the underlying disease. The site of the perforation can be seen with the cystoscope. We now proceed to the clicinical examination of the urine. The chief information which this affords, apart from the demonstration of carbonates and phosphates previously mentioned, concerns the reaction of the urine. Diminution of acidity, or even the presence of an amphoteric reaction, has no serious significance, as long as the urine is odourless, and if any cloudiness which may be present disappears on the addition of acid. On the other hand, a diminution of acidity in pus-containing urine, and the presence of an alkaline reaction, indicates secondary infection of the urinary passages by organisms like the staphylococci and Proteus vulgaris, which decompose urea. The latter causes, in addition to an alkaline reaction ammoniacal fermentation, which betrays itself at once by the smell. If pus-containing urine is acid, but does not smell offensively, the condition is usually tubercular or one of streptococcal infection. If it is acid and offensive in smell, the Bacillus coli, and probably other inflammatory organisms, are responsible. It goes without saying that the chemical examination of the urine must always include tests for albumin and sugar, and for biliary and blood pigment when necessary. The most important part of the microscopic investigation of the urine concerns the various forms of cells. If polynuclear leucocytes pre- ponderate, the morbid process is an acute one ; if mononuclears GENERAL REMARKS OX DISEASES OF THE URINARY ORGANS 435 preponderate we should rather think of tuberculosis. Bladder epithelium indicates the presence of ulcers, especially if it is found in shreds, and if specimens of the deeper layers occur (caudate epithelium). Red blood corpuscles point to the same conclusion. Whenever pus cells are present, cylindrical cells should always be sought for. It is then necessary to note the presence of various kinds of uiicro- organisms. The demonstration of tubercle bacilli possesses a special significance, and to prevent their confusion with smegma bacilli, a catheter specimen must be obtained, a precaution requisite in all bacteriological investigations of urine. If nothing is found, this is naturally no evidence against tuberculosis. But we must not hastily conclude that the suppuration has been adequately explained by the discovery of the Bacillus coli, staphylococci or streptococci. These organisms may certainly exist independently, but they often accompany the tubercle bacillus, even in uncatheterized cases, and may indeed completely overshadow it in the urine. We may even go a step further and say that every case, wherein these organisms persistently occur in the urine, is very suspicious of tubercle. The suspicion is even greater, if only pus cells are found and no micro-organisms at all. Such cases are almost always tubercular. This diagnosis is obviously arrived at by a process of exclusion, but it can be confirmed by the inoculation of guinea-pigs — a procedure which should never be neglected if tubercle bacilli are not found in the direct examination of purulent urine, in cases wherein there is no other cause for the suppuration. If this experiment, conducted with an adequate amount of sediment, yields no result, we are then justified in assuming that the case is one of pyelitis due solely to the " ordinary" pus organisms. Experience, however, shows that such cases are really of quite unusual occurrence. (2j ADMIXTURE WITH BLOOD. The presence of blood in the urine is always a serious matter, whether there are only a few red cells detected by the microscope, or whether there has been profuse haemorrhage. (i) If the blood is quite red and also flows independently of micturition, it comes from the urethra and must be ascribed to injury, possibly by a foreign body. Smaller periodical h?emorrhages independently of micturition indicate some ulcerative process in the urethra (cancer, or stone in a diverticulum). The appearance of hloocUstaincd semen should also be mentioned. Cases occur wherein there is a discharge of blood-stained semen, quite apart from any sexual activitv, and even after the period of sexual life has been left behind, although no objective demonstrable disease of the sexual organs be present. 436 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA (2) If the blood is mixed with the urine and appears only with micturition, it must come from the , bladder, ureter or kidneys. Attempts have been made to decide whether the blood comes from the kidneys or the bladder, on the basis of the more or less pro- nounced change in the colour of the blood. These are, however, unreliable, because everything depends on the rapidity of the haemorr- hage, the amount of blood and the duration of the contact between the urine and the blood. If the haemorrhage in the bladder is slight, and the blood remains within it for any considerable time, it under- goes the same changes as occur in haemorrhage in the pelvis of the kidney. Much more reliable conclusions may be derived from the associated symptoms. If the haemorrhage is attended by vesical colic — due to the expulsion of coagula — and by no other symptom, the blood most probably comes from the bladder. If renal colic is present, its origin is in the kidneys. If there be no pain, nor any indications of tumour in the bladder or kidney, we may be able to obtain some information by examining the urine after massage of the kidneys. The last stage of the examination consists of cystoscopy. (3) If there be pus in the bloody urine, or in the urine of the intervals wherein it is free from blood, we should think especially of tubercle, or of some vesical or renal disease with secondary infection, however slight the traces of pus may be. (4) Microscopic traces of blood, constantly found in the sediment or the centrifugalized portion, indicate either stone or tuberculosis. (5) Intermittent haemorrhage and the presence of cylindrical cells and albumin in the intervals when the urine is free from blood, are signs of chronic haemorrhagic nephritis. Nephritis may, however, occur without albumin and without cylindrical cells, as shown by Rovsing. But we should only conjecture such a diagnosis in cases wherein the blood comes from both sides and cannot otherwise be explamed. It is also necessary to add, for the sake of completion, that renal haemorrhage may occur in haemophilia and in transitory ha3morrhagic diatheses, as in purpura. Whether, apart from the above-mentioned conditions, bleeding may occur from healthy kidneys — idiopathic renal haemorrhage — as is often assumed, must be left an open question. Such a diagnosis can only be made with certainty /)os^ mortem, because anatomical changes cannot be excluded unless histological examination of both kidneys has been undertaken. (3) ADMIXTURE WITH INORGANIC DEPOSITS OR CON- CRETIONS. (URINARY GRAVEL.) Inorganic sediment is the third form of urinary admixture which worries the patient and impels him to seek advice. This sedi- ment varies from a flocculent deposit of microscopic particles and GENERAL REMARKS ON DISEASES OF THE URINARY ORGANS 437 crystals, to the size of a pea, e.g., to a calibre which can just pass through the urethra. We have already referred to sediment composed of carbonates, phosphates and oxalates. In the case of "gravel" or larger concretions the diagnosis of calculous disease is obvious. Bot such a diagnosis should not satisfy us. It is much more important to decide whether we are dealing with an '' aseptic " or with an " infected " case. In the former, the urine is free from pus and the concretions consist of calcium oxalate, uric acid, urates and occasionally of cystin. In the latter, the urine is purulent and the concretions consist, exclusively or largely, of ammonium-magnesium phosphate and basic calcium phosphate. (U ,, -J . , f With ammonia — purple red Murexide test -^ with ^dausUc potash-purple violet Uric Acid Urates s ,, -j^^i With ammonia — yellow Murexide test | ^^.^^ ^^^,^^j^ potash-orange Xanthin U The powder burns with a slightly luminous blue flame, and smells like burning sulphur and oil of asafoetida Cystin IS The powder effervesces with hydrochloric acid Calcium Carbonate .0 s u c I— 1 The powder does not effervesce with hydro- chloric acid but does so after heating to redness Calcium Oxalate and does not do so, even after heating to redness Earthy Phosphate The diagnosis can often be made from the microscopical examina- tion, because the urine frequently contains, in addition to the peculiar granules of gravel, some crystals of the corresponding salts, illustra- tions of which are given in any text-book of clinical methods. If these crystals are, however, absent, the diagnosis can be made by the experienced observer without any difficulty, from the above scheme suggested by Ultzmann. The origin of these concretions cannot be determined forthwith, at any rate not of all of them. We may, however, assume that clinically aseptic concretions originate in the renal pelvis, while secondary stones may form either in the renal pelvis or the bladder. Gravel might come from either source, but small facetted burnished stones usually originate in the renal pelvis. C— LOCAL SYMPTOMS. An accurate diagnosis can only be made after the direct examina- tion of the organs concerned. We shall later on discuss the various groups of disease in detail, but for the present, will limit ourselves to a 438 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA few remarks on the method of examination, and the so-called ////?r//o//c7/ diagnosis of renal disease. The patient must first pass a portion of his urine — if he can — and we put this aside for a careful examination, particularly to ascertain whether there is any admixture with blood. The character of the stream and the naked-eye appearance of the urine will already have furnished important information (gonorrhoeal threads, pus, gravel). We then feel the urethra, lest we miss some foreign body, tumour, or scar tissue which may be felt from the outside, and afterwards we palpate over the bladder and kidneys. A wide Nelaton catheter is then introduced, having previously satisfied ourselves as to the con- dition of the instrument. It is very unfortunate if the practitioner has to extract a broken piece of catheter himself, or obtain the services of some one else to do it for him. The following are the usual possibilities: — (i) If the catheter enters the bladder easily, although the patient cannot himself micturate, the neck of the bladder must be obstructed by a stone, foreign body, or tumour ; or it may be a case of enlarged prostate, or compression of the urethra from without — assuming, of course, that a nervous derangement is not in question. In cases of enlarged prostate or external compression of the urethra, the catheter experiences some little difficulty when it reaches the pars prostatica. We then take a medium-sized metal catheter of the ordinary curve, and introduce it very carefully. If we reach the bladder after impinging on a hard, rough substance, there can be no doubt about the diagnosis of stone or foreign body. If nothing is felt, we must notice whether it is necessary to depress the eye of the catheter very much before the urine flows. In this event the pars prostatica is lengthened, which means that an enlarged prostate is probably present. Sometimes it is necessary to elevate the patient's pelvis in order to depress the catheter sufficiently. The diagnosis obtains further confirmation if we cannot empty the bladder with the ordinary shaped catheter, but succeed in doing so with a semi-circularly curved tin catheter, or with an elastic catheter with Mercier's curve. Having succeeded in introducing into the bladder a medium-sized or wide catheter, either with or without this special manoeuvre, the c]uestion arises as to whether we are dealing with a simple prostatic hypertrophy, a prostatic tumour, or with some pathological structure in the vicinity, which is pressing on the urethra. The latter usually signifies a swelling, which is more often malignant than innocent, and includes tumours of the pelvic bones and connective tissue, such as sarcomata, chondromata, osteomata, and cysts, mainly dermoids. The distinction between these conditions and enlarged prostate is made by rectal and combined recto-abdominal examination. GENERAL REMARKS OX DISEASES OF THE URINARY ORGANS 439 With the finger introduced into the rectum, we first feel the anterior wall of the ampulla, and follow the outlines of the prostate with tiie finger tip. It is impossible to learn from books what this feels like ; it must be studied on the living subject. If the mucous membrane is soft and cedematous, with the prostate enlarged and rather elastic, feeling like a pillow, and at the same time tender to pres- sure, the case is one of acute prostatitis or of prostatic abscess. If the swelling is higher up, the case is one of inflamed vesiculae seminales. If the prostate is enlarged, but not painful on pressure, the case is one of enlarged prostate, cancer, or sarcoma. If there is nothing special found in the prostate, the hypertrophy may be in the direction of the bladder with or without a middle lobe, or the prostate may be in a state of diffuse sclerosis, or there may even be a contracting cancer present. (See further Chapter LXIX,). Otherwise there must be present one of the previously mentioned tumours, pressing on the neck of the bladder from without. (See Chapter LXXIII.). In the female sex, in addition to the pressure of the foetal head during labour, it is necessary to mention uterine tumours incarcerated in the true pelvis, as well as retroflexion of the gravid uterus. Every- one of experience knows those tumours, reaching as high as umbilicus,^ which beginners look upon as ovarian cysts, but which disappear as soon as a catheter is passed. It is most important to make an accurate estimate of the state of affairs, as a very prolonged over-distension may result in complete sloughing of the mucous membrane of the bladder. A similar result may occur from rapidly growing tumours, strangulated within the true pelvis, as I have seen in a case of sarcoma of the uterus. (2) If a medium-sized catheter does not enter the bladder, but a narrow one does, a stricture is present. If it is not very definite, it is useful to employ Guyon's olivary bougie, because we are better able to appreciate the obstruction with this instrument than with a cylindrical or a cylindro-conical catheter. But if even the smallest catheter will not enter, we must try a series of elastic bougies of the calibre of catgut, putting in one after the other. A path will some- times be found in this manner. The cause of the stricture is either gonorrhoea or new growth. If the age and history of the patient, and slight haemorrhage from the stricture suggest cancer of the urethra, it may be possible to establish this diagnosis by palpating the urethra and the use of the urethroscope. (3) If no instrument at all passes, the case is a severe example of one of the two above-mentioned classes. If the age, sex, and external circumstances do not give a clue, and if the over-filled bladder prevents a satisfactory examination, we must puncture the bladder as a 440 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA matter of urgency, and then provide an exit as rapidly as possible, either above or below, in accordance with the physical condition found. (a) Unilateral inhibition of the renal function (trauma, in- farct). Local sj-mptoms. No marked disturbance of urinary excretion (function taken on by other kidney). (a + a'') Bilateral inhibi- tion of the renal functions (nephritis). Anuria. Bladder empty. Death from uremia. (fi) Unilateral obstruction of renal pelvis (kinking owing to abnormal insertion, or floating kidney, blocking by stone). Unilateral renal colic. Hydronephrosis. No uraemia. (i + 31) Bilateral obstruc- tion of renal pelves (most fre- quently stone). Bilateral renal colic, anuria, uraemia. (3 -f ffll) Obstruction by stone, with reflex anuria. Same symptoms, but colic only unilateral. (c) Blocking of one ureter. (Stone, pressure by tumours). Same symptoms as in ^. a^ = a - ^1. (d) Obstruction of neck of bladder by stone. Retention of urine. Bladder distended. Flow of urine variable. Catheterism easy. (e) Neck of bladder ob- structed by tumour. (En- larged prostate, cancer, sar- coma.) Retention of urine, partial (residual urine) or complete. Large catheter usually passes easily. (/) Obstruction by urethral stricture. (Trauma, gonorr- hoea). Retention of urine. Only a small catheter can be passed, but this sometimes fails. ^ Fig. 201. — Diagram of the various surgical derangements of micturition. (4) If the bladder is easily accessible, and it is necessary to decide the nature of the vesical disease, or the source of blood or pus, we must employ the aid of the cystoscope. GENERAL REMARKS OX DISEASES OF THE URINARY ORGANS 441 This instrument shows us whether the mucous membrane is healthy, inflamed, covered with tibrin, or ulcerated. It also shows us the position of ulcers which may be present, and if they are arranged around one ureteral orifice, it indicates to us which kidnev is diseased. It also shows us the shape of the ureteral orifices, it tells us whether the wall of the ureter is thickened, and enables us to decide the character of the urine, which trickles at intervals from the ureteral orifice, in accordance with its transparency or cloudiness. By its means we are also able to see stones, foreign bodies, tumours, and diverticula. But it is indispensable that the bladder should be able to hold 80 c.c. of water, and that there should not be any severe lijcmorrhage. The technique of the examination is not described here, because the general practitioner cannot be expected to do more than have the examination carried out early enough for the successful issue of any surgical operation which may be necessary. If, finally, we have to determine the functional capacity of the whole renal apparatus, or of each individual kidney, this is a matter of the so-called functional diagnosis of renal activity. This does not come within the province of the general practitioner, because it requires more technical practice, experience, and time than he has at his disposal. He will, however, desire to know how it is carried out, and what results it yields. The functional activity of the total renal parenchyma is first estimated, and then that of each individual kidney. The first task demands the estimation of the freezing point of the blood, according to Koranyi. The lower this is, the more *' urinary" substances there are in the blood, and the functional activit}^ of the total renal apparatus is correspondingly unsatisfactory. The normal freezing point is o'59, but the lower limit of 0*56 is allowed. There are many sources of error in the method, but in some cases it is useful. Important information may be derived from the estimation of the amount of urea passed in a day on a definite diet, and by testing the permeability of the kidneys to water and to sodium chloride. The solution of the second problem demands the separation of the products of the two kidneys, by means of an intra-vesical partition or by catheterizing the ureters. The activity of each kidney is then tested by determining the freezing point of the urine, by estimating the nitrogen, or by examining the reaction of the kidneys towards certain subcutaneous injections. Thus the time which it takes for a gluteal injection of indigo carmine (4 c.c. of a 4 per cent, sterile solution) to appear in the urine is estimated (normal time ten to fifteen minutes). Or a subcutaneous injection of "005 grm. of phloridzin is given and the amount of sugar excreted by one kidney in a definite time is measured ; or one notes accurately w^hen the excretion begins. None of these methods as hitherto emplo^'ed are quite free from objection, but the sum total of the conclusions which they yield may be of distinctive significance from the point of view of diagnosis and treatment. 442 SURGICAL diseasp:s of the abdominal and pelvic viscera CHAPTER LX. INFLAMMATION IN THE NEIGHBOURHOOD OF THE KIDNEY. It is necessary to begin with a word about nomenclature. An attempt has been made to distinguish betw^een paranephritis and peri- nephritis, w^hich were previously considered synonymous. It has been suggested to limit the term perinephritis to inflammation of the connective tissue capsule of the kidney, and paranephritis to suppura- tion within the fatty covering. Further, Israel has designated the inflammation which occurs exclusively between the kidney and retro- renal fascia as epiiiephritis. However logical these distinctions may be, they cannot be applied in actual practice, because these three different anatomico-pathological conditions do not present separate clinical pictures. Perinephritis, defined as above, is never a disease by itself, but is ahvays an accompanying symptom, and has neither diagnostic nor clinical significance. It is almost impossible, clinically, to suspect any distinction between paranephritis and epinephritis. Such a distinction is only possible at the operation or the autopsy, and it really possesses no practical significance. We therefore will adhere to the term perinephritis as implying all inflammation between the kidneys, peritoneum and lumbar muscles — a uniformity of nomen- clature which should obtain international sanction. There are three stages of perinephritis, each of which gives rise to a special train of diagnostic considerations. (i) The indications which should suggest a perirenal abscess are somewhat similar to those which suggest a subphrenic abscess. The patient becomes ill with high fever and obscure symptoms, which he attributes to some malady in the loin, because that region is painful. If the lumbar spine is rigid, and probably also held obliquely, the suspicion of perirenal abscess is confirmed, and the condition of the lumbar muscles must be investigated. If they are contracted on one side, or if they contract on being palpated, we are in all probability within reach of the site of the disease. In this stage the most frequent error arises from confusion with pleurisy. In the latter, however, the pains radiate towards the shoulder, whereas in perinephritis they radiate towards the half of the abdomen on the affected side, towards the external genitals and even as far as the thigh. I have had a case wherein definite lumbar pain which radiated downward caused me to expose the kidney, whereas the real trouble was a commencing empyema which, however, afforded no clear local symptoms. The difficulty in diagnosis would be much greater if a purulent pleurisy supervened on an early perinephritis. The result obtained by an exploratory puncture is attended by the same difficulty of interpretation as occurs in cases of subphrenic abscess. INFLAMMATIOX IN THE NEIGHBOURHOOD OF THE KIDNEY 443 (2) In the second stage the diagnosis is much easier, because, in addition to the above symptoms, a resistance can be felt in the lumbar region. If this resistance is sharply defined, and round in contour, the inflammation is usually in the kidney itself. If it is diffuse and indefinite, the perirenal tissue is involved, although, of course, the kidney itself may also be affected. If we are doubtful about the definition of the swelling, because it appears to be too sharply defined for a phlegmon, and insufficiently defined for a kidney, we must note whether the swelling moves on respiration. A kidney always moves downwards on deep respiration, even if it is morbidly enlarged, provided there are no perirenal changes. A perirenal abscess remains immovable. Sharply defined abscesses are otherwise generally of a tubercular nature, and are recognized by the slight pain which they cause on pressure and by the very moderate effect which they have on the temperature of the body. (3) In the third stage, the abscess may open into the lumbar region, causing a subcutaneous phlegmon, or it may travel into the pelvic fossa, provoking flexion of the thigh, or, finally, it may reach the pleural cavity, and burst into a bronchus. In all these conditions, the diagnosis of abscess can hardly be mistaken, but its original source in such advanced cases can only be ascertained from the history. We should not, in any case, be content with the diagnosis of psoas abscess, which used to be a very favourite one. Psoas abscess inay be a tubercular burrowing abscess, an osteo-myelitic suppuration, inflammation arising from the kidney or intestine invading the muscle, or, finally, a phlegmon which has originated in the broad ligament ; a psoas abscess never constitutes a disease of itself. So far, our diagnosis has been directed to suppuration in the peri- renal fatty tissue. We look for its origin particularly in the kidney, pelvis, or spinal column. But its source may also be in one of the intraperitoneal viscera — appendix, liver, gall-bladder or large intestine. If the urine contain pus, we must refer the perinephritis to renal tuberculosis, nephrolithiasis or some other kidney disease attended by suppuration. If the history does not point to any previous kidney trouble, we should think of some acute metastatic renal abscess, and search for a primary source of infection, e.g., a fuiuncle, sore throat or eczema. In other cases the primary disease is some infectious disorder, such as typhoid fever, small-pox, &c. If nothing abnormal is found in the urine, this is not to be regarded as conclusive against a renal origin. If, despite the absence of any abnormality in the urine, there is a history of some old-standing renal disease, we must assume that the ureter on the affected side is blocked up. If there be no evidence whatsoever pointing to the kidneys, we must examine the adjacent bony parts, not only when the abscess is 29 444 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA chronic and bears tubercular characteristics, but also when the abscess lias developed acutely, because this may be due to osteo-myelitis of the pelvis. Should nothing be elicited here, we must next think of the appendix, which, not infrequently, lies in a lumbar or even a pre- renal position. In such cases we cannot attain to anything more than a probable diagnosis, unless the appendix had originally been intra- peritoneal and given rise to typical attacks of appendicitis. There is no difficulty in diagnosis in the cases wherein a phleg- monous parametritis, following an abortion or confinement, has extended as far as the lumbar region. Liver and gall-bladder abscesses rarely encroach upon the perirenal tissue, but such secondary abscesses are recognizable by their history and the localization of the antecedent inflammatory symptoms. If no other cause whatsoever can be discovered, we may assume that the case is a primary perinephritis, i.e., an infection of perirenal tissue by micro-organisms of unknown origin, and without any demonstrable involvement of the renal tissue. These abscesses usually arise through the coalescence of small abscesses of the renal cortex, which cause no symptoms in themselves, and do not alter the character of the urine. CHAPTER LXI. MOVABLE KIDNEY. At one time movable kidneys were very fashionable, and to undergo treatment for them was regarded as an evidence of good tone; but this is now a thing of the past. We are now better able to realize the significance of this condition than we were fifteen years ago, and although movable kidneys have been unjustifiably condemned for all kinds of ills, nevertheless they do raise important problems of diagnosis, which should be considered together. Firstly, as to the evidence of their existence. The term should only be applied to kidneys which have acqnircd increased mobility, and not to those which are the subject of congenital displacement — a matter already discussed. This acquired mobihty may, however, often be due to congenital causes. Thus I have seen a movable kidney in a young girl, aged ii, who was otherwise in perfect health — an abnormality which was most probably the result of some congenital predisposition. MOVABLE KIDNEY 445 The following method should be adopted to demonstrate a movable kidney. The patient — usually a female — must lie f]at and as relaxed as possible. The lumbar muscles must be supported with one hand, but they must not be allowed to become tense ; the other hand is gently pressed under the costal margin against the spinal column, but care must be taken not to make the muscles contract. The patient is then told to breathe deeply with the diaphragm. In this way it is usuallv possible to detect the descent of the kidney. In some cases, however, the kidney is hrst felt at the moment it slips upwards into its bed. The examination is immediately successful if the patient is thin and is able to breathe according to instructions, but if she is fat and cannot carry out the abdominal type of breathing as requested, a little practice is necessary. If examination with the patient on her back yields no result, she must be turned on to her side — on to the left side for the right kidney — or she must be examined in the erect posture. What is the iioniuil degree of mobility ? This varies in the two sexes. In a male, it should hardly be possible to feel the lower pole, even of the right kidney ; but in a female there is nothing abnormal in being able to feel the lower third. In slender women it may be possible to feel even a half of the kidney, without the condition being pathological, whereas in a man this should certainly be regarded as an early stage of movable kidney. If the upper pole of the kidney can easily be felt, it is obviously abnormal. We have been assuming that the structure felt at the side of the abdomen is really the kidney; but this assumption is not always correct. On the left side, we may be deceived by an intestinal tumour, but only if we fail to observe that the structure does not move with respiration. On the right side, error may arise not only from an intestinal tumour, but especially from a constricted lobe of the liver and from a tensely filled gall-bladder. We have, however, discussed these possibilities in connection with the surgery of the liver and biliary passages, to which section the reader is referred. Exceptionally, it may be quite impossible to arrive at a decision. If the diagnosis is important from the point of view of treatment, some assistance may be derived from a skiagraphic examination, after introducing a ureteral catheter, opaque to X-rays, or a collargol solution as far as the renal pelvis. If the structure felt is really the kidney, we must next inquire whether it is responsible for the pains of which the patient complains, bearing in mind that most movable kidneys never cause any symptoms at all, even when the degree of mobility is great. On the other hand, we should remember that a movable kidne\^ is not usually an isolated phenomenon, but is part of a general visceroptosis which is, primarily or secondarily, associated with a neurotic state which depresses the patient, both physically and 446 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA mentally. Stiller calls this condition " constitutional asthenia," although, of course, this term does not explain it. The psychical and organic reflexes are abnormally irritable in this condition, and the slightest discomfort — sometimes even physiological processes — is felt as a severe pain, or, at any rate, complaint is made. But, nevertheless,. a movable kidney may itself give rise to pain by attacks of so-called strangulation — a term which is meaningless and ought to be abandoned. These attacks are really due to intermittent hydro- nephrosis, which will be described in the next chapter, and which are produced by the sharp kinking or twisting of the ureter, as a result of the displacement of the kidney. But, apparently, paroxysms of pain may also be caused by kinking or twisting of the renal nerves, also a result of the abnormal mobility of the kidney. It is, therefore, better to speak of torsion, rather than of strangulation. The polyuria which usually follows these attacks, does not depend upon the discharge of urine which has been dammed back, but upon some reflex process, as is also the case in many instances of inter- mittent hydronephrosis. As abnormal mobility of the kidney may produce these severe paroxysms, it is only natural to suppose that milder pains may also be due to the same cause. But this assump- tion should only be made under certain conditions, a main one being that the pain is limited to the affected side, or, at any rate, is- strictly distinguishable from other pains of which the patient may complain. The pain should radiate towards the inguinal region^ scrotum and thigh, in contrast to the pain of gall-bladder disease,, which radiates towards the right shoulder. The principal point, however, is that the pain is increased by any movement which dis- places the kidney considerably downwards (over-flexing the trunk backwards, raising the arms on high) and is relieved by the horizontal posture. The pain is often diminished by wearing an effectual binder on the lower abdomen (especially Glenard's abdo- minal binder) and also by the support of the gravid uterus. If the patient describes attacks which appear to be due to torsion, we must wait until another one comes on, and examine the patient during its continuance, in order to determine whether the kidney is tender and swollen. We may then find that the pain has nothing to do with the kidney, but that it indicates an attack of mucous colitis. The same care and repeated exami- nations of the bowel and stools are especially necessary when the pains vary between the right and left side, although the movable kidney is unilateral. Such pains are nearly always of intestinal origin,, and are usually accompanied by alternating diarrhoea and consti- pation, and by the passage of some mucus. To attempt to stitch up the sunken organ in such individuals, would usually mean ta HYDRONEPHROSIS AXD ITS COXSEOUEXCES 447 operate on the kidneys, stomach, colon, liver and uterus. The result would probably be a faihire, because the pains due to excessive mobility would merely be replaced by pains due to adhesions. It is this kind of experience which has damped the enthusiasm of those who were staunch advocates of stitching-up displaced viscera, and it is now recognized that a movable kidney does not necessarily require stitching, because its anatomical disposition is not the only matter to be taken into account. These patients principally require a rational diet and a natural mode of life to invigorate their tissues and improve their nervous system. We may, indeed, prescribe these remedies, but we cannot secure them for the patients, because some are too low in the social sphere, while others are too high. CHAPTER LXII. HYDRONEPHROSIS AND ITS CONSEQUENCES. The retention of urine in the pelvis of the kidnev produces a number of clinical pictures, varying with the conditions under which it has arisen, and each one gives rise to its own diagnostic problems. We may distinguish : — (i) Closed Hydronephrosis. — This appears as a tense swelling, situated in the hypochondrium, and its differential diagnosis is discussed in the chapter on Abdominal Tumours. It is only necessary to add that, in rare instances, cystic swellings which do not depend upon retention in the renal pelvis, make their appearance in the kidney region. These are the congenital cystic kidneys (see also under Renal Tumours), which are distinguishable from hydronephrosis by their nodular surface, and which are often associated with a cystic liver. One should also think of hvdatid cvst in districts where this is endemic. As has already been observed in connection with hydatid of the liver, unexplained attacks of urticaria may suggest this diagnosis. If the sac of a hydronephrosis becomes infected through the blood-stream, it develops into a closed abscess with all the symptoms of pus retention. Unless an exit is made for the pus, the perirenal tissue may become infected, and, finally, also the pleura. The following case is typical : — 44^ SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA A middle-aged female was suffering from a movable tumour^ which had been discovered bv her medical attendant eight years previousty. An operation was proposed, but she refused, because the swelling gave her no pain. But after an attack of influenza the swelling became larger, painful and immovable. High fever and great weakness set in. There was no pus in the urine. Diagnosis : Infected closed hydronephrosis. At the operation, the perirenal tissue was found to be already infiltrated with pus, and pints of streptococcal pus issued forth from the renal sac. The subsequent course of the disease was marked by suppurative pleurisy of the same side. (2) Open Hydronephrosis. — This is distinguished from the closed variety by the fact that, within certain limits, its volume is variable. It may be subject to an ascending infection along the urinary tract,, which cannot occur to a closed hydronephrosis, and in this event the urine will contain pus, either temporarily or persistently. (3) From the point of view of diagnosis, intermittent hydro- nephrosis is the most interestmg form. It depends upon congenital anomalies in connection with the renal pelvis or ureter, or upon the results of a movable kidney. This latter cause acts most frequently on the right side and in women. The patient, who is either in perfect health or has been suffer- ing from a dull ache in the loins, is seized with severe pain in one kidney — pain which radiates to the inguinal region, the genitals and the thigh. Sometimes the picture is completed by vomiting, great pallor, a collapsed pulse and cold sweats. If the hypochondrium is examined at this time it will be found to be occupied b}^ a swelling varying in size from a fist to a man's head. This swelling is sometimes very difiticult to feel, because of the reflex rigidity of the muscles. The symptoms persist for a few hours, rarely more than a day, and then subside after the profuse micturition of clear urine, which occasionally also contains blood. Sometimes the emptying of the kidney is delayed, especially if the sac is large ; in other cases the kidneys do not return to their normal volume between the attacks — remittent liydvoiiephrosis. This may merge into the chronic open variety, and, finally, into the acute variety. On examin- ing a case of pure intermittent hvdronephrosis during a free interval nothing abnormal is found, except perhaps a movable kidney. The diagnosis may be made in some cases from the fact that a swelling is to be felt in one side of the abdomen during the attacks and that they end with the abundant evacuation of clear urine, sometimes also containing blood. If, however, these indications are not pre- sent, one must wait until the next attack occurs. It is impossible to miss the diagnosis during the attack itself, at any rate, if the h^-dronephrosis has attained any definite size. But in the early stages before the tumour has reached the size of a fist the muscular HYDRONEPHROSIS AND ITS CONSEQUENCES 449 rigidity may render its detection very difficult. The diagnosis will then lie between renal colic, biliary colic and even appendicitis, the last because the pain radiates downwards. But the localization of the pain on pressure and of the muscular rigidity in the lumbar region is decisive against biliary colic or appendicitis. Nevertheless there are cases wherein the question of an attack of gall-stones must be left in suspense. It may be still more difficult to distinguish pure hydronephrosis from hydronephrosis due to an attack of stone. If red blood-cells can be demonstrated in the centrifugalized urine between the attacks, and if these cells increase in number after active exercise, there is a great probability of stone. But this sign will fail in the case of a small stone in the ureter. A skiagram should be taken as a final means of diagnosis. If the renal pelvis is tilled with a colloidal silver solution by means of a ureteral catheter, it can be rendered visible on the skiagraphic plate. If the hydronephrosis has become infected more or less pus will be found in the urine during the free intervals, and signs of infec- tion will be present in addition to those due to the retention, viz., fever, rigors, dry tongue. The longer the disease lasts the more serious becomes the condition of the patient. Cystitis follows the hvdronephrosis, and the other kidney is involved by an ascending infection. The disease finally terminates in uraemia, with or without the secondary development of stones. When confronted with such a clinical picture as this, we must always inquire whether tuberculosis is not responsible, for this may for a long time perfectly resemble in symptoms a case of infective, intermittent hydronephrosis. It may be remarked in conclusion that intermittent hydro- nephrosis enables the practitioner to come to a decision in regard to the function of the other kidney without the process of separating the urine. For instance, if in a case of aseptic hydronephrosis albumin is always found in the intervals of the attacks — that is to say, when both kidneys are acting — but is not present during the attacks, we may draw the conclusion that the albumin comes from the hvdronephrotic kidney, and that the other kidney is healthy. 450 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA CHAPTER LXIII. IDIOPATHIC SUPPURATION IN THE RENAL PELVIS AND KIDNEY. Urine which persistently contains pus, ascertained by the pre- viously explained methods to be coming either entirely or partially from the kidneys, always raises the question whether the suppura- tion is an independent process, or whether it is a consequence of some antecedent condition, such as hydronephrosis, stone in the kidney, tumour or tuberculosis. We purposely avoid the terms ''primary" and ''secondary," because the manner in which they are generally used is liable to cause misunderstanding. An infection of the kidney is primary when the cause is intro- duced directly from without, and the kidney constitutes the first seat of attack. The same term is applicable if the causal organism has produced no pathological change at the point of entry, but has reached the blood, and thence has become deposited in the kidney. The suppuration is secondary if the kidney is not the first organ to be attacked ; for instance, if a cystitis has preceded the pyelitis (nrogenous infection) ; or if the kidney infection which has taken place is metastatic, by way of the blood-stream, and has arisen from some anatomically demonstrable primary focus. If, however, the renal suppuration arises and remains within the kidney itself without the aid of any other morbid condition, it should be termed idiopathic. If it has followed any serious pathological change in the organ, such as tuberculosis, stone or tumour, we apply to it the term complication or seqnela. After all, it is only a matter of words, and we might, with equal justice, insist on some other nomenclature. The main point is, how- ever, always to use the same expression for the same pathological process. No scheme has the advantage of being strictly maintained throughout, and there are alwavs some processes which might pro- perly be classified in various positions. For instance, pyelitis, which is caused by urinary obstruction in enlarged prostate, may be looked upon either as a sequela or as an independent suppurative process. The point turns upon the amount of predisposing influence we will allow before we abandon the conception of " independent suppuration." There is really no definite border line, and if we have, for example, fixed it on the other side of prostatic hypertrophy it is solely for the purpose of classification. Tuberculosis is certainly a form of "idiopathic" suppuration, but as we are discussing the causes of acnte suppuration, and as uro- genital tuberculosis is clinically an independent disease, we will not include it here, but will devote a special chapter to it. When the purulent infection is merely a seqnela or a complication of an existing renal disease, it will usually have been preceded by a IDIOPATHIC SUPPURATIOM IN THE RENAL PELVIS AND KIDNEY 45 1 stage wherein the symptoms of the primary disease have been clearly manifested, especially in the case of hydronephrosis, often also in the case of stone, and occasionally, though less definitely, in tumours. If not, we must rely upon the physical examination for the differential diagnosis. An abscess sac as large as an infant's head, or larger, does not indicate idiopathic suppuration, but has probably originated in an old hydronephrosis. A large irregular tumour indicates a new growth, A constant, although slight, admixture of blood with the urine, in a case of renal suppuration suggests stone or tuberculosis ; greater haemorrhage might also be due to stone. But if nothing of this kind can be discovered, we may regard the suppuration as " idio- pathic " in the above limited sense, and we must search for the conditions which might account for it. Boils, erysipelas, sore throat and gonorrhoea — in an ascending scale — are the main distributors of infection, and pregnancy, the puerperium with its deficient micturition, are causes of slight urinary obstruction, in addition to others already mentioned frequently. The midwife often provides the infective material in these latter cases. It is only rarely that bacteriological examination will elucidate the matter — for instance, if it demonstrates the presence of Staphylococcns anreus, the pneumococcus or the typhoid bacillus. Streptococci and colon bacilli are, however, such frequent denizens of diseased urinary passages that we cannot draw any definite conclusion from their presence. The gonococcus is hardly ever found. This is, as a rule, only the first link in the chain of infection, and is followed by cystitis and pyelitis due to mixed infection — these are the second and third links. I have seen vesical stone and renal stone after gonorrhoea — constituting fourth and fifth links, and in a similar case also cancer — a sixth link. Of course, a "harmless" gonorrhoea does not always proceed as far as this. More frequently a stricture is interposed in the chain of sequelae, which may lead, in after years, to an ascending urinary infection. It is important to ascertain whether such an infection is nnihitcnd or bilateral. The etiology may help to decide this point, for the pyelitis of pregnancy and post-gonorrhoeal pyelitis are usually unilateral — at any rate at first — whereas in prostatic patients it is generally bilateral. If the disease is metastatic in origin, it may be on one side or on both. If the patient states that his pain is sometimes in one loin and sometimes in the other, the pyelitis is very probably bilateral. Valuable diagnostic points are afforded by the demonstration, by palpation, of tenderness on pressure, by reflex muscular rigidity and sometimes by enlargement of the kidney. Frequently, however, the kidney is neither tender nor enlarged wlien in a condition of pyelitis. It is then advisable to attempt to palpate the ureters, t'lihei- per vagi nam 452 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA or per rcchun. If they can both be felt as cords, then both kidneys are diseased (Garre). A final decision may be arrived at by means of the c^'Stoscope and the separation of the urine. The ancitoinical diagnosis presents the most difficult problem, and it involves the differentiation of the following conditions — simple catarrh of the renal pelvis, i.e., pyelitis ; simultaneous disease of the renal parenchyma, i.e., pyelonephritis ; and, finally, disease exclusively confined to the parenchyma, i.e., simple or multiple abscess of the kidney. Both pyelitis and pyelonephritis are very frequently due to ascending infection, but they are of a hsematogenous nature, more often than was previously supposed. Pain on pressure and enlarge- ment of the kidney, as well as acute symptoms, only occur in either condition during the stage of retention (pyonephrosis). The involve- ment of the renal tissue is recognized by the fact that the albumin is proportionately too high in comparison with the amount of pus, and also occasionally by the presence of cylindrical casts. But even in the absence of these signs, experience tells us that the renal tissue does not remain healthy after a long-continued pyelitis. Renal abscess, whether single or multiple, is the result of metastasis, and is accordingly a pure infection, in contrast to an ascending infection, which is usually of a mixed character. It is easily overlooked, because there is no pus in the urine at first, and nothing but the fever and lumbar pain indicate its presence. There is no difficulty in distinguishing it from pyelitis, but it is impossible to differentiate it from early perinephritis, and as far as the indications are concerned, it is quite unnecessary. We cannot tell whether multiple abscesses are present, but palpation will detect whether the affection is unilateral or bilateral. In rare cases a renal abscess sets up so little local reaction that one is tempted at first to think of a new growth. A man, aged 60, came for advice regarding an indefinite pain in the left loin. Examination showed that there was in this region a moderately tender, somewhat nodular and rather movable swelling. There was no pus in the urine, but a quantity of sugar. There was moderate pyrexia, and the patient died in a few days from pyjemia. At the autopsy it was seen that what appeared to be a renal tumour was really the kidney, infiltrated by a well encapsuled abscess. The following case will show how one may occasionally be misled : — A middle-aged man was suffering from an old neglected gonorrhceal stricture, cystitis and intermittent attacks of " urinary fever." He received some casual treatment from a chemist, but suddenly became ill with severe septic symptoms, spontaneous pain and tenderness on pressure over the right kidney, which, however, was not enlarged. The left kidney was slightly tender, but also of normal size. The urine was almost free from pus, which was attributed to retention STONE IX THE KIDNEY AND URETER 453 within the pelvis of the right kidney. But nephrotomy on the right side showed that there was neither retention nor pus. The septic symptoms increased and the patient soon died. The autopsy revealed recent multiple non-infective infarcts in both kidneys, due to vegetative endocarditis. CHAPTER LXIV. STONE IN THE KIDNEY AND URETER. Primary stone in the kidney plays a very small part in the renal pathology of some countries, while in others it is one of the most frequent of maladies. In some countries stone has even become quite a disease of children. We distinguish primary from secondary stones, and we separate the former into a non-infected and a secondarily infected variety. .4.— PRIMARY STONE IX THE KIDNEY. (1) NON-INFECTED STONE. There are four important symptoms which establish the diagnosis of nephrolithiasis, viz. : (i) attacks of renal colic ; (2) dull aching pain in one loin during the intervals ; (3) haematuria, which may be very slight, but increases with movement; (4) presence of gravel or larger concretions in the urine. Renal colic runs a similar course in stone, as in intermittent hydro- nephrosis, with the one difference, that the swelling due to the retention is not so large, and that, in consequence, the urine which is passed after the attack is over is smaller in quantity and contains less blood. But, nevertheless, a temporary reflex polyuria may occur. The radiation of the pain into the inguinal region may resemble an appendicitis, and the pain on pressure under the liver may lead to confusion with gall-stones. Spontaneous pain at the testicle is very suggestive of renal stone. The testicle is very often tender on pressure. Dull aching in Hie loin is a symptom of great significance, but must be employed with discretion, especially if there is any doubt about the diagnosis of renal disease, as against biliary colic, for example. We have already dwelt in detail on Juvinaluria and gravel in the general section, and we have seen that the former symptom is more constant, but less in amount, than in cases of tumour. Recent 454 suR{;icAL diseases of the abdominal and pelvic viscera down to lumbago or rheumatism. observers have laid great stress on the fact that traces of blood in the sediment of the urine, increasmg in amount after movement, may, for a long time be the onlv sii^n of stone in the kidnev. There mav be no renal colic, and the dull pain in the loin may be entirely absent, as occurs with stones which remain latent for years. These cases do not, as a rule, seek any advice. The traces of blood in the urine are discovered quite accidentally ; for instance, if the patient consults his doctor for indigestion or some other condition which apparently has no connection with the kidney. The dull pain in the loin is often put If there be no pain at all in the case of a small stone sit- uated in the ureter and causing no haematuria, a diagnosis is absolutely impossible during the quiet interval. A skiagraui, taken by an expert and interpreted bv an experienced ob- server, should have the last word in all diagnos- tic difficulties connected with stone in the kidney. The diagnosis of stone in the kidney by the X-rays is not easy, be- cause stones composed of uric acid and of urates only cast a faint shadow, which in fat patients is hardly perceptible. But the experience in districts wherein this disease is common has been that even these stones often contain so much lime that they may be rendered visible on the plate, under proper con- ditions. No decisive conclusion should, however, be made until every doubtful appearance has been examined on several impressions. The composition of the stone is important from a therapeutic aspect. If the patient is a gouty subject, or if he comes from a gouty stock, the stone probably consists of uric acid or of urates, even in children. If crystals or gravel be found in the urine, we shall obtain some guidance from their microscopic and chemical examination, the details of which have already been referred to (Chapter LIX). Fig. 202. — Skiagram of stone in kidney. X. TUMOURS OF THE KIDNEY 455 (2) INFECTED STONE. In addition to the symptoms of aseptic nephrolithiasis, those of infection are present : pus in the urine ; fever and rigors where there is retention. The correct diagnosis is very often missed, and the condition appears to be either an independent pyehtis or tubercle. It must be remembered that when the ureter is temporarily obstructed the urine may be quite normal, because it all comes from the healthy kidney, and it is, therefore, always necessary to examine the urine during an interval when the ureter is not blocked. Z>\— SECONDARY STONE IN THE KIDNEY. Most renal concretions which occur in non-calculous districts are secondary in character. Their symptoms consist of those of the underlying suppurative disease, to which are superadded the symp- toms of stone. The clinical picture is practically the same as that of an infected primary stone, but the history is different. In the present instance, suppuration precedes the stone ; in the other instance the stone precedes the suppuration. This consideration will indicate the difficulties which may arise in differential diagnosis, as well as their solution, and we will therefore not repeat what has already been said. Chemically, all secondary stones consist of earthy phosphates and carbonates. Their formation is recognized in the urine by its ammo- niacal smell and the abundance of triple phosphates. Rontgen-rays reveal these stones very clearly, because of their rich calcium content. CHAPTER LXV. TUMOURS OF THE KIDNEY. Tumours of the kidney, as long as they are not infected, at e recognized by three symptoms: (i) hcviiiorrliage ; (2), local, and especially radiating pain; and (3) swelling. The predominance of the one symptom or of the other depends upon the position or manner of growth of the tumour. Haemorrhage is absent in very few cases only. It is much more profuse, but also much more irregular, than in the case of stone. If the haemorrhage is very pronounced, the clots may obstruct the ureter temporarily, causing genuine renal colic, which must, however,. 456 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCEKA be distinguished from the persistent radiating neuralgic pain. It is noteworthy that such haemorrhages may continue for vears. The radiating pain does not occur until a late stage, so that the haemor- rhage, with or without renal colic, may be for vears the onlv svmptom of a small stationary tumour of the kidnev, which cannot be felt. It is only by the cystoscope, showing that the blood comes from one side, that such a case can be distinguished from chronic haemorrhagic nephritis, which may exist for a long time without albumin or cylindrical casts. If the cystoscope does not yield a decisive result, it can then only be obtained bv an exploratory incision. If the haemorrhage is verv profuse and persistent, one should think of the possibility of a new growth from the pelvis of flic kidiicv, especially if no appreciable swelling can be demonstrated, or if the examiner can feel a haematoma which is causing extreme distension of the renal pelvis (Israel). Persistent, local, and radiating neuralgic pain merely tells us that the tumour is malignant, and that operation will probal:)ly be fruitless. If such pain is unaccompanied by any other symptom, the unfortunate diagnosis of lumbago is often asci'ibed to it, but this is an eri"or which tumours of the kidney share with all painful diseases of this region. If the tumour is the most striking symptom we must first decide whether it is really connected with the kidney. If haematuria is present at the same time the matter is clear. But if the urine is normal, and the cvstoscope shows that it comes from both kidneys, then we should think of a liver or gall-bladder tumour on the right side, a splenic tumour on the left side, and a tumour of the large intestine on either side. If the timiour is of unusual size, an ovarian cyst should be thought of. There is, however, one sign which distinguishes a renal tumour from all of these, the fact that, on bi-manual palpation, it can be felt most distinctlv from behind, in the angle between the spine and the twelfth rib. A tumour of the intestine would generally cause some intestinal disturbance. A tumour of the gall-bladder has its own special previous history, and a swelling of tiie spleen betrays itself bv the sharp anterior border, which can usually be felt quite easily. It is only in the case of an irregular round tumour of the spleen that serious difBculty can arise. An ovarian tumour is recognized by the circumstance that when the intestine is artificially distended it is seen that the large bowel runs over the new growth. It takes the same course in the case of new growth of an ectopic kidney. Soft tumours of the fatty capsule of the kidney (lipomata, fibromata, myxosarcomata) which may attain a large size, have hitherto only been diagnosed at the operation. They may cause the most extraordinary displacements of the viscera. A cystoscopic examination may enable a decisive opinion to be TUMOURS OF THE KIDNEY 457 given either for or against a renal tumour (persistent absence of urinary flow from one side). Having" decided tliat a tumour of the kidney is present, we must determine whether it is a retention tumour — hydronephrosis or pyonephrosis — or whether it is a genuine new growth. This point is usually elucidated by the history and the condition of the urine. The consistence of the tu- mour may be very mislead- ing, because a sarcoma may feel just as elastic as a hy- dronephrosis. One would only think of a hydatid in districts where this disease is rife, but localization in the kidney is always very rare. Exploratory puncture, which is occasionally recom- mended, is just as inadvis- able here as it is in the case of the liver, and the serum test is still unreliable. It is difficult, or quite impossible, to infer any- thing about the histological characters of a renal tumour diagnosed by its clinical signs. There are of course cases wherein the uneven surface and the slight mo- bility of the tumour stamps it conclusively as malignant. But we often remain in doubt because, as we have seen, the haemorrhage from malignant tumours even may persist for years. It is only rarely that external circum- stances permit us to make a definite diagnosis on clinical grounds. This, however, applies to the tumours of child- hood, which experience shows are either pure sarcomata or mixed sarcomatous tumom's. If there is no haemorrhage one would be obliged to think of hypernephroma, which so often arises in the cortex. If the tumour is bilateral, round and uneven, without Fig. 203. — Sarcoma of the left kidney. 458 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA hjemorrhage or suppuration, and if the discomfort is limited to a dull pain with occasional renal colic, the only possible diagnosis is congenital cystic kidney, especially if there is also enlargement of the liver (cystic liver). From the point of view of treatment the precise nature of a new growth of the kidney is not of much importance, because as soon as a renal iinnoiiv has been demoiisirated it must be removed, unless it is too late. Cystic kidneys are an exception to this rule ; these are only to be removed in the rare instances wherein it is certain that they are unilateral, and then onh' if thev cause sufhcient trouble to justify the operation. Finally, it must be remembered that renal tumours do not always occupy their normal position, resembling in this respect the kidneys themselves. Tumours in floating kidneys are not uncommon, and new growths may develop in congenitally displaced kidneys, which usually lie at the level of the pelvic inlet. I once removed a hypernephroma of such a pelvic kidney. Its true nature was only recognized at the operation by the fact that the kidney was absent from its normal position. The clinical diagnosis fluctuated between a solid ovarian and a renal tumour. CHAPTER LXVI. TUBERCULOSIS OF THE URINARY PASSAGES. Although the prognosis of tubercle of the urinary passages is favourable in its early stage, the pi"05pect is one of the gloomiest when the disease is advanced. Unfortunately the eai'ly stage is often overlooked, because it does not declare itself very definitely. Every disturbance of the urinary organs of gradual onset should therefore make one think of tubercle, and decide for or against it, instead of allowing the patient to go about for months, with the vague diagnosis of vesical catarrh, vesical irritation, or simply " neuras- thenia," and with unsystematic or so-called " symptomatic " treat- ment. The first symptom is usually a certain amount of tenesmus. The patient notices, as the most striking objective sign of this change, that he has even to get out of bed once or twice during the night. This differentiates him from a neurasthenic, who may micturate very frequently during the day, but is not disturbed at night. At this stage, the naked eye can detect nothing wrong with the urine. A TUBERCULOSIS OF THE URIXARY PASSAGES 459 careful examination may, however, reveal traces of albumen and a slight deposit of pus cells, epithelial cells and isolated blood cells, in the centrifugalized sediment. There are usually no bacteria present, nor even tubercle bacilli. This condition of the urine absolutely excludes a simple neurasthenia, in which one finds phos- phates, carbonates, calcium oxalate and occasionally one or two seminal threads. Such a urine supports the view of some organic disease, and the patient should be thoroughly examined, when it is most likely that some old scars of glands or an apical catarrh will be met with. At this stage, palpation of the kidneys will not usually yield any result, but a tender spot will often be found in the prostate, especially on its superior surface, and occasionally also a nodule in the epididymis. But if none of these points affords a positive indication of tubercle, it will be necessary to inoculate a guinea-pig with an adequate amount of the scanty sediment. It may then be found that, although the recent examination of the urine revealed no tubercle bacilli, the animal becomes tubercular within four to eight weeks. In this way, an early diagnosis of tubercle may be made, and appropriate treatment started. Having thus detected that the urinary system as a whole is affected with tubercular disease, we must now search for its point of origin. Clinical experience is accumulating proof that the disease starts in the kidneys, or in one of them. Spontaneous pain, local tenderness on pressure, slight rigidity of the lumbar muscles, perhaps also some demonstrable enlargement of the organ, and, occasionally, thickening of the ureter, felt through the rectum or vagina, will show which kidney is affected. If none of these indications is present, the practitioner will have done his duty by referring the patient to the surgeon as a case of " urinary tuberculosis," and a case may go on for years without definite indications, especially if the tubercular process is developing itself in the renal pelvis rather than in the parenchyma. If however the practitioner is able to avail himself of a cystoscope, the inspection of the two ureteral openings will show which is the diseased side. On the aft'ected side the margins of the ureteral opening are red- dened and swollen, whilst the orifice itself is often strikingly gaping. Around it, there maybe a few tubercles or small ulcers. In somewhat more advanced cases the urine which escapes is distinctly turbid. This examination is completed by separating the urine within the bladder. If this procedure is repeated several times it yields most useful results. Catheterization of the ureters is even more reliable, but demands more skill. The question of operation and its method must then be left to the surgeon. The decision depends upon the presence of a healthy, or at least of an adequately functional and non-tubercular kidney on the other side. 30 460 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA In this connection, it must be emphasized that all these manipu- lations must be carried out with special care and with asepsis. An instrument should not be introduced into a tubercular bladder, Avhich is not affected by a mixed infection, or only slightly so, unless some definite diagnostic information is anticipated from the procedure, or unless it is done for a definite therapeutic purpose. Whenever an examination is made with a sound, cystoscope, separator or ureteral catheter, it should have been preceded by the administration of a urinary antiseptic such as urotropine, or at any rate be followed by it. The differential diagnosis of the early stage of urinary tuberculosis varies with the initial symptoms. If JuviiiorrJiage is the predominant sign, as occurs in exceptional cases, one thinks of neiv growth. If the early stage is characterized by renal colic, there is a possibility of confusion with stone in the kidney, intermittent hydronephrosis, and even with appendicitis. I once saw a patient whose first symptom of renal tuberculosis was an attack which was regarded by most experienced sui'geons and physicians as one of appendicitis. The correct interpretation of the condition was not forthcoming until the urine was examined. If there are no striking bladder symptoms, but lumbar pain is present, the diagnosis of rheumatism or lumbago usually suffices, if the patient thinks it at all necessary to consult a doctor. But there are some cases in which we must assume an original focus of tubercle in the kidney, but wherein the bladder symptoms are so predominant that they attract all the attention. Generally, it is the vesical tenesmus which is so conspicuous and causes the patient most torture. But this is not always a proof of associated tubercle of the bladder ; because it may arise reflexly from the kidney. If it is very severe, it suggests the secondary formation of stone. The later stages of urogenital tuberculosis are often mainly charac- terized by this formation of stone, with all the symptoms of secondary infected renal and vesical stones, with renal colic, fever and rigors. The liability to secondary stone formation starts, as we have seen, at the time when the urine, which was originally acid, becomes alkaline owing to mixed infection. This affords us a reliable means of recognizing whether the renal colic which is present is due to stone or not. Sometimes, however, this diagnosis is facilitated by the passage of small concretions. It is important to recognize this secondary stone formation early, because the removal of these stones will give great relief even in cases where, owing to the tubercle affecting both sides, there is no prospect of complete cure. In a case of bilateral renal tuberculosis, where radical operation was impossible, I removed a large number of stones in two sittings from the right pelvis, one stone from the right ureter, and a large stone from the bladder. In this way great relief was afforded to the STON?: IX THE BLADDER 461 patient for about a year, although, of course, it did not prevent the eventual onset of uraemia. On the other hand, we must not attribute, without careful examina- tion, a genuine case of stone to suspected tubercle, as has actually happened. Even large vesical stones may cause no other symptom but tenesmus. We must also refer here to perinephritis — a not infrequent complication of renal tuberculosis. It occurs in two forms, which are easily distinguishable clinically. One form consists of a sharply- defined abscess which, without any marked symptoms, tracks down- wards or bursts through, in the lumbar region. Cultures made from the pus are sterile, but an inoculated guinea-pig becomes tuber- cular. This form constitutes the purely tubercular stage of the disease, wherein the focus in the kidney bursts externally just as a focus in bone leads to the development of a cold abscess. In the other form the perinephritis manifests itself by acute symptoms, fever, rigors, and severe pain, and instead of a circumscribed abscess W'e have a phlegmon. This process is really a mixed infection, and its intensity depends upon the virulence of the streptococci or colon bacilli, &c., which take part in it. We must, therefore, not discard the possibility of a tubercular origin for the renal malady because of the acute character of the perinephritis. Tubercle does not usually penetrate lower than the sphincter vesicae, but may cause changes at that site which may be mistaken for late sequelae of gonor- rhoea, if there be a history of that disorder and a bacteriological examination of the urine is neglected. Tuberculosis of the genital organs is not dealt with here, having already been discussed in a previous chapter. CHAPTER LXVII. STONE IN THE BLADDER. We differentiate between aseptic and infected stones, just as in the case of renal stones. (i) Three symptoms point, as already seen in Chapter LIX, to non-infected stones in the bladder : irregular and varying distur- bances of micturition, not affected by changes in posture, vesical tenesmus and haemorrhages. Obstnictioii at the neck of the bladder by a valve action is very significant of stone, but this is frequently absent, especially when the 462 SURGICAL DISEASES OF THE ABDOMINAL AXD PELVIC VISCERA Stone is large or within a diverticulum — in the latter circumstance the stone is no longer aseptic. Teiiesuiiis is the result of direct mechanical irritation, and is very marked in the case of rough oxalate concretions. The tenesmus is aggravated bv anv vibration of the body, especiallv bv riding. A patient of mine with an oxalate calculus always selected the back platform of a last carriage when on a railway journey, so that he could empty his bladder from there, as the need became urgent. The luvuion'liage is usually very moderate, just as it is in renal stone, and in contrast to the haemorrhage of new growths. Whenever a vesical stone is suspected we should investigate the history in regard to gout, and also search for any indications of renal stone. Most vesical stones originate in the kidney, but become large in the bladder. We then examine the urine, or the sediment obtained from a large quantity thereof, for crystals or small concretions. Then, after the bowel is emptied, a bi-manual examination of the bladder is made with one finger either in the rectum or vagina and the other hand on the abdomen. Large stones may then be felt quite easily. We may next proceed to use the sound. This examination must be conducted with great patience and with the bladder in varying degrees of fullness, if the stone cannot be felt on the first attempt. The sound also gives information as to the smoothness or roughness of the surface of the stone ; in some cases we may be able to tell its size, and occasionally also whether there is more than one speci- men present. If nothing can be demonstrated, and the suspicion still remains, we must resort to the cystoscope and an X-ray examination (fig. 204). The patient must be undressed for this examination, otherwise one runs the risk of opening the bladder for stone when in reality the shadow is due to a trousers button — an incident which has actually happened. An aseptic stone in the bladder may be mistaken for — - {a) Tunioiir of the bladder, especially for a polypus at the neck of the bladder, causing obstruction by \'alve action, and tenesmus — a verv rare occurrence. Such a condition should be thought of, if the sound and the skiagram yield negative results. Under these cir- cumstances a cystoscopy is decisive. (b) Stone in the kidney, if the predominant symptom is reflex vesical tenesmus. If there are no renal symptoms the case can only be fully elucidated bv X-ray examination and by the cystoscope. Sometimes stones are present in the kidney and in the bladder at the same time. (2) If a bladder containing a stone become infected spontaneously or through catheterization, the previous symptoms are supplemented by suppuration and by an increase in the tenesmus. The other STONE IN THE BLADDER 463 symptoms remain /// statu quo. The case is then very hable to be mistaken for some form of cystitis — especiahy of a tubercular nature. Secondary stones in the bladder resemble, in their behaviour, infected primary stones. They are found as a result of suppurative infection of the urinary passages and of alkaline, generally am- moniacal, decomposition of the urine. Their nucleus is often some foreign body, such as a piece of catheter, a hairpin, a nail, &c. The history of these secondary stones differs from that of the infected primary stones, because in the former the infection either with or without a foreign body precedes the stone, whei'eas in the latter the stone precedes the infection — just as in the case of renal stones. Fig. 204. — Skiagram of stone in bladder. The original malady is often an old gonorrhoeal or puerperal cystitis or one due to spinal paralysis. In other cases it may arise from urinary infection after an enlarged prostate ; sometimes tubercle is the underlying cause. In rare cases it is a congenital diverticulum which has led to local congestion of urine, to the occurrence of a spontaneous infection, and, eventually, to the formation of stone. It happens sometimes that there is no interference with mic- turition, which is due to the circumstance that the stones may be firmly fixed in divei ticula, or that they may be too large to act as ball valves. These cases manifest themselves by an extremely agonizing 464 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA vesical tenesmus, which cannot possibly be relieved, and which eventually resembles incontinence. Stones within diverticula are easily missed by the sound, and this makes their diagnosis all the more difBcult. Cystoscopy sometimes fails to yield the desired result in these cases, because of the diminution in the capacity of the bladder, consequent upon the constant strangury ; but these stones can always be demonstrated by a skiagram. CHAPTER LXVIII. CYSTITIS. In devoting a few lines, in addition to what has already been said^ to the diagnosis of cystitis, the most important consideration to emphasize is, that this diagnosis is made too often. There is a tendency to be content with the assumption that there is a catarrh of the bladder, instead of ascertaining the origin of the trouble. One who always diagnoses cystitis when there is pus in the urine and strangury is present, will miss most cases of prostatic abscess, uro- genital tuberculosis, pyelitis and infected stones. It matters not that there is some catarrh of the bladder present in most of these cases^ because it is not the incidental malady, but the fundamental disease which has to be recognized and treated. Even if the cystitis should be the primary and original disease, we must not be content with this diagnosis, but must, if the disease does not rapidly recover, follow up the secondary changes — pyelitis and stone formation — which permit of the trouble becoming chronic. The etiology renders the principal assistance in the diagnosis of a primary cystitis. Catarrh of the bladder never originates " of itself," through some constantly prevalent infection, like a cold. It is always due to some definitely demonstrable cause — introduction of some infective organisms from the kidney or from without, on the one hand, and such predisposing conditions as uriuaiy congestion, injnries and the presence of foreign, bodies on the other hand. The more virulent the organisms, the less individual predisposition is required to evoke an attack, and vice versa. The puerperal bladder, with its dilatory powers of micturition, affords a well-known example of the influence of even slight congestion. The following cases illustrate the significance of injuries to the mucous membrane : — CYSTITIS 465 A healthy young woman, in whom gonorrhoea could be excluded, was suddenly seized with severe cystitis, and the passage of offensive urine. The history, which was elicited with difficulty, showed that in using a vaginal injection prescribed by her physician, she had by mistake introduced the tube into the urethra, and this had severely injured the neck of the bladder. The bladder would have soon got rid of the infection if it had not been for the injury. The same applies to foreign bodies. A practitioner had the mis- fortune to leave a piece of a Nelaton's catheter in the bladder of an elderly female. Severe cystitis with ammoniacal decomposition rapidly supervened, and I found the foreign body on examination, fourteen days subsequently, completely encrusted with triple phos- phates. This cystitis did not signify that the practitioner was not cleanly in his procedure — he was well acquainted with the theory and practice of asepsis — but simply that a slight, and perhaps unavoidable, infection sufficed to provoke a severe catarrh of the bladder in the presence of a foreign body. I say " perhaps unavoidable," because we know that even a healthy urethra harbours micro-organisms which we may introduce into the bladder, even with the most careful asepsis. The reason that the passage of a catheter does not more frequently lead to an infection than it does, is because the normal bladder is able to dispose of most micro-organisms quite easily. For the same reason, cystitis occurs so rarely when micro-organisms are excreted from the kidneys into the bladder. Indeed, the very fact of bacteria shows that micro- organisms may continue to develop in the urine without injuring the healthy bladder. If a large amount of pus suddenly appears from the bladder without any severe signs of irritation of this organ, the most probable cause is rupture of a perivesical abscess into it ; the symptoms of the original disease— generally appendicitis — easily allow the diagnosis to be made. Our modern period of operations for hernia has often witnessed infected sunken sutures and ligatures make their way into the bladder instead of externally, and thus cause cystitis, or the secondary formation of stones. If nothing points to the cause of the infection of the bladder, and if its progress from the start has been very gradual, we shall rarely err in ascribing it to tubercle. Nevertheless we often find, even in children and young people, cases of obstinate cystitis, which soon lead to deposits of lime, whose chronic character can only be ex- plained by some general decrease in resistance, in the sense in which we have used the term scrofula, but which are not definitely tuber- cular. (Chapter XXIV.) 466 SURGICAL DISEASES OF THE ABDO.MIXAL AND PELVIC VISCERA CHAPTER LXIX. TUMOURS OF THE BLADDER. (1) TUMOURS OF THE MUCOUS MEMBRANE OF THE BLADDER. The chief symptom of these tumours, Hke those of the kidney, is irregular haemorrhage, which, having once started, becomes very severe and may cause profound anaemia, before any other signs appear. All the other svmptoms depend upon the position and form of the tumour, and upon complications. Thus, if the growth is near the neck of the bladder strangury and retention may occur ; if it is of polypoid shape the symptoms are very rariahle ; if it soon begins to invade the surrounding parts, radiating pains are felt in the region of the pelvic nerves and the great sciatic ; if it compresses a ureteral orifice renat colic is experienced, and difficnlty in defcecation if it grows into the rectum. A growth situated at the vertex of the bladder will betray itself chieflv bv increased strangury, in addition to haemor- rhage, but, nevertheless, this form is one which goes longest unrecog- nized. As soon as cystitis supervenes, and this rarely fails in growths from the mucous membrane, vesical tenesmus occurs in addition to haemorrhage, and becomes predominant, whatever be the situation of the growth. This tenesmus increases if deposits or concretions of triple phosphates form. These symptoms having suggested a tumour of the bladder, vre must examme the urine for the narrow villous-like shreds, which may at once furnish a diagnosis, or for the greyish-red pieces of tissue which require microscopic examination to determine their nature. We then palpate the bladder in the full and empty state, after the bowels have been emptied. Growths of the base of the bladder can be felt distinctly, either from the rectum or vagina — frequently, however, as a diffuse resistance rather than as a defined growth. New growths of the vertex of the bladder can be more easily reached from the abdomen, but always by bi-manual examination, even in the male sex. A fat patient, or one whose abdominal wall is unyielding, will require an anfesthetic. If we feel a resistant circumscribed structure, it may even be a stone, which, if enclosed in a diverticulum, will be immovable. Examination with the sound and cystoscope will at once show whether a stone is or is not present. Care must be taken not to mistake the not infrequent incrustation upon a growth for a stone, and in using the cystoscope in a female the uterus projecting into the TUMOURS OF THE BLADDER 467 bladder must not be regarded as a tumour. If sufficient experience is brought to bear upon the interpretation of the cytoscopic appearance, it should be quite decisive in regard to the diagnosis of tumour. But sometimes the size of the growth and the smallness of the interior of the bladder prevent such an examination. In such circumstances, however, palpation can elucidate the condition, except in the case of a very soft papilloma. If the cystoscope does not exclude the diagnosis of stone, an X-ray examination should be made. Stones and incrustations are both recognizable upon the skiagram. This aid to diagnosis is especially valuable in the case of stones within diverticula, which, otherwise, may easily be mistaken for growths, on bi-manual palpation. The question of the innocence or malignancy of the growth is not one of great importance, because the only histologically innocent tumour of the mucous membrane — a papilloma — is often clinically very much on the border line. A small villous tumour which has been removed quite early, mav be innocent, but an extensive papilloma approximates very much to a malignant growth, owing to its tendency to spread at its edges and to recur. Papillomata which are apparently innocent at first, may eventually become cancerous, and definite cancers may originally have possessed all the external characters of papillomata. A growth which bleeds and feels hard must be regarded as cancer, without hesitation. If nothing, or at most some indefinite resistance in the bladder region, is felt on palpation, we should think of a papilloma as most probably present. This may invest the whole bladder, without forming a large tumour. A cystoscopic examination is indispensable in such a case. This sometimes reveals the cause of severe haemorrhages to be a small papilloma, which could not be demonstrated by any other method. It looks like a small shrub on the mucous membrane, or like a piece of red coral, presenting a most striking appearance, because of the shadow which it casts. (2) TUMOURS IN THE MUSCULAR COAT OF THE BLADDER. The conditions are quite different when a tumour arises in the muscular laver — fibroma, myoma, sarcoma. The tumour breaks down and the haemorrhage starts, if at all, in a late stage, so that the disease is only recognized when its extension compromises the functions of the bladder by mechanical interference. If the new growth is on the posterior wall of the bladder, it may resemble a myoma of the uterus growing forward ; an operation alone can reveal the correct relations of the tumour. 468 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA A myoma of the uterus sometimes grows between this organ and the bladder, connected to the uterus by a narrow stalk only, displacing the muscular layer of the bladder to a very large extent, and may in fact cause its total disappearance. On the other hand, a fibroma or myoma arising in the wall of the bladder may invade the uterus to such an extent that it is only the absence of a pedicle connecting it to that organ which shows that it is independent thereof. CHAPTER LXX. HYPERTROPHY, TUMOURS AND ABSCESS OF THE PROSTATE. Although we have already touched upon diseases of the prostate, we will summarize once more the most important of them and amplify our previous remarks by a few points. (1) HYPERTROPHY AND TUMOURS. If an elderly man has constant trouble in emptying his bladder, although a large catheter can be introduced, we should at once think of enlargement of the prostate. Rectal examination will in most cases show that the organ is enlarged. If we can inspect the interior of the bladder, we will usually see two lateral swellings of somewhat unequal size at its entrance ; sometimes only one eminence in the centre (clinically known as the middle lobe) ; occasionally a ringed-shaped pad-like projection is seen at the neck of the bladder. Enlargement of the prostate does not usually affect the whole organ, nor even any special part of it ; but consists generally of a fibro-adenomatous proliferation of the tissue of the gland, which immediately embraces the urethra, and is separated from the rest of the prostate by a layer of smooth muscle. The two lateral lobes are flattened by the proliferating mass and displaced to the sides. This explains why the hypertrophied tissue shells out so easily, and also that it does not form part of the lateral lobes, even when it appears to consist of two lobes. It also explains why the vasa deferentia are not interfered with, and why, fortunately, recurrences are so rare. The wall of the bladder will already in the early stage present the appearance of a trabeculated bladder. In simple cases it is quite impossible to mistake the diagnosis. We must take care not to confuse the early stage of tabes with enlargement of the prostate. This is quite possible if the tabetic HYPERTROPHY, TUMOURS AND ABSCESS OF THE PROSTATE 469 patient micturates frequently and has residual urine. The trabeculated condition of the bladder would appear to support this mistaken diagnosis, unless one remembers that it also occurs in tabes. The distinguishing point is the fact that the tabetic has genuine incon- tinence. He allows his urine to pass long before his bladder is filled to its maximum, and therefore, as it were, runs away. We should at once be very suspicious if the patient is not well within the age when enlargement of the prostate is common. Having diagnosed hypertrophy of the prostate, it becomes im- portant to ascertain the stage in which the patient is, and also the complications which have taken place. The examination of the urine will show whether this is infected ; the use of the catheter immediately after spontaneous micturition will indicate whether the patient can empty his bladder completely or has residual urine ; and palpation of the kidneys wn'll sometimes — by no means always — inform us whether any infection has ascended as far as the renal pelvis. The diagnosis of pyelitis can, however, be more securely based on lumbar pains, sometimes on the right and sometimes on the left side, on persistent digestive disturbances, and especially on acute attacks of retention, wnth fever, rigors, vomiting, diarrhoea, headache and occasionally slight delirium. These symptoms proclaim that the patient has arrived at the condition which Guyon has classically described as '^ urinaire," composed of signs of uraemia, at first intermittent and subsequently persistent, combined with septic absorption. Infection very often leads to the secondary formation of stones w^hich are not necessarily free in the bladder, but which may be fixed in diverticula like a deposit in a boiler. They are most commonly found in the post-prostatic pouch, which so frequently forms in prostatic patients, and in which further diverticula may develop. This classical course may be attended by several variations, which are important from the diagnostic standpoint. Sometimes the syui- ptoms appear to set in snddenlv. This may occur after indulgence in an abundance of liquor, when the alcohol temporarily paralyses the micturition mechanism, or when there has been more opportunity of filling the bladder than of emptying it ; in these circumstances the patient wakes up to find that he cannot pass his urine. He has care- lessly allowed it to become overdistended, and the detrusor is no longer capable of overcoming the obstruction. On close questioning of the patient, one can generally elicit that he has had, of late, to get up frequently at night, and that the urinary stream has long lost the force which it possessed in his youth. In other cases the first complaint does not concern difficulty in micturition, but rectal tenesnins, or some unpleasant sensation in the rectum or perinaeum. One patient complained of feeling "as if he sat on a bail." 470 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA Examination showed that there was a distinctly enlarged prostate in this case. Although there was no trouble with the urine, in the ordinary sense, the cystoscope showed that the bladder was definitely trabeculated. The patient was still in the stage of perfect compensation, i.e., he had no residual urine. In some cases, hcvmorrliages are predominant. They may be very profuse and cause rapid debility. Hitherto we have been assuming that the prostate is found to be enlarged on rectal examination. But this is not always the case. A middle lobe may — not very often— be responsible for the urinary difficulty ; or a hard prostate, although not very much en- larged, may be responsible, so that one may, wuth justice, speak of " prostatic patients who have no hypertrophy of the prostate." The cystoscope clears up all these points, and may also reveal a cancer which has been masquerading in the form of a slight hypertrophy. The more often prostates are removed the more frequently does one come across carcinoma, instead of the expected innocent hyper- trophy. The whole subject of malignant growths of the prostate is at the present moment under revision, and to all appearances the diagnosis does not promise to be very much facilitated. A malignant neoplasm is at once suggested if we feel an uneven asymmetrical tumour in the prostatic region, growing towards the rectum, or if we feel a hard mass, which is not especially tender to pressure, but is sharply defined at the sides. If the cystoscope reveals an uneven irregular structure, instead of the two smooth swellings, we should make the same diagnosis. If a round circumscribed tumour develops in a completely asymmetrical manner the condition is very suspicious. It depends entirely upon the direction of the growth whether rectal or urinary symptoms predominate, but this has no bearing on the diagnosis. The diagnosis is corroborated if the patient begins to complain of sciatica, or if we find any metastases — especially in the skeleton. Lt is sometimes possible to tell from its shape whether the tumour is carcinoma or sarcoma. If it is hard and uneven we think of cancer, if it is soft and roundish, of sarcoma. But, as already stated, operation has shown that cancer is often concealed within a hypertrophy which appears to be innocent, both to the examining finger and to the cystoscope. The suspicion of cancer is not confined to the cases of pronounced enlargement, but is shared by the small hard forms. It is not possible to be dogmatic, but we may say that every enlargement of the prostate, whose symptoms are on the increase, is suspicious of cancer. The presence of cystitis or the formation of secondary stones do not help the diagnosis, because these may occur both with innocent hypertrophy or with cancer. But if persistent haemorrhages occur the case is very suggestive of cancer. HYPERTROPHY, TUMOURS AND ABSCESS OF THE PROSTATE 47 1 (2) INFLAMMATORY PROCESSES. Chronic irritative conditions of the prostate, such as occur in gonorrhoea! cases, are of much less interest to the surgeon than prostatic abscess proper. If a patient suffers from rectal tenesmus and severe pain on defcccation, upon which symptoms there super- vene shortly afterwards strangury and possibly also complete obstruction of the urethra, it is obvious that there must be some acute inflammatory process between the rectum and the exit from the bladder, i.e., in the region of the prostate. If, on passing a finger into the rectum and on feeling over one of the lateral lobes, we detect a soft or elastic swelling over which the mucous mem- brane is thickened like velvet, we diagnose an abscess. The speculum shows the mucous membrane to be oedematous and sodden, but otherwise it does not give such a realistic picture of the disease as the finger does. The introduction of a Nelaton catheter into the urethra will encounter a more or less definite obstruction. Metal catheters should not be used in these cases, because they may easily injure the oedematous mucous membrane. It sometimes happens that the whole clinical picture disappears suddenly by itself, with the discharge of pus into the rectum or into the bladder, or into both, and the patient, thus relieved, begs us to put aside the knife which was held in readiness. But if this simple termination does not occur, we must operate in order to give relief. The cause of the abscess is important from the point of view of prognosis. The principal question to decide concerns its gonor- rhoea! or tubercular origin, and there is not usually any difficulty in this. Gonorrhoea, even if not confessed to, may usually be recog- nized at the stage wherein it causes a prostatic abscess, by the remains of urethral discharge. But it is also necessary to be able to demonstrate the presence of the gonococcus. The discharge of the pus from the abscess into the urethra, which does not always pour out, but may only exude drop by drop, may completely resemble an active gonorrhoea, and it is therefore indispensable to examine the pus microscopically, when the history is negative. A young man had a typical bilateral prostatic or periprostatic abscess. On examination a few drops of thick pus exuded from his urethra, and he appeared to have a recent gonorrhoea. But this suspicion could be put aside, absolutely definitely, for the bacterio- logical examination showed a pure culture of Staphylococcus aureus. The patient had recently suffered from a large boil on his sacrum. If nothing points to gonorrhoea we should think of tubercle, and if the symptoms have come on suddenly the infection is a mixed one. A young man with a very tubercular family history became ill suddenly with typical symptoms of prostatic abscess. Gonorrhoea 472 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA could be excluded. The abscess opened into the bladder and the pus contained a pure culture of the Bacillus coll. A guinea-pig inoculated with the pus became tubercular. Nevertheless the focus in the prostate healed rapidly, so that without the inoculation the diagnosis would have remained doubtful. If both tubercle and gonorrhoea are excluded we must think of some other source of infection, as in the case previously mentioned. CHAPTER LXXI. INJURIES OF THE URETHRA. The injuries which concern the posterior portion of the urethra possess the greatest diagnostic interest. They are divisible into three groups: (i) Injuries from within the urethra; (2) injuries produced by external violence without causing a wound; and (3) the con- sequence of fracture of the pelvis. False passages play an important part in the causation of injuries from within the urethra. A haemorrhage, which is generally rather severe, warns the practitioner who passes a catheter carelessly, or the patient, that some damage has been done. These injuries are most easily inflicted by the so-called English catheters, which were formerly in considerable vogue and were given to patients for their own use as being harmless. Unfortunately they have not entirely gone out of fashion. They are not stiff enough for introduction wnthout a stylet, but are quite stiff enough to do some damage. Injury by such articles as pencils, nails, hairpins, &c., are less general. One should think of this possibility if a patient otherwise healthy — at any rate, physically — bleeds from the urethra and has pain on micturition, apparently without cause. It would appear from English's summary that almost everything which could possibly get in has been found in the urethra. Contusion of the urethra by violence which causes no external wound is of great practical importance. If one falls astride on the edge of a board, on a pommel, or a bicycle wheel or some similar object, the urethra is crushed between the pubic arch and surface on which it rests. A kick on the perinaeum produces a similar result in a different way. The symptoms which are observed after such an injury indicate very distinctly the nature of the anatomical damage, even without passing a catheter. This pro- INJURIES OF THE UKETHRA 473 ceeding, which is not ahvays free from danger, should be the final step in diagnosis. The following forms may be distinguished in this variety of injury : — (i) If the patient has some trouble in micturating, but is able with a certain amount of force to empty his bladder of urine, which is free from blood, he has sustained 3. pcri-uretliral IhTiuatoiua without anv injury of the mucous membrane. The effusion of blood may be felt in the perinaeum as a hard exudate. The catheter should not be used as long as the patient can pass his urine. (2) If some blood comes with the first few drops of urine, although the bladder can be completely emptied, some slight injury 1ms been inflicted on tlie niucons nienibrane ; but the passage of a catheter is not justified unless signs of extravasation of urine appear. (3) But there is another series of symptoms which occur with such constant uniformity that, once seen, they can never fail to be recognized. The patient lies groaning, because, notwithstanding strong contractions of the bladder, and his own pressure, he can only evacuate pure blood from the urethra, although the bladder is quite full. There is a hard, dark blue swelling which extends symmetrically like a butterfly's wings on either side of the perinasum. The longer one waits the more tense becomes the swelling and the patient's condition more agonizing. In the presence of such a clinical picture the diagnosis is clear enough without passing a catheter. The patient has a complete, or almost complete, rupture of the urethra, and all the urine which the bladder cannot retain is being extravasated into the connective tissue of the perinjeum. The urine must inevitably decompose unless relief is given by opera- tion. As a rule the catheter is held up at the site of injury, and it would only be a lucky accident if it entered the bladder by following up the anterior surface of the urethra, which sometimes is not torn through. The fact that such a luck}^ accident is possible justifies a cautious attempt at passing a catheter, but we must be careful not to draw a false conclusion. Clinical records often relate that the practitioner has withdrawn a certain amount of bloody urine, but the patient experiences no relief therefrom. If we make the attempt we shall arrive at the same result, and at the same time feel that we have not succeeded in entering the bladder. The explanation is probably that the urine, which is escaping from the bladder under pressure, has found a cavity for itself in the perinaeum, which holds a certain quanity of blood and urine. In such cases we should not persist with the catheter, but must at once provide for emptying the tissues of urine by a perinatal incision. 474 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA Obstruction of the urethra through a fractured pelvis is of less frequent occurrence. The considerations mentioned in connection with contusions from without, apply here also. The difticult evacua- tion of pure urine without blood strongly suggests compression of the urethra by a haematoma, such as would occur in the case of frac- ture of the symphysis. But the cause may be kinking of the urethral canal, due to its being dragged on by the displacement of the two pubic bones one against the other. If the normal function return within a few days, and if a catheter passed subsequently encounters no obstruction, the case is one of a simple haematoma. But if we still meet with some obstruction after the lapse of time — obstruction which cannot be overcome at all, or which requires some special form of catheter or some special manoeuvre to do so — we must assume that there is a kink in the urethra due to displacement of the bones, although there may be little difficulty in spontaneously emptying the bladder. In these cases the skiagrams show that one pubic bone overrides the other to the extent of one or more centimetres. If blood is passed with the urine, the urethra is certainly injured — perforated, crushed, or lacerated by a fragment — but not torn right through. A catheter must not be passed in such a case, as long as the bladder can empty itself and there is no extravasation of urine. If nothing but blood comes from the urethra, and the bladder fills up, while signs of extravasation of urine appear, we must decide to adopt the same treatment as in the cases which manifest the same symptoms after external contusion. CHAPTER LXXII. SURGICAL DISEASES OF THE PENIS. Injuries or deformities of the penis present no diagnostic difficul- ties. The so-called fractures or dislocations of the organ are only curiosities, and have little practical importance. Constriction is easy to recognize, if effected by means of the neck of a bottle or a female screw, but not so easy if a wire ring or a loop of thread has been employed. The last may cut so deeply into the penis that surgical interference is required to render it visible and to remove it. A similar condition is seen in paraphimosis caused by the retraction of a tight prepuce (fig. 205). SURGICAL DISEASES OF THE PENIS 475 In the case of deformities, the first glance shows whether the cleft is above or below, whether epispadias or hypospadias is present. The degree of the latter is determined by the place at which the urethral orifice is situated. (See reference to Hermaphroditism, Chapter L). Tumours and ulcers are much more important from the diagnostic standpoint. For practical purposes we must differentiate between subcutaneous growths on the one hand and inflammatory ulcers or ulcerated growths on the other hand. (1) SUBCUTANEOUS GROWTHS. These very rarely occur on the penis. Sebaceous cysts and dermoids are the only innocent growths which ever occur, and sarcoma the only malignant one. The former are either in the skin or under it ; the latter usually arises in the corpora cavernosa. The diagnosis presents no difficulty, but one must not mistake the hard nodular or cord-like induration which indicates chronic in- flammation of a corpus cavernosum for a commencing sarcoma. Bony growths in the penis, which are very rare, are easily recognized by palpation and X-ray examination. Elephantiasis, a condition which is very frequent in the Tropics, is not really a growth, but it converts the penis into a club-shaped, and finally into an enormous and shape- less tumour, A similar condition occurs in other countries after repeated attacks of erysipelas. (2) ULCERATIVE CHANGES. In addition to venereal ulcers there exists a whole series of inter- mediate clinical forms, ranging from acute inflammatory conditions to an ulcerating cancer, which require complete exposure of the glans — sometimes with the aid of the knife — before they can be diagnosed. (a) If there be pronounced inflammation of the foreskin and glans at an age when venereal infection is more or less infrequent, we should think of simple balanitis or balano-posthitis. In young lads, the cause is almost always phimosis; in old people it may also be due to retention of smegma or narrowing of the foreskin. If the inflamma- tion is very pronounced or very obstinate, or if it dates from middle age, the urine should be examined for sugar — always assuming the presence of a certain degree of retention of smegma. 31 Fig. 205. — Paraphimosis. = Penis, b = Constricting furrow, c = Prepuce, d = Glans penis. 476 SURGICAL DISEASES OF THE ABDOMINAL AND PELVIC VISCERA Sometimes considerable inflammation of the foreskin or glans occurs in the course of severe acute infective fevers. It is, of course, obvious that the inguinal glands may enlarge in all these conditions. Extensive lymphangitis and phlegmonous compli- cations may exceptionally occur. (6) If venereal disease is not excluded — there is no age limit in regard to chancre, and even impotence is no guarantee against it — the prepuce and glans must be carefully examined, and a diagnosis of balanitis must not be made unless it is quite certain that no circum- scribed ulcer is present. It is, of course, important not to confuse a superficial erosion with a genuine ulcer. Erosions may occur in any, case of balanitis, and are especially common in herpes genitalis. But they heal in a very few days with any mild treatment if the part is kept clean, whereas a real ulcer takes a long time to scar over. Sometimes a hard chancre looks like a superficial erosion, but it can be easily distinguished from a harmless erosion bv its indurated base. (c) If the disease does not consist of any diffuse change, but merely of a circumscribed ulcer, we have to think of those conditions which we have already studied in connection with the oral mucous membrane, although, of course, they do not occur in the penis with anything like the same frequency. A tubercular ulcer has been observed on the foreskin and glans in cases of uro-genital tuberculosis, but it is extremely rare. Instances have been recorded wherein tubercular lesions have followed suction of the blood by a tubercular operator, after ritual circumcision. The problems of diagnosis mainly centre around the differentia- tion between soft and hard chancres, gumma, and cancer. An ulcer which appears a few days after sexual intercourse is usually a soft chancre, but it may become a hard chancre within two or three weeks. The former diagnosis is proved by the onset, within a few days, of diffuse infiltrating and painful buboes. The diagnosis of subsequent syphilitic transformation is proved by the obstinacy with which the chancre resists non-specific treatment, by the demonstra- tion of spirochete, and by the serum test, but above all by the appear- ance of constitutional symptoms. If the ulcer has not appeared until after two or three weeks' incubation, the diagnosis of a hard chancre is quite certain ; the discovery of spirochetal and tiie onset of glandular enlargement after another couple of weeks, only serve to confirm the diagnosis. The diagnosis is more difficult when a patient, who has just entered within the cancer period, denies all possibility of infection — an old proverb says " Omnis syphiliticus mendax." No denial is of avail in the presence of a soft chancre with rapidly forming buboes, and the SURGICAL DISEASES OE THE PEXIS 477 diagnosis of hard chancre only requires a little patience if a search cannot at once be made for the spirochjete. Consequently, there can only be anv real doubt as between gumma and cancer. Experience shows that an error of diagnosis may damage a practitioner both in reputation an.d in money. If he amputates for a gumma, as has actually happened, he becomes responsible for wanton mutilation. If he treats a cancer for weeks or months as a gumma he runs the danger of converting a curable malady into an incurable one, and the patient will make him responsible for the lo_ss of the organ, But both mistakes are avoidable by a little examination. A cauUftower-like cancer, if definite, is immediately recognizable. This form usually follows an old phimosis, and in time ulcerates through the external foreskin. A ficit cancer bears more resemblance to a svphilitic ulcer, but it lacks the fatty base of the gumma. The inednUarv noclule- fonning cancel' is quite unmistak- able. We have already seen that the glands do not enlarge in cases of gumma, and that their enlargement may be absent in cases of cancer, or supervene at some later time, where- as the enlarged glands in connec- tion with a hard chancre always appear at the classical moment. If any doubt still persists, a small piece of the base of ulcer should be taken for microscopical exam- ination. A positive diagnosis can then be obtained within a few days, and until then no suggestion should be made for the removal of the penis ; otherwise the patient is perfectly justified in rejecting such a proposal. Cancer can often be detected in its early stage, when phimosis is present, by the offensive discharge from the prepuce. Finally, some confusion is conceivable between a commencing papillary cancer and an acuminate condyloma. The assertion that the latter is always a consequence of gonorrhoea is incorrect, and is misleading to diagnosis. Acuminate condyloma is an infective condi- tion of its own ; but is distinguished from cancer by its invariably soft base. The significance of phimosis may be inferred from the statement of Barney that Jews very rarely suffer from cancer of the penis. Just as other cancers, this form may also develop in a venereal scar. 31A Fig. 206. — Cancer of glans penis. PART V. THE SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN. CHAPTER LXXIII. TUMOURS OF THE PELVIS. The major portion of the pelvis is so extensively covered by soft parts, that it is very easy to overlook tumours in their early stage, even if they do not grow exclusively inwards. It is therefore most important to devote due and timely attention even to their indirect symptoms. If a pelvic tumour grows inwards, it will sooner or iTiier press upon and displace the pelvic organs. Bladder and rectal derangements will usually point to this result. A definite conclusion can only be formed after a careful bi-manual examination, per rectum and the lower abdominal region, an examination which should never be neglected in any obscure case of bladder disturbance. The derangements which occur during labour are well known, and they may be imitated by tumours within the pelvis, even if they are small. The experienced obstetrician will always think, among other possibilities, of a new growth in the pelvis, when the head of a child refuses to engage normally. Symptoms of displacement of the pelvic viscera are not always predominant in the clinical picture. If the growth extends mainly outwards, or if it is situated in the false pelvis, it gives rise to two other symptoms — the appearance of a protuberance in some part of the pelvis, and the result of pressure on the nerve-roots. A new growth of the pubic crest is distinguished by the early stage at which it can be seen and felt. It requires no further diagnostic consideration. But a growth more often announces itself by nerve disturbances long before it can either be seen or felt, and the patient is accordingly provided with various diagnoses and ordered to all possible spas. A man, aged 52, had consulted many doctors for sciatica. At our TUMOURS OF THE PELVIS 479 first examination no organic cause for the neuralgia was evident. The rectum was free, the prostate normal, and nothing could be felt in the pelvis. The spinal column was also normal. The treatment for the sciatica had apparently secured temporary improvement. The patient returned in nine months' time, and then it was clear that the pains affected the region supplied by the anterior crural nerve rather than the sciatic nerve region ; at the same time there was a striking weakness of the flexors of the thigh. The patient had to lift up his left leg with both hands to put it on the examination stool. In addition there were pains in the lumbar region; the twelfth dorsal vertebra and the centre of the sternum were painful to pressure. The diagnosis of "sciatica" was obviously discredited, and one had to think of organic damage to the great nerve-roots which supply the left leg. Meanwhile a tumour of the left iliac bone had become palpable on deep pressure, and this explained all the symptoms. A loud souffle could be heard with the stethoscope over it, and this confirmed the diagnosis of "sarcoma." The pain over the lumbar spine and the sternum indicated metastases, which therefore contra- indicated any operative interference. It is not always pressure on nerves which suggests a concealed pelvic tumour ; sometimes the pressure is exerted on blood-vessels, producing an increasing oedema of one leg. If both symptoms are present simultaneously, the suspicion becomes very great. How can we tell whether a tumour which is found in the pelvis really originates from the pelvic bones ? First, we must be able to exclude any connection between it and the pelvic viscera by con- sidering the previous history and the actually existing symptoms. For instance, if a patient has for months been losing blood with his motions, and has symptoms of rectal stenosis with a growth adherent to the sacrum, he is not the subject of pelvic tumour, but of a rectal cancer which has contracted secondary adhesions to the sacrum. Physical examination, however, furnishes the clearest indications. Tumours which grow from the internal surface of the pelvic bones are usually more or less globular or uneven structures, connected with the pelvis itself at a narrowly circumscribed site. Malignant growths of the pelvic viscera, once they have become fixed to the pelvis, give the impression of a dift\ise hard mass, which seems to have been poured out by the pelvic cavity. Innocent growths of the pelvic viscera never become so firmly fixed to the pelvis as to cause any mistake. It might be quite possible to mistake a pelvic enchondroma for a firmly incarcerated fibromyoma ; but examination under anaesthesia would clear this up, because some movement could then be obtained, even with a firmly incarcerated myoma. In exceptional cases a very elastic, tense bnrrowing abscess which occupies the pelvic fossa, or the true pelvis, may be mistaken for a sarcoma, especially if it causes circulatory disturbances in one leg. 480 SUKGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN But such an error would only be pardonable in the absence of any physical sign of tubercular disease of the spine or pelvic bones. If a pelvic tumour has become large enough to be grasped by the ' hand, or to make special demands upon the tailor, there is no longer any difficulty in diagnosis. Tumours of a knotty structure within the pelvic cavity, especially in the vicinity of the ileo-sacral joint, are either osteomata or chondromata. They may, in the course of years, grow as large as a man's head, or even larger. They are not absolutely innocent, because they do sometimes produce metastases. But, in contrast to sarcomata, they do not cause any nerve dis- turbances until late. On the other hand, if we are dealing with a tumour which announced itself by pressure on nerves, before it could be demonstrated objectively, and whose symptoms are rapidly increasing, there can be no doubt about the diagnosis of "sarcoma." If auscultation shows that there is vascular engorgement (a systolic murmur), this tends to confirm the diagnosis of sarcoma. If the clinical diagnosis should still remain in doubt, it can be settled by 2i skiagram, which will also show how much new bone formation there is in the tumour, its extent, or the amount of bone destruction which it has caused. Sarcoma of the acetabulum presents a special clinical picture. At first it suggests hip disease, but the early onset and persistent neuralgia, combined with the absence of any disturbance in the mobility of the joint, makes the careful observer suspect something worse. Similarly, sarcoma of the ileo-sacral region is at first thought to be ileo-sacral tuberculosis. But it is just in this case that ausculta- tion enables an early diagnosis to be made in some circumstances. In addition to the pelvic tumours hitherto discussed, one should mention the rare fibromata which grow from the iliac bone into the anterior abdominal wall. They usually occur in the female sex and their clinical behaviour approaches malignancy, so that they are very suggestive of the well-known fibromata of the abdominal integuments. In considering the diagnosis of pelvic tumours one must think of fibroma and sarcoma of the pelvic muscles, which are most frequently found originating in the gluteal muscles. As long as they are movable while the muscles are relaxed, they present no difficulty in diagnosis, and their recognition either as a sarcoma or fibroma is made by their form and consistence and comparative rapidity of growth. But this is not always possible, because some growths, which to the naked eye and microscopically appear to be fibromata, are liable to persistent recurrence, and their histological appearances may even change to those of sarcoma in the course of time. If the tumour has become adherent to bone, even the skiagram may fail to indicate its site of origin. The subject of pelvic tumours suggests reference to another class CONGENITAL ABNORMALITIES IN THE SPINAL COLUMN 481 of tumours, which usually escape adequate discussion among abdominal tumours, because they do not originate in a viscus. These are the tumours of the connective tissue of the pelvis. With few ex'ceptions they are dermoids, which originate in the pelvic connective tissue, or rather in the peri-rectal tissue, develop above the levator ani, generally on the left side, behind the rectum. If they grow chiefly upwards, they are usually looked upon as ovarian tumours adherent in Douglas's pouch — occurring as they mostly do in the female sex. If they extend in a downward direction, they are especially liable to be taken for burrowing abscesses. But their tense con- sistence, their well-defined roundish shape, and the extreme displace- ment of adjoining viscera should show that they are independent growths. Positive evidence is only furnished by exploratory puncture and operation. The rule not to perform exploratory puncture until everything is ready for operation applies here just as well as on other occasions. Dermoids suppurate very easily and the portion of the body through which the puncture has to be made, does not always permit of thorough cleansing. These dermoids are very rare in males, but when they do occur, and the patient is at the age of prostatic hypertrophy, they usually suggest this condition. For eighteen years a patient of mine went about with this diagnosis. But after he had made a false passage for himself and even the village midwife failed to pass a catheter, he came to the hospital with a cyst the size of a man's head. The same applies to the very rare cysts of the prostate or of the retroprostatic connective tissue. Sufferers from these tumours do not usually consult the surgeon until they get retention of the urine, and probably have a false passage in addition. The diagnosis is first made at the operation. In a few cases, hydatids have been found in this region. CHAPTER LXXIV. CONGENITAL ABNORMALITIES IN THE SPINAL COLUMN. If a new-born infant presents a median swelling situated on the spinal column, either slightly or not at all movable, we should at once think of a " spina bifida." As it is not possible to distinguish all the finer differences in this malformation by clinical signs, we shall merely detail the main features upon which the diagnosis turns. In some cases the spinal column, the spinal meninges and spinal 31B 482 SURGICAL DISEASES OF THE PELVIS AXD SPINAL COLUMN cord are completely cleft, and form a hood over a shallow groove, or cause a protuberance, if a kyphosis is also present — posterior rachischisis (fig. 208). Other malformations, incompatible with life, usually exist at the same time, especially on the skull and in the brain. NiglalNlaillt^liJifaiHfilsltell-. jlli'^NIIaBstasWIiMteteM Fig. 207. — Diagrammatic scheme of the more important forms of spina bifida. I. (black)Skin_. 2. (blue) Dura. 3. (red) Pia. 4- ^yellow) Spinal cord. P-Pi. Polar depressions. (a) Meningocele, (b) Myelocystocele. (c)—(e) Various degrees of myelo-meningocele. (/) Myelocysto-meningocele. In less severe cases the spinal cord is also cleft and gives rise to the reddish medullo-vascular area, but the extent of the fissure is less. The " tumour " is formed by an increased collection of cerebro-spinal fluid in the area of the soft spinal meninges on the ventral side of the hooded cord— Myelo-meningocele (fig. 209). This form merges by CONGENITAL ABNORMALITIES IN THE SPINAL COLUMN 483 intermediate varieties into the form wherein the spinal cord is closed, but projects out of the canal, adherent to the posterior wall of the sac. The collection of fluid in this form is also found ventrally in the soft membranes, but is often found at the same time in the dilated central canal — Hydromyelo-meningocele. The tumour has normal Fig. 208. — Posterior rachischisis. The dark portion corresponds to the medullo-vascular area. Fig. 209.-— Myelo-meningocele with the superior depression clearly seen in the illustration (X). skin at the periphery, and is covered at its top with fine scar-like epidermis (fig. 210). If the spinal cord is free in the sac, and entirely covered by arachnoid membrane, and if the central canal is considerably dilated, the case is one of myelo-cystocele. If the tumour only consists of 484 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN protruded arachnoid, the case is one of pure meningocele. The dura takes no part here either in the composition of the wall of the sac, but stops short at the level of the gap in the bone. How can these various forms be distinguished clinically ? In the first place by the rest of the child's condition. The more severe any other malformation, the more severe is the malformation of the spinal Fig. 210. — Myelo-meningocele. Fig. 211. — Myelo-meningocele in the region of the conus terminalis and the cauda equina. cord. Then the condition of the tumour itself is significant. If there be a meduUo-vascular area present, or if a superior and inferior de- pression are found on an epidermal surface (fig. 209), one may be certain that the spinal cord is cleft. If tracts are seen through the sac wall, running from a dorsal thickening thereof towards the spinal column, they will be recognized as nerve-roots, and we may assume that the spinal cord, whether cleft or not, is adherent to the dorsal CONGENITAL ABNORMALITIES IN THE SPINAL COLUMN 485 wall of the sac. If such tracts are absent, the case is either a myelo- cystocele or a meningocele. But the latter may also contain m its wall coiled-up nerve-roots, running back to the spinal canal, and thus the diagnosis may be rendered difficult. When the sac is very large the diagnosis can be facilitated by examination through transmitted light, and also by the circumstance that a pure meningocele only occurs in the sacral region. The diagnosis is most difficult when the condition occurs at the lower end of the spinal column, where the conus terminalis and the Cauda equina may be more or less extensively prolapsed. Special diagnostic interest attaches to those somewhat infrequent cases wherein the cleft formation of the spinal column and the change in the spinal cord or in its cavity are so in- definite that they are not observed on a superficial examination. The patient, however, seeks advice about slight sensory or paralytic symptoms, or occasionally about trophic disturb- ances of the lower extremities. If the symptoms are specially of a motor character, one is inclined to attribute them to poliomyelitis. But, on an in- spection of the back, we will at once be struck by the well developed hairi- ness of an area, usually situated in the lumbar region. The hairs are generally arranged in a semicircle, transversely to the spinal column, with its convexity downwards. They often become quite long. Slight cicatricial changes are fre- quently seen on the skin. On palpating the spinal column a gap will be noted in the series of vertebral spines, at the level of the hairy patch. In this gap there is an elastic swelling, which usually varies in size from a pea to a cherry. This constitutes the malformation known as spina bifida occulta. The swelling, Avhich is felt, may either be a pure inciiinoocelc or a niyclo-iiieiiingoccle. In some cases there is not even any nervous disturbance, and the only indication of the malformation is the abnormal hairiness. When assistant to Kocher, I saw a peasant lad in whom temporary paralytic symptoms of the lower limbs supervened after a blow on the back. The abnormal hairiness of the lumbar region easily led Fig. 212. — Vestigial tail. 486 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMX to the diagnosis of spina bifida occulta, which had been injured by the blow. Finally, the sacral region is the site of all possible congenital tumours : Fibromata, angiomata, lipomata, sarcomata, teratomata. The last include an unbroken series from simple dermoid cysts to foetal implantations and double monsters. These tumours are some- times isolated, at others they are associated with clefts in the spinal column and spinal cord. Sometimes the peculiar character of the tumour allows it to be identified as a fibroma, lipoma, dermoid or lymphangioma ; but as a rule one must be content with the diagnosis of congenital sacro-lumbar tumour, and further detail must be left to the microscope. If a dermoid ruptures it gives rise to a dennoid sinus, already referred to among the perinseal fistulae. If the sacrum has an appendage looking like a tail, it can very rapidly be decided by palpation and b\' a skiagram whether the structure onlv consists of soft tissue — a false tail (lipoma, fibroma) or is a vestigial tail without bone — or whether it contains a prolonga- tion of the spinal column and constitutes a real tail. These vestiges of a "tail " period are never found among an entire people, as has been stated. They occur in individuals (generally males) of all races, and vary from a modest stump to a quite con- spicuous structure, even resembling the tail of a pig. CHAPTER LXXV. LUMBAGO. Many a diagnosis, made with a pretence of learning, is merelv the cover of our ignorance by a classical term. This is very often true of " lumbago." A pain in the lumbar region, whose cause we do not know, is usually provided with this name. We cannot apparently dispense with this term, but we should reserve it for a pain which comes on suddenly. It is because of the suddermess of the pain and its unknown causation that it is called in German " Hexenschusz " (witch's shot). This excludes a large number of lumbar pains which have nothing to do with general lumbago. Among these may be mentioned as the more important the lumbar pains of tabes and paralysis ; spinal caries, renal stone and tuberculosis ; chronic colitis (especially on the left side). The lumbar pains which occur in acute febrile diseases, from influenza to small-pox, are also excluded. Our LUMBAGO 487 discussion of the subject is, therefore, hmited to the two conceptions — rheumatic lumbago and traumatic lumbago. Formerly, the malady was called either rheumatic or traumatic, according to personal taste, and the nomenclature had no further significance. But since insurance against accidents has become the vogue, there is hardly any condition as fertile as lumbago as a cause of actions for damages. The blame for this is not only to be attributed to the proverbial greed of the insured for compensation, but to some extent to the circumstance that the diagnosis of rheumatic lumbago is based on very insecure foundations. Here, as elsewhere, a condition which we cannot explain is termed rheumatic. No one who has ever suftered from lumbago, and, therefore, ob- served its progress with accuracy, can possibly believe that a genuine inflammation, be it of rheumatic or other nature, can set in with such suddenness. It always originates in some slight and unexpected move- ment which the spinal column is not prepared to meet by the fixation of its joints. The first consequence of this want of fixation is that the lateral articulation gives way, and the final result is twisting of this joint. There can be no doubt that some people suffer from an effect of this kind more than others ; but this is no evidence for the in- flammator}^ origin of the pain. This does not, however, dispose of the contingency that pains may also arise owing to rheumatic inflammation of the muscles of the back or the lumbar nerves. But although these pains apparently begin without any direct cause, they are not sufficiently sudden in their onset to merit the designation of lumbago. The confusion between the two conditions is due to the fact that the pains in both are similarly localized, and are of the same subjective character. Thus we see that there is no sharp line of demarcation between the ordinary and the traumatic form of lumbago ; the transition between them is gradual. The actual strain which causes traumatic lumbago may be so slight as to be well within the range of normal movements ; the traumatic effect is simplv due to the neglect of the individual to fix the spine in anticipation of the movement. As far as the legal definition of " accident " is concerned, the term " traumatic lumbago" should be limited to injuries which result from abnormal movements of the spine, such as over-bending, over-strain- ing and excessive twisting — movements which are calculated to produce distortion, rupture of muscles, and tearing off of articular and transverse processes, despite any amount of muscular fixation. In both groups of cases the most striking feature consists of the muscular rigidity of the affected spinal segment, generally, but not always, the lumbar spine. There is, in addition, a certain amount of localized pain on pressure and on movement ; but no sign is 488 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN absolutely conclusive in the differential diagnosis. A definite diagnosis can be more satisfactorily based upon a correct knowledge of the trauma on the one hand, and the course of the symptoms on the other hand. Reliable information as to the injury is often unattainable, because the patient's statements are apt to be exaggerated. It is only when there has been some evident cause (lifting an unusually heavy weight, a fall, or external violence) for a severe trauma, that we should regard the symptoms which are present as due to an "accident" in the legal sense. The course of the symptoms furnishes conclusive evidence of the diagnosis, except in the case of insured patients, w^ho have an interest in the prolonged duration of their malady. Ordinary lumbago disappears in a few^ days, but the consequences of an extensive rupture of muscle, of a severe twMst, or the tearing off of bone, may persist for weeks and months. The diagnosis is easy enough if a good skiagram reveals a torn fragment of bone (fracture of a transverse process). But in the absence of this, or of evidence supplied by a haemorrhagic discoloration of the skin, a few days after the accident, pointing to a superficial haematoma, we are bound to rely on the bona fides of the patient, and on careful observation in hospital. The differential diagnosis receives little aid from inquiries directed to previous rheumatic symptoms, because genuine lumbago has nothing to do with rheumatism. It is much easier to recognize pain in the back which follows a direct contusion. The nature of the trauma is obvious, and we often find its immediate consequences in abrasions and ecchymosis of the back. Compression fracture of the spinat column can only be mistaken for lumbago if the history has not been taken into account, and the symptoms of compression-fracture are unknown to the practitioner. It is important to realize that fragments of bone may be broken off by indirect violence — either through muscular contraction, or the dragging of ligaments. Such small fragments may be missed, even on careful X-ray examination, especially in fat patients. Cases which show no physical symptoms, but wherein the subjective complaints are severe, constitute the most difficult of medico-legal problems. The patients delay their return to work from time to time, extending over a period of years, whereas they would resume their occupation in a few weeks or months if they w^ere not insured. 00 OO T^ ■■■□■■■■I ■giiiiiii N> N e CD c s a INJURIES OF THE SPINAL COLUMN 489 CHAPTER LXXVI. INJURIES OF THE SPINAL COLUMN. Injuries of the spinal column resemble those of the skull, in that their study is dominated by the associated injury sustained by its contents. In our examination, chief attention must be devoted to this consideration. Let us assume the case of a patient who has had an injury to the spine, generally through a fall from a height, or through something having fallen on him, and who then complains of his back. But he comes on foot, and presents no change in the shape of the spine, nor any symptoms connected with the nervous system. He is suffering either from a contusion or distorsion, or possibly from a fracture of a spinal or transverse process, the situation of which is indicated by the spine that is most painful on pressure. The absence of dislocation is shown by the normal position of the spinous processes, by the normal posture of the head or back, and, as far as the upper cervical vertebrae are concerned, by the absence of any displacement which can be felt through the pharynx. For further details, see Chapter XXV. We only propose to deal here with the more serious injuries of the spinal column in relation to the spinal cord. I.— METHOD OF EXAMINATION. Let us start with a concrete case. A man has fallen off a scaffold, and is brought in, on an ambulance. We place him in bed, being careful to support his entire spme. Our next task is to make a diagnosis, and therewith also a prognosis, with the very minimum of disturbance to the patient. (1) In order to examine his power of inohiUty, we first ask him to carry out a few ordinary movements. If he lifts one leg after the other, extends and flexes the knees as directed, we may at once be reassured as to the worst ; he has no complete lesion of the spinal cord. But if he does not lift his feet, but contracts his thigh muscles with pain, we may conclude that the nerve-tracts retain their con- ductivity, but that movement is hindered by the pain. He may have sustained a severe injury to the spinal column, he may even have a fracture of both thighs, but the spinal cord has not been crushed through. If he is able to raise one leg, while the other remains helpless, he either has a unilateral injury to the spinal cord, which is very rare in the case of fracture, or a unilateral contusion or com- pression of the Cauda equina, which is also rather rare. The most 490 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN probable condition is a fracture of the thigh or pelvis, which may at once be assumed if the patient can move the foot and toes, while he is incapable of moving the thigh. The mobility of the trunk is next examined, for which purpose the method of respiration is of great assistance. If the respiration is purely of the abdominal type, i.e., diaphragmatic breathing, and if thoracic respiration is impossible, it means that the intercostal muscles are paralysed, and that only the phrenic nerve, which arises from the fourth and fifth cervical segment, remains in action. The injury is therefore severe and situated high up. We come next to the mobility of the dipper extremities. The very position of the arms is significant. If they are freely movable down to the finger-tips, and can adopt any posture desired, it means that the injury is at any rate lower than the first dorsal segment. If the hands are half closed, the elbows flexed, and the forearms are lying moderately pronated on the chest, we may conclude that the injury is about the level of the seventh cervical segment (fig. 213). If the arms are turned outwards and held upwards, with the fingers semi-flexed, the forearms supine, and the elbows bent, the sixth segment is injured (fig. 214). If they lie immobile, completely paralysed against the trunk, the position of the injury is at the fifth segment. It cannot be any higher, because all severe injuries above this level cause paralysis of the phrenic nerve and sudden death. In the case illustrated in figs. 213 and 214, the autopsy showed that there was a contusion between the seventh and eighth segments. When the patient came into hospital his posture was as depicted in fig. 213. On the following day, when the circulatory disturbance had increased, he presented tiie posture shown in fig. 214, and the hyper- cesthetic zone was displaced one segment higher up. In a few days there was so much improvement that even the eighth segment resumed its functions ; but death from broncho-pneumonia followed three weeks later. Fig. 216 illustrates the spinal injury which had occurred in this case. (2) After this summary examination of mobility we proceed to test sensation. If this is preserved in the lower extremities, although possibly weakened, or lost to certain stimuli, a complete lesion can be excluded, even if motion is entirely absent. But if it is entirely lost, as is usually the case when there is total motor paralysis of the corre- sponding section, complete contusion of the spinal cord is very probable. The level of the injury can be ascertained from the limits of normal sensation. An area of complete anaesthesia is frequently bounded by a zone of partial loss of sensation and a zone of hyperaesthesia. This zone of hyper^esthesia is not only caused by irritation of the nerve-roots, but also by irritative changes within the cord itself, as is Plate 3. Fig. 1. Distribution of sensory root-segments on the superficial skin (after Kocher). Note: L. 1 u. 2, L. 1 u. 2 on groin should appear as L. 1—2. INJURIES OF THE SPINAL COLUMN 491 proved by the fact that this zone ascends in cases of ascending myehtis. The examination of the sensation should always be completed by testing the sensations to pain and temperature. In cases wherein there is partial disturbance of sensation, various kinds of sensation produce different reactions. Sensibility to pain and temperature is Fig. 213. — Posture of arms in a transverse lesion at the level ot the seventh cervical segment. Fig. 214. — Posture of arms in a transverse lesion at the level of the sixth cervical segment. more greatly deranged than the sensation of taste, or the pain and temperature sense may be completely lost, while the sense of taste is only slightly disturbed. (3) jWe now examine the condition of the vasomotor nerves. Their paralysis is indicated by hyperaemia of the paralysed extremities, by a rise in the temperature of the skin, and by congestion of the corpora cavernosa penis 32 This organ is usuallv in a state of moderate 492 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN congestion, and if touched, for instance to pass a catheter, it may pass into a state of erection, and emission may follow, (4) The condition of the bladder and rectum are especially important in regard to the visceral functions. In a total lesion both these organs are completely paralysed. Paralysis of the bladder is shown by a retention of urine, combined with so-called paradoxical incontinence. The bladder is fully distended and is recognizable at a first glance at the abdominal wall ; it empties only by overflow after the resistance of the sphincter has been overcome. We cannot here argue the question whether the closure of the sphincter is merely an action of elasticity (Kocher) or whether it depends upon some peripheral innervation thereof. Nor can we here go into the details of the diagnosis of paradoxical incontinence. If the injury is not situated too low down, the function may in time unconsciously return at periodic intervals, as the spinal cord resumes the automatic discharge of its duties. A condition comes on, which Kocher compares to enuresis. It matters not whether we locate the centres involved in the sacral segments or in the sympathetic, in accordance with the views of most recent authors (L. R. Miiller). In either case the fibres run through the conus medullaris. If they are torn through, a permanent loss of voluntary power over the bladder and rectum follows in every case. The newer researches indicate that automatic action may return after a complete destruction of the conus, a circumstance untenable according to the older views. The onset of enuresis after paradoxical incontinence has once started, is especially found in cases of partial damage to the spinal cord. We know that this may also occur in dogs after a complete lesion, but the subject has not been sufficiently worked out in man. On examining the rectum, it will be found to be full of faeces, as long as they are solid — retentio alvi. If the rectal contents are liquid, they escape involuntarily — incontinence of faeces. Extreme meteorism, which is a sign of intestinal paralysis, is another symptom of visceral derangement. It is a sign which has often suggested genuine intestinal obstruction, and which has led to the performance of laparotomy. We must finally refer to disturbances in the Innervation of the pupils. If reflex fixation of the pupil be present with miosis, it follows that the pupillo-dilator fibres are interrupted somewhere in their course through the spinal cord, and that therefore the lesion must be above the first dorsal segment, in the roots of which these fibres leave the cord. (5) There now remains the important matter of the examination of the skin and tendon reflexes. INJURIES OF THE SPINAL COLUMN 493 In a complete lesion the superficial or skin reflexes are usually lost, but they return again. Kocher has, however, pointed out that the genital reflexes are not lost, viz., the erection reflex, and unilateral contraction of the lower abdominal muscles on squeezing the testicle (Kocher's testicular reflex). The tendon reflexes, especially the patellar reflex, are of greater importance. If it is absent, it signifies a very severe injury, generally a complete lesion. If it remains per- manently absent there is no doubt at all about this (Bastian-Brun's law). It may also be absent in partial lesions. It does not then usually take more than a few hours for it to return, though I have seen the absence persist for days, in rare cases. If, on the other hand, the patellar reflex remains after an injury to the spinal cord, or is actually increased, we may safely exclude a complete lesion, even if the other symptoms are severe. These remarks only apply to human beings and to sudden traumatic complete laceration. In dogs, the tendon reflexes may also, in such a case, return after a short delay. In man, the reflexes are either retained or even increased, in cases of gradual interference with the cord, through tumours or inflammatory processes. On the other hand, there is no record of a case wherein the tendon reflexes had previously been normal, and in which they were either retained or increased after the spinal cord has been suddenly torn through. I will not dispute the possibility of a partial return of the tendon reflexes months after a complete traumatic division of the cord, even in man, but I have never seen such a case ; but this does not invalidate the diagnostic importance of Bastian-Brun's law. II.— DIAGNOSIS OF THE NATURE, DEGREE AND POSITION OF THE INJURY. Our examination now puts us in a position to answer the two important questions to which every spinal injury gives rise, namely : — (i) Is the injury complete or partial ? (2) At which level is it situated, and what conclusions may we draw from the injury to the cord, in regard to the injury to the spinal column ? (A) THE DEGREE AND THE NATURE OF THE SPINAL CORD INJURY. We have first to decide whether the injury has caused complete or partial division of the cord. We may summarize the indications already referred to in the following way : — We may assume a complete lesion wJien there is persistent, sym- metrical, total, flaccid motor paralysis, with sensory paralysis in the corre- sponding area, and when the tendon reflexes are lost for a considerable 494 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN time, and when the bladder and rectum are paralysed, in the absence, Jiowever, of all motor and sensory irritative symptoms in the paralysed regions. We tnust, on the other hand, assume a partial lesion when signs of voluntary innervation and of sensation are present beloiv the site of injury ; ivlien, in their absence, the patellar reflex is retained or is soon restored ; when motor or sensory symptoms of irritation appear in the paralysed regions, in the first few days after the accident, and when bladder and rectum still act volnutarily, or at any rate wlien their automatic function sets in early. A partial lesion can naturally occur in various degrees and forms. Hemi-section of the cord produces a somewhat typical form of lesion with a symptom-complex to which the name of Brown- Sequard's paralysis has been given. The more complete and the sharper the hemi-section, the more accurately do the symptoms correspond to the following scheme, viz. : — On the side of the injury :— (a) Motor-paralysis, in the form of paralysis of a pyramidal tract, with a localized zone of cornual paralysis at the upper border. (b) Vasomotor paralysis. (c) Hypercssthesia for all forms of sensation. (d) Loss of the muscle sense, which is no longer generally recognized as a separate function (deep sensibility). (6^) Increase of the tendon reflexes in consequence of the break in the conducting path. ~ (/) In the cervical cord ; paralysis of the oculo-pupillary fibres. On the uninjured side we find : — Sensory paralysis either for all or for certain forms of sensation. It would be of great interest from the point of view of treatment, if we could go further and distinguish between contusion and com- pression. The present state of our knowledge, however, does not allow us to do so. We might very well indirectly conclude that contusion had taken place if we can demonstrate displacement of a vertebra. If we have concluded, from the absence of this sign and from the slightness of the symptoms, that the case is one of mere compression by a hcematoma (always a very uncertain diagnosis), then the presence of much blood in the cerebrospinal fluid, drawn off by lumbar puncture, would suggest that the h?ematoma is situated inside the dura. This intradural haemorrhage is also distinguished from haemorrhage inside the the cord (haematomyelia) by the predomin- ance of symptoms of irritation. (Paraesthesia, increase in the muscle tone and of the reflexes.) In haematomyelia the paralytic symptoms predominate ; if the haemorrhage is in the cervical cord, the disturbance is most marked in the lower extremities. The sensations of pain and of temperature INJURIES OF THE SPINAL COLUMN 495 undergo most disturbance, just as in syringomyelia. Very circum- scribed haemorrhages lead to diplegia, and as they are most frequent in the cervical cord, the diplegia is of the brachial type. Finally, it should be noted that such haemorrhages in the cord (especially in the grey substance) may occur without any injury to the spinal column, as they have been observed to follow a temporary overstrain of the spine and consequent dragging on the cord. These have always been situated in the cervical or in the lumbar cord. (B) THE POSITION OF THE SPINAL CORD INJURY. (The Diagnosis of the Level of the Lesion.) The level of the lesion may be ascertained by co-ordinating the results of the tests for motion and sensation. We need not enter into details because they are clear, from Plates I, II, and III, taken from Kocher's work, which are diagrammatic representations of the dis- tribution of motion and sensation in accordance with the individual segments, and also from the adjoining diagram (fig. 215). It is only necessary here to add a few general remarks. (i) In injuries of the cervical cord the posture of the arms tells us at once the approximate level of the injury, as previously stated. We must, however, not be content with the demonstration of these postures, but must carefully examine power of movement. In comparing what we find with the plates, we must remember that motor symptoms are not all due to the same cause. They may be caused : — (a) By compression, or the tearing through of the pyramidal tracts. (6) By destruction of the anterior cornua and of the intra- medullary roots. (c) By damage to the roots after their exit from the spinal cord or from the dural sheath. According to the rules of spinal cord pathology, the first form should cause spastic paralysis, without the reaction of degeneration, the other two should cause flaccid paralysis with the reaction of degeneration. But, as a matter of fact, all paralyses are flaccid at first, and even when due to a break in the pyramidal tract, the spasticity does not come on for some considerable time, indeed until the lower spinal segment has regained its automatism. But, on the other hand, the reaction of degeneration enables us to distinguish between paralysis due to a break in the pyramidal tract and paralysis due to a lesion in the cornua or in the roots, at any rate after a few days. The nuclei are, however, not accurately divisible into segments, so that the nerve supply of one muscle may be derived from several segments. The reaction of degeneration, however, only manifests itself when the whole of the nucleus or all the roots are destroyed. If a transverse lesion, for example, hits off the upper end of a 32A INJURIES OFTHE SPINE MOTION 5mall cervical muscles _5c_a£ujar rnuscles uo Sterno - mastoid, Tra pezi us SENSATION Fig. 211;. INJURIES OF THE SPINAL COLUMN 497 nucleus, only a small part of the muscle undergoes trophic change. The rest of the muscle is paralysed owing to the break in the pyramidal tract, and we must not expect the reaction of degenera- tion. Patients with severe damage to the cervical cord have generally succumbed before the reaction of , degeneration has had time to develop. We are apt to diagnose the lesion in too low a segment, owing to the fact that auxiliary innervation may be derived from the segment next highest to the one affected. On the olher hand, the upper limit of the symptoms may, in exceptional cases, be due to an ascending traumatic myelitis, or to some transitory distant cause, and so we may diagnose the lesion higher up than it really is. It is, therefore, of the greatest importance to make repeated examinations, comparing the one with the other before deciding as to the level of the injury. In general, we may say that the shoulders and the elbows are supplied from the fifth and sixth segments, the wrist from the seventh, the long muscles of the fingers from the eighth, the small muscles of the hand and fingers from the first dorsal segment, which is function- ally connected with the eighth cervical. We examine sensation on the arms, because the neck and shoulder, as well as the thorax as high as the level of the second rib, are supplied by the fourth segment (supraclavicular nerves). The radial side of the arm corresponds to the fifth cervical segment, the ulnar side to the first dorsal segment. The areas corresponding to the other segments lie between them in the form of bands. As the segments also coalesce in regard to sensation, we must onl}^ make use of complete loss thereof, for the purpose of focal diagnoses, at any rate in total lesions. Kocher's Plate III is constructed on this assumption ; for instance, the upper border of the sixth segment does not indicate the limit up to which its fibres themselves reach, but it represents the limit to which the auxiliary fibres of the fifth segment reach ; in other words, it is the upper limit of total anaesthesia caused by destruction of the sixth segment. When the lesion is partial we define its level by the zone in which the disturbance is most pronounced and in which the most forms of sensation are lost, that is to say, we do not take into con- sideration the sensibility to touch only, but also to pain and temperature. Symptoms of irritation are of more importance here than in the case of motor disturbances. They do not, in cases of a total lesion, indicate the actual segment which is injured, but the one directly above it, sometimes even one higher. This is the case if auxiliary fibres are irritated in the area corresponding to the next higher segment. In partial lesions of the cord, the irritative symptoms may also correspond to the injured segment itself. We may assume this to be the case, when irritative and paralytic symptoms are combined in the same zone, and when there is no complete paralysis below it. 32B 498 SURGICAL DISEASES OF THE PELVIS AND SPIXAL COLUMN Ascending myelitis may affect sensation just as it does motion, and therefore give rise to the diagnosis of a segment, which is one too high. (2) In injury to the cord in the dorsal region, the motor conditions are not of great vahie for focal diagnosis, because neither the nerve supply of the muscles of the back, nor that of the intercostals can be applied to the purpose. The nerve supply to the abdominal muscles, derived from the seventh to twelfth dorsal segments, are equally useless for this purpose. The sensory nerve supply is, therefore, of more importance. As previously remarked, the supraclavicular nerves, derived from the fourth cervical segment, supply sensation as far as the second intercostal space. Next to this lies the area of the second dorsal segment, with its border transverse, and not parallel to the ribs, and the other dorsal segments follow. These areas lie lower than the point of exit of the corresponding nerves in the upper part of the chest to the extent of three spinous processes, and lower down to the extent of four or five. Kocher has suggested a very convenient indication, according to which the upper border of insensibility corresponds to the lowest anterior point of the intercostal space in which the injured nerve runs. From this point the border line runs, not obliquelv, but rather horizontally backwards. The areas widen out in the neighbourhood of the linea alba, because the area of the twelfth intercostal nerve reaches as low down as the symphysis. What has been said of the cervical cord, in regard to the limitation of the areas, applies here also. The behaviour of the pupils will show whether the first or the second dorsal segment has been destroyed, as previously stated. (3) As the segments of the Iinnbo-sacral cord are very small in extent, we may expect several to be involved in one injury. The cornual lesion predominates over the paral^^sis of the pyramidal tract, and the return of automatic activity to the cord below the site of injury is compromised by the great extent to which it is injured. The shortest reflex arcs are very liable to be directly interrupted, so that some reflexes do not return, even after prolonged delay. The diagnosis is also rendered difiicult owing to the course of the nerve trunks being more oblique than in the other parts of the spinal cord, and therefore more subject to extensive contusion. It may even be difificult, under these circumstances, to decide whether there is a genuine lesion of the cord, or merely a contusion of the cauda equina. In actual practice, the following may be taken as a guide: if, in a case of complete motor and sensory paralysis, some reflexes are still obtainable, the condition is certainly one of cord lesion ; a comparison of the physical features found on examination with the INJURIES OF THE SPINAL COLUMN 499 appropriate plates, will show the precise position of the lesion. If no reflexes are obtainable, we may be in doubt, especially for the first day or two, whether the cord or the cauda equina has been injured. In such a case the onset of irritative symptoms, "paraplegia dolorosa," would point to compression of tJie cauda equina. If, later on, some reflexes return, despite the persistence of the paralysis, it shows that the cord has, at any rate, participated in the injury. If the reflexes are persistently absent, the onset of the reaction of degeneration in all the paralysed muscles, strongly suggests contusion of the cauda equina, whereas the persistence of electrical irritability in some of the paralysed muscles would indicate that the cord is also injured. Subsidence of the paralysis and a simultaneous return of the reflexes naturally also occurs in contusion of the cauda equina. The position of tlie injury in tlie spinal column is obviously of significance. If it can be shown that it is situated above the first lumbar vertebra, it is con- clusive of injury to the cord; if the injured vertebra is much lower down, it is equally conclusive of injury to the cauda equina. But it is very often impossible to tell which is the injured vertebra, or the indications are too indefinite to be relied upon. A young man, who was hurt in a motor-car accident, sustained, among other injuries, a contusion in the sacral region. He exhibited for a few weeks nervous disturbances, which, from his description, appeared to be due to a lesion of the cauda equina. Examination, however, showed that the only trace of his accident consisted of great increase of the tendon reflexes, especially on one side. This was conclusive of injury to the cord. Many types of paralysis have been described in connection with the lumbo-sacral cord, as for the cervical cord — almost as many types as segments. It is quite unnecessary to enumerate them, because they can all be inferred by co-relating the motor and sensory nerve areas as depicted in the plates. They are not so striking to the observer as the types of cervical cord injury, recognized by the peculiar postures of the extremities. (C) RELATIONS BETWEEN THE INJURY TO THE CORD AND THE VERTEBRy^. Just as clinical examination and skiagraphy often enable us to diagnose the level of a lesion in the cord, so, on the other hand, are we able, in some cases, to diagnose the segment affected by the displaced vertebra. A few anatomical data are necessary for this. We begin with the cervical vertebra'. The cervical cord has eight segments, and as the first dorsal segment lies behind the last cervical vertebra, if follows that the seven cervical vertebrae correspond to nine segments. The segment in the middle of the cervical cord must be one higher in number than the corresponding vertebra. At the end of the cervical vertebrae, the number of the segment is one and a half to tvv'o higher ; thus behind the 6th vertebra, we have, not the 6th 500 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN Fig. 2i6. — Dislocation-compression-fracture in the dislocated position. (From a post-nioriein pre- paration). Tlie 7th cervical vertebra is compressed, and the 6th is displaced slightly forwards. The 5th vertebral spine overrides the 6th. The articular processes of the 6th and 7th are not interlocked, but their extremities are in contact with each other. Wfft*^ Fig. 217.— Complete bilateral dislocation between the 2nd and 3rd lumbar vertebra;. Interlocking of the articular processes a and b. Indication of an oblique fracture at the anterior border of the 3rd lumbar vertebra. (From z. post-mortem preparation.) segment, but the yth and a portion of the 8th, and be- hind the 8th vertebra there are the remainder of the 8th and the whole of the ist dorsal segment. In the dorsal vertebra', eleven segments (2-12) are divided between the first ten vertebrae. In the upper of these vertebras the number of the segment is one higher than that of the correspond- ing vertebra, whereas in the lower vertebrae the difference is two. Thus the 3rd seg- ment lies behind the 2nd dorsal vertebra, while the 12th segment is mainly be- hind the loth vertebra. The whole of the linuhar and sacral segments lie be- hind the nth and 12th dorsal and the ist lumbar ver- tebrae. It is not practicable to sep- arate these seg- ments anatomic- ally. We may, however, say that the upper edge of the 12th dorsal vertebra corre- sponds to the 2nd lumbar seg- ment, and that the upper edge of the ist lumbar ver- tebra corresponds to the 5th lumbar segment. If we apply on the basis of these INJURIES OF THE SPINAL COLUMN 501 statements and the table in fig. 215, the existing nerve disturbances to the indirect diagnosis of the injured vertebra, we must remember that the cord is not contused by the anteriorly displaced vertebra, but by the upper edge of the one immediately below (fig. 217). Sometimes the cord is contused by a small piece of the upper displaced vertebra, resting on the posterior edge of the vertebra below (fig. 220). In cases of compression-fracture the cord may be damaged by a fragment of the vertebral body, forced into the spinal canal. If we wish to verify the diagnosis based upon the nerve symptoms and obtain a direct detennination of the displaced or injured vertebra, we must be careful to move the patient with the very greatest caution. Anticipating what will be said later, we will observe here only that the spine of a vertebra displaced forwards, either by dislocation or by fracture - dislocation, is depressed, and generally turned somew^hat upwards, and that it, therefore, limits anteriorly the gap found in the row of spinous pro- cesses. If, on the other hand, one in- dividual vertebra is compressed, its spine projects somewhat backwards as the summit of a more or less pronounced angular kink in the spinal column. If several vertebras are compressed, their spines will form a round curvature. (D) THE FORM OF THE SPINAL INJURY. It is of therapeutic and prognostic importance to recognize the form of the spinal injury. If this is not elucidated by a skiagram, w^e must depend upon the indirect evidence furnished by the spinal cord injury, or by the signs found in the spinal column. We may distinguish, in accordance with old custom, between Fig. 218. — Compression-fracture of 2nd lumbar vertebra. The vertebra lower than the adjoining ones. Intervertebral disc narrower than normal. 502 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN dislocations and fractures, at any rate on paper. The dislocations are either unilateral (rotation-dislocation), or bilateral (total dislocation). Thev are incomplete when the articular processes override each other (fig. 216) and complete when the particular processes are interlocked (fig. 217). Fractures conctvn either the arch and processes only, or the body itself. The latter, which claim our main interest here, are either compression-fractures (figs. 216, 219, 221), or oblique fractures, i.e., fractures which traverse the body of the vertebra obliquely, from Fig. 219. — Oblique fracture-dislocation. (From a pust-viortem preparation.) Fig. 220. — Compression-fracture-dislocation, with dis placement of upper section, backwards. {Post-moriet. preparation.) above and behhid to below and forwards. These oblique fractures sometimes involve two neighbouring vertebrce. It is only rarely that the line of an oblique fracture ascends from one side to the other. There are finally some fractures, intermediate between oblique fractures and compression fractures, in that the wedge-shaped fragments exhibit signs of shattering by pressure, in addition to their wedge-like form. The right to distinguish between oblique and com-' pression fractures follows from the different ways in which the two INJURIES OF THE SPINAL COLUMN 5^3 injuries occur. In compression-fracture the force acts in the axis of the spinal column ; in oblique fractures it acts more or less vertically to it. The more these two forces co-operate the more mixed is the type of the fracture. The more the force acts perpendicularly to the spinal column, the more displacement takes place between the two vertebrae, and the final effect of the injury is to resemble a dislocation. If the displacement has produced complete dislocation we describe it as a total dislocation fracture, which may be either an oblique fracture dislocation, or a compression-fracture dislocation, according to the degree and form of the shattering. How much can we recognize clinically of all this ? The main question which concerns the future of the patient is this : Is he suffering from an injury without displacement and therefore generally without severe contusion of the cord, or from an injury with displacement and therefore with more or less severe contusion thereof ? Compression- FlG. 221. — Compression-fracture ot the lower dorsal vertebrae (X). Very slight cord symptoms. Simultaneous localized compression-fracture of 3rd dorsal vertebra and transverse fracture of the sternum. fractures and fractures of the arch belong to the first group, total dislocations and total dislocation-fractures in their various forms belong to the second group — injuries which we may class together as total displacements. (1) Fractures of the Spinous and Transverse Processes. Fracture of a spinous process is caused by a direct localized force, and the objective signs consist of a circumscribed persistent pain on pressure over the spinous process, striking preternatural mobility thereof, and the subsequent onset of ecchymosis. As a rule, however. 504 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN a positive diagnosis can only be made from a skiagram, taken from the side. It is more difficult to recognize fracture of a transverse process. This injury may result from direct violence or from muscular action. It may be suspected from the presence of a persistent and pronounced pain on one side, on lateral flexion of the spinal column, and from pain on pressure on one side, while the corresponding spinous process is not painful. A positive diagnosis can only be made after an X-ray examination. This injury is practically confined to the lumbar vertebrae, and often causes prolonged discomfort. The actual pain may not be very great, but it suffices to incapacitate people from employment for many months, especially when there is no ardent zeal for work. Fracture of a transverse process in the neck is directly combined with fracture of the articular process. The mechanism of rotation- dislocation usually comes into play, but the interlocking of the articular processes is prevented by the fracture of one of them, so that the position of rotation is not fully developed. Under these circumstances the diagnosis is very difficult. The symptoms are too severe for a simple sprain, and insufficiently distinct for a unilateral dislocation. The differential diagnosis is only possible by X-ray examination. We thus see that opportunities for wrong diagnoses are very abundant, unless X-ray examination is employed, especially when the ■patients are workmen insured against accidents. Formerly, if the symptoms did not coincide with the physical signs, some observers called the patient a malingerer, others of a more kindly disposition called him the subject of a " traumatic neurosis." But it has become evident that pure malingering is rare, and that the term traumatic neurosis ought not to be applied unless the accident has produced serious results, accompanied by psychical damage. The view now taken of the cases where there is no anatomical injur}^, is that it is neither a matter of malingering nor of traumatic neurosis, but rather of — often unconscious — exaggeration. This is a much more probable view, and, psychologically more intelligible. The main point, however, is that the patients must be thoroughly examined, and if the skiagram is doubtful, additional pictures must be taken in various positions until the case becomes clear. (2) Fracture of the Vertebral Arch. If there are no spinal cord symptoms, there is every probability that the arch only has been fractured, but it does not necessarily exclude fracture of the spinous process. In the presence of cord symptoms we should think of fracture of an arch, if the spinal column has not lost its supporting power, and if axial pressure is only slightly. INJURIES OF THE SPINAL COLUMN 505 or not at all painful, and when these symptoms are combined with a severe pain on pressure over one spinous process, possibly with some anterior displacement thereof, and moreover if there is also a local Inematoma and the injury has been direct and narrowly circumscribed. The early diagnosis of fracture of the arch is important from the point of view of treatment. It is the only form of fracture in which, when complicated by damage to the cord, early operation is clearly indicated — the elevation or removal of the depressed arch — and in which very good results are obtained. (3) Compression-fracture. This is suggested when the cord symptoms are slight, or quite absent, when the spinal column loses its hold, either incompletely or not at all, but when — in contrast to fracture of the arch — there is very pronounced pain on axial pressure. Caution is required in applying this test. The injury is usually in the nature of a blow in the long axis of the body, being produced by a fall from a height on the head or the feet, or on the buttocks. The bodies of the vertebrae, which are chiefly composed of spongy bone, yield more readily to these blows than the arches and the articular processes, which are mainly composed of compact bone. The crushing of one vertebral body causes the spine to bend forwards in an angular manner, but when several vertebral bodies are involved, as is usually the case, the bend- ing is more like a kyphosis. When only one vertebra is compressed, the curvature may be limited to a slight prominence of the spinous process of the affected vertebra, and a hardly perceptible angular kink in the spinal column, whereas if several vertebrae are crushed there is always a round curvature (fig. 219). Sometimes one has to search carefully for the symptoms, for the fracture may easily be overlooked in the absence of cord symptoms, especially if our attention is diverted to other injuries besides those of the spine, or if the patient walks about again soon after the accident. A young man was brought into the hospital with a compound fracture of the skull and a fracture of the leg after falling from a scaffolding on to his head. As there w^ere no suspicious symptoms, the spinal column was not specially examined, but as soon as the patient left his bed and put his w^eight on his spinal column, he began to complain of pains in his back. As a matter of fact there was a slight kink at the level of the fourth dorsal vertebra, with local pain on pressure, which must have been due to compression-fracture. These compression-fractures are most frequently found in the dorsal and lumbar vertebrae. When situated in the upper dorsal vertebrae, our attention is often directed thereto by a transverse fracinre in the upper portion 0/ the steniitni. Slight compression-fracture in the lumbar vertebrae does not 506 SURGICAL DISEASES OF THE PELVIS AND SPIXAL COLUMN usually cause any visible kink or protuberance. The change of form is just sufficient to straighten out the normal lordosis of the lumbar spine. It frequently happens that vertebrje which have been damaged by a compression-fracture undergo secondary absorption of bone, and then give way after long delay, so that a protuberance appears months after the accident — possibly also with nervous symptoms. This is known as Kiimmel's disease, and is also, inappropriately, termed traumatic spondylitis. Axial contusion of the spinal column represents the slightest degree of damage by a blow in its long axis, the intervertebral discs being especially damaged. We may diagnose this condition when, after such an injury, there is pain on axial pressure, but neither any change in shape nor cord lesion, (4) Complete Dislocation. Complete dislocation may be diagnosed when a severe or complete cord lesion exists, and when the spinal column has completely lost its supporting power. The latter symptom is not always present in com- plete dislocation in the cervical spine, because the ligaments may retain some supporting power. The cord lesion is much less severe in these cases than in fracture-dislocation. A very powerful trauma is required to cause a complete displace- ment, and it must, at any rate partially, be of the character of an over- bending. The diagnosis must be based, as in compression-fractures, on the presence of change in shape of the spinal column, apart from the chief symptoms previously mentioned. But the nature of the injury is such that the dislocation may rectify itself spontaneously by appropriate posture, and on examination it may not be possible to discover anything beyond a spinous process which is painful on pressure and is depressed. The absence of any striking change in form does not, therefore, exclude a complete displacement as long as indirect symptoms thereof exist. In the cases wherein the change in shape persists, we find an increased interval between two spinous pro- cesses. The spine, which limits the gap above, is depressed forwards, in consequence of the displacement of the vertebral body, with which it is connected. If two vertebrae are broken, this gap is found between the spines of these two vertebrae, and here also the lower spine is the more prominent. An exception to this condition occurs in the rare cases when the upper vertebra is displaced backwards instead of forwards (fig. 220). It would be too much to expect any further details in diagnosis, and to decide between the various forms of complete displacement, in the living patient. Besides, it is quite impossible to distinguish oblique fracture-dislocations from dislocation-compression-fractures. Indeed, SURGERY OF XOX-TRAUMATIC DISEASES OF THE SPINAL CORD 507 the matter has no practical significance. It is more important to be able to distinguish between complete dislocation and dislocation- fracture in the cervical spine, because the former is capable of being correctly reduced, and the reduction should be carried out. Complete dislocation without interlocking of the articular processes, is in no way distinguishable from dislocation-fracture, because in the latter case also, the kinking and displacement may be rectified by appropriate posture (spontaneous reduction). It is quite different, however, if complete dislocation is combined with interlocking. Whether the head is bent forwards or backwards it is always anteriorly displaced in relation to the back, and there is no tendency for it to return to its normal position, either spontaneously or by appropriate posture. This immovability and the freedom of the cord should always suggest a complete dislocation rather than a dislocation-fracture, and we should therefore attempt reduction. A skiagram furnishes conclusive evidence. Complete dislocations, pure and simple, have been observed in the upper dorsal vertebrae, but they resemble dislocation-fractures in every respect, and it is quite impossible to effect any reduction, as in the case of dislocations in the neck. CHAPTER LXXVII. THE SURGERY OF NON-TRAUMATIC DISEASES OF THE SPINAL CORD. The recently qualified practitioner, during the first few years of practice, usually endeavours to classify the spinal cord diseases which he sees under one of the schemes he learnt as a student. But as their memory begins to fade and the more he realizes his thera- peutic helplessness the simpler become his diagnoses, and he finally limits himself to such groups as tabes, syphiHs, paralysis due to spinal caries, infantile paralysis, and " obscure diseases of the spinal cord." The patient suffers no great harm from this process of simplification, unless his case happens to be one which surgery can cure, or, at any rate, relieve. This applies especially to tumours within the spinal canal. Not all the tumours which damage the spinal cord possess equal interest for us. If an obstinate sciatica or an intercostal neuralgia 33 508 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN comes on a few years after an apparently successful operation of cancer of the breast, it is easy to diagnose a secondary growth in a vertebra ; but, unfortunately, the therapeutic interest is ////. If a period of unexplained neuralgia is followed by the appearance of a tumour on the surface of the spinal column, and if the spine kinks simultaneously with the sudden onset of a paraplegia, there is no difficulty in diagnosing a primary malignant growth, but the therapeutic significance is no greater than in the case of a secondary growth. But, in addition to these very frequent incidents, tumours which are accessible to operative treatment occasionally occur. Such are the innocent tumours of the spinal colmnii, which grow into the spinal canal, especially osteornata, fibromata, and choiidroinnfa and hydatid cysts, and also new groivths and in/iaiiinintorv granulation tnuionrs of the spinal cord and its coverings. Root symptoms, most of a sensory character, appear first as a rule ; i.e., localized unilateral neuralgias, hyperaisthesia, and, finally, anaes- thesia or, at any rate, hypo-aesthesia. Motor symptoms very rarely appear first. It is only in cases of tumour of the cauda equina that the root symptoms are from the first symmetrical and both sensory and motor in character. It is obvious that these root symptoms do not exist, or at least are not pronounced, if the position of the tumour does not encroach upon the roots. Pressure upon the spinal cord itself begins after a certain time, varying with the growth of the tumour. The result of this pressure is more or less loss of the conducting power of the cord. If the tumour has a lateral situation the symptoms are essentially those of Brown-Sequard's paralysis. Otherwise, the only difficulty in determining the exact relation of the tumour to the spinal cord or the extent to which it has pene- trated, is due to the fact that not only must one take into considera- tion the anatomical position of the growth but also the susceptibility of the individual nerve-tracts to pressure. The following questions present themselves as the suspicion of a spinal cord tumour arises : — • (1) Is a Tumour Actually Present? (a) We may begin with the stage of root symptoms. One should think first of tabes in the differential diagnosis from the common spinal cord diseases ; but this condition is easily recognized by its characteristic symptoms, especially by the loss of the knee-jerks. In tumour of the cord these are increased. Then it is important to decide whether the symptoms may not be due to an early spinal caries or a rare hypertrophic pachymeningitis ; but the symptoms SURGERY OF NON-TRAUMATIC DISEASES OF THE SPINAL CORD 509 are usually bilateral in these conditions, whereas, in cases of tumour, they are always unilateral at first. They are also much less severe in pachymeningitis than in tumour. It is more difficult to exclude a commencing spinal caries ; indeed, it is quite impossible to make a differentiation as long as the symptoms are unilateral and no change in the spine can be detected either clinically or by X-rays, and the patient himself is not tubercular nor possesses hereditary disposition thereto. The greater frequency of herpes zoster in cases of tumour furnishes only a very indefinite indication, and nothing but the con- tinued progress of the case can elucidate it. In spinal caries the root symptoms either become bilateral in the course of a few months or the cord symptoms subside, but in cases of innocent tumour the root symptoms may remain unilateral for years without any other essential changes occurring. The appearance of spinal column symptoms, viz., pain on pres- sure, prominence of a spinous process and pain on axial pressure, disposes of the posssibility of spinal cord disease and pachymeningitis, as well as of tumour of the spinal canal. The diagnosis must then lie between spinal caries and sarcoma of the spinal column ; but the differentiation is sometimes impossible. The fact of the much greater frequency of spinal caries, however, justifies the practitioner in diagnosing that condition. If the case is not eventually cleared up by the appearance of a burrowing abscess on one side or the other, or by metastatic growths, then we may follow Berard in decid- ing upon the possibility of a tumour if confinement to bed and weight extension produce no improvement. A skiagram should also be taken. {h) If the patient has paraplegia without any deformity in the spinal column we should not, even then, entirely exclude spinal caries, although this would be a very rare event. The case is more likely to be chronic myelitis, or multiple sclerosis, and if the lesion is in the cervical cord, hypertrophic pachymeningitis. If a neuralgic stage preceded the paraplegia, or if radiating pains persist, we may exclude myelitis and multiple sclerosis. If the paraplegia was not preceded by pain, the diagnosis may be in doubt, or exploratory operation may be indicated, for cases of spinal cord tumour occur wherein sensorv root symptoms are completely absent. (c) If root and cord syniptonis have occnrred siinnltaneonslv iviili deformity in the spinal column the diagnosis lies exclusively between spinal caries and malignant growth. If a burrowing abscess be present, it decides the matter, but sometimes a hydatid cyst which has reached the surface has been mistaken for such an abscess. In the absence of all objective indications, we must rely upon the history, and if the symptoms have existed for years we must attribute 5IO SURGICAL DISEASES OE THE PELVIS AND SPINAL COLUMN them to spinal caries ; if their course has been rapid and does not extend beyond months, they must be attributed to a sarcoma. Very vascular sarcomata are sometimes recognizable by loud murmurs. (2) What is the Nature of the Tumour? The remarks already made in connection with tumours of the brain apply also to solid tuberculomata and gummata of the cord. The history should guide us, but not control us. Solitary tubercles may exist in the spinal cord, exhibiting all the symptoms of tumour. They may be shelled out like tumours — an operation which has been attended by good results. In a neighbourhood where the echinococcus is endemic, we should think of the possibility of hydatids, and our diagnosis would be confirmed if the patient presented any other localization of this disease. Symptoms which have persisted for years, without causing any appreciable change in the spinal column, suggest a more or less innocent tumour of the spinal canal, especially of the spinal meninges. Schlesinger holds that a tumour which has persisted for more than three years is generally intradural and solitary, and therefore appropriate for operation. The more localized the symptoms, the more hopeful is the prognosis. This is of course very unfavourable in the case of the more widespread symptoms caused by sarcoma of the spinal cord itself. Operation has often revealed, instead of the expected tumour, localized encapsuled collections of serous fluid which might probably have been removed by simple puncture if the diagnosis had been possible (Krause, Oppenheim, Nonne, &c.). (3) At Which Level is the Tumour Situated? The accurate diagnosis of the level is an indispensable precedent of operation. Reference should be made to the remarks in con- nection with spinal cord injuries, and it is only necessary to add here that in practice the level which is diagnosed is usually too low. One should always fix upon the highest possible root which may be involved ; but this may often be too low, and it will be necessary to search higher up at the operation. INFLAMMATORY DISEASES OF THE SPIXAL COLUMN 5 II CHAPTER LXXVIII. INFLAMMATORY DISEASES OF THE SPINAL COLUMN. .J.— TUBERCULAR CARIES. Tubercular caries is so much more frequent than any other form of inflammatory disease of the spine that, as far as the practitioner is concerned, it may be considered as the only important one. Diffi- cuhy in diagnosis only exists before the appearance of the charac- teristic symptom — sinking in of the diseased vertebra and the resulting deformity of the spine, the so-called Pott's curvature. For purposes of diagnosis the disease is divided into several classes : — (I) TUBERCULAR CARIES WITHOUT DEFINITE CURVA- TURE, AND WITHOUT A BURROWING ABSCESS. This occurs more frequently in adults than in children, because the diseased vertebra soon softens in children, and the curvature develops early in a pronounced form. Nevertheless, a careful mother often seeks advice before the disease has reached the stage of deformity. The history and the method of examination varies with the age of the patient. {a) If an infant is brought with the complaint that its entire behaviour has changed, that it is in marked distress, that it has become helpless, that it avoids any rapid movement of the body, that it cries even if lilted out of bed, although the mother is sure of not having hurt it, we should at once think of spinal disease. There is probably nothing to be seen on the back. i\t most, there may be a httle rigidity, combined, perhaps, with some scarcely perceptible diffuse kyphosis, or at least with loss of the normal lumbar lordosis. A similar kyphosis is seen in rickets, but the spine remains movable in that disease, and the back at once makes a concave bend, if we swing the child, with its abdomen downwards, by its four extremities, as remarked by Hoffa. In spinal disease the vertebral column remains rigid, even in this posture, owing to the muscular fixation. We might also be misled by Barlow's disease (scurvy-rickets) due to improper feeding. In this condition the child is also helpless, and cries when moved; but the pain is situated in the legs, and not in the back. Swelling and bluish-red discoloration of the gums in the vicinity of the erupted teeth indicate the nature of the disease. (b) If the child already walks, we will be struck by the fact that it no longer plays with other children, and that it has difficulty in going up, and especially down, stairs. 512 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN On the other hand, children are sometimes seen with definite curvature, but without any subjective disturbances. This means that the acute process is over, that cicatrization and consohdation, which take place much earlier in children than in adults, have already occurred. Fig. 222. — Early stage of spinal caries. Fig. 223. — Same case, seen in proSle. On examination, we are struck by the rigidity with which the spine is held, and by the way in which the child carefully avoids any movement of bending, over-straining, or rotating the spine. If the child is told to look round, he turns the whole body. If he has to INPM.AMMATORY DISEASES OF THE SPINAL COLUMN 513 Fig. 224. — Early stage of caries in cervical spine. At X, edge of vertebral body eaten away. (From living subject. ) get np from the floor, ne behaves Hke a child with progressive muscu- lar atrophy, i.e., he sup- ports the hands on the knees. If we palpate the vertebral column, pressing on each spi- nous process separately, we shall be able to elicit pain at one delinite spot. This also occurs if we press upon the spinal column in its long axis, obviously with care. If on re- peated examination we are able to elicit this double form of sensitiveness to pressure, we are justified in assuming that caries has started — although it may be difficult to make the par- ents understand that some 1 bone has already been eaten away, notwithstand- ing the striking mildness of the symptoms. It is necessary forthwith to explain the significance of the disease, otherwise it is impossible to secure the requisite careful treat- ment, and the patience which is demanded for it. (c) The previous his- tory will be somewhat ■ more ample in the case of older ehihlren and adults. We are, however, liable to be misled in these cases unless we have the possibility of spinal caries in view. Sometimes the patient localizes his pains to the umbilicus. More frequently we are ZtlX' X XI XE ZI Fig. 225. — Bending of spine due to caries. Greater part of nth and 12th vertebral bodies destroyed. {Post- mortem preparation.) 5H SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN consulted for sciatica, indefinite, abdominal, or lumbar pains, inter- costal neuralgia, "rheumatic" pains in the arms or back of the head. As long as these pains are unilateral, the diagnosis is often very difficult. But they almost always become bilateral after a few months, thus pointing definitely to disease of the spinal column. As previously stated, pain in the back on going down stairs, or knocking up against a stone on a level road, is quite pathognomonic. An elderlv, apparently vigorous, man became paraplegic without any apparent cause. On examination, the legs were found to be r ^.-. •V? Fig. 225. — Caries of cervical spine {5th and 6th vertebrae). Head displaced somewhat forwards. Neck abnormally wide in profile. Fig. 227.— Abscess of neck due to caries. paralysed, and the bladder distended to the umbilicus. The shape of the spinal column showed nothing special, and the excellence of the general condition did not suggest any tubercular disease. The key to the condition was found in the patient's statement that he had felt for some weeks increasing pain in the back when walking about, when bending his spine, and especially when going downstairs. In such a case the question of a primary or a secondary new growth might also arise. The occurrence of verv severe pain in the lower extremities, on any head movement, is very significant of commencing tubercle in the cervical spine. IXFLA^niATOKV DISEASES OF THE SPIXAL COLUMX 3^0 The patient must be undressed for examniation, and must stand with his knees close together, and be directed to bend his back forwards and backwards. If tlie movement is but slow and imperfect, and limited to the hip and knee joints, it must excite very grave suspicion, especially if the attempt to bend the spine backwards is a failure, and causes the patient to groan. There can be no doubt about the diagnosis if, in addition, pain on. axial pressure is present. This latter test mu.->t be done verv carefullv, especiallv if the disease is in the cervical spine. We should not take the risk of making a patient paraplegic, or breaking off the odontoid process of the axis, \n order to establish the diagnosis. On pressing upon each separate spinous process, the detection of the diseased vertebra usuallv becomes very easy. Careful palpation and inspection of the patient in profile may probably reveal, even at this stage, some slight projection bevond the adjoining spinous pro- cesses (fig. 223), if this is not already evident from behind (fig. 222). In caries of the cervical spine there will also be some rigidity, and often some slight displacement of the head forwards (widening of the neck m profile) before any definite curvature is evident (fig. 226). The cases wherein these primary symptoms of pain on axial pressure and local tenderness are absent are more difficult to diagnose. A vigorous young girl, aged 20, the picture of health, began to complain of lumbar pains, and wandered therewith from one hospital to another. The brother was tubercular. Caries was thought of, but the most careful examination failed to substantiate this view. The diagnosis remained in suspense until a burrowing abscess con- firmed the suspicion. Even then there were no appreciable symptoms in the spinal column. The patient died from amyloid disease two years later. Fig. 225 is the skiagram of the preparation, and it shows ver}^ clearh" the process of the formation of the curvature. The skiagram does not alwavs, however, show anvthing conclusive in the early stage of cases of this kind. (2) SPINAL CARIES WITH BURROWING ABSCESS. In every case of spinal caries we must look for that common accompaniment of all tubercle of bone— a cold abscess — which is termed a burrowing abscess, because of its usual course. Its im- portance for diagnosis and treatment is evident from the fact that it is present in at least one-fourth of the cases — according to other statistics, one half. There are cases wherein a burrowing abscess is the first, and for a long time the only appreciable sign of spinal caries. Before we discuss its diagnosis, we will briefly refer to its anatomical relations,. In caries of the upper cervical spine it is found in the posterior pharyngeal wall, or, more frequently, at the side of the neck, in front of or behind the sterno-mastoid. Exceptionallv it may run under 5l6 SURGICAL DISEASES OF THE PELVIS AXD SPINAL COLUMN the clavicle towards the axilla. If the caries affects the loiver cervical spine, and the abscess originates in the transverse process or the vertebral arch, it mav also run under the muscles of the back, but as a rule it tracks along the oesophagus, penetrates the thorax, and behaves like abscesses which are derived from the dorsal vertebra;. The latter reach the surface between the twelfth rib and the ilium, or they dive down deeply, following the large vessels over the ileo- psoas muscle as far as Poupart's ligament, and eventually burst somewhere through the muscles and reach the surface. If, in lumbar caries, the diseased focus is in the body of the vertebra, the abscess burrows in front of the spine, in the sheath of the psoa:^, travelling downwards either over or under Poupart's ligament, to appear in the inguinal region or in the anterior femoral Fig. 228. — Caries of 4ih lumbar vertebra, with bilnteral inguinal burrowing abscess. Fig. 229. — Commencing abscess in tubercle of left sacro-iliac joint. triangle. The abscess appeared in the former position in the case illustrated in fig. 228. Despite the two burrowing abscesses, there was neither curvature nor definite disturbance of function at first ; nothing but slight tenderness on pressure over one spinous process. The skiagram showed clearly that the fourth lumbar vertebra was affected. More rarely the abscesses follow the hypogastric artery and the sciatic nerve, traverse the great sciatic foramen, run under the gluteal muscles, and sometimes from there proceed to the posterior surface of the thigh. If the focus of disease is situated in the lateral portions or in ilie vertebral arcJi, the abscess appears on the back. INFLAMMATORY DISEASES OF THE SPINAL COLUMN 517 The same applies to foci of disease which are situated posteriorly in cases of tuberculosis of the sacrum, or of the sacro-iliac Joint. But if the disease is situated on the anterior surface of this joint, the pus gains access to the sheath of the iliacus muscle, fills the side of the pelvis, and may burrow thence under Poupart's ligament into the thigh (fig. 230, so-called iliac abscess). It is then situated either at the side of, or beneath the sartorius. If the focus of the disease is more deeply situated, the abscess burrows towards the perinaeum and makes its appearance there as a peri-rectal abscess. If we have already ascertained the correct diagnosis by means of signs in the vertebral column, there is no difficulty in under- standing the significance of a burrowing abscess. But if this is the first symptom which the patient notices, and for which. he consults the doctor, many errors of diagnosis are possible, as already mentioned in detail, unless a careful examination is made. We may summarize these once again for the purpose of taking a rapid view of the position. In the iicck one might think of a deep lipoma, a deep branchial- cleft cyst, or of an oesophageal diverticulum. Burrowing abscesses have even been mistaken for goitres. In the tlionix one should think especially of lipoma, cold abscess originating in the rib, or a pleural effusion which has spontaneously broken through. In the lumbar region one should think of lipoma, lumbar hernia, caries of the ribs or pelvis, and also of the possibility of a tubercular perinephritis, which has burst through posteriorly. The urine must, therefore, be examined in every case of lumbar abscess. An abscess of the pelvic fossa may, if on the right, be mistaken for an ileo-ca?cal tumour; if on both sides, for caries of the pelvis or chronic pelvic osteo-myelitis, or even for pelvic tumours. The correct diagnosis depends upon the accurate observation of the superior connections of the swelling. Very frequently flexion of the hip-joint is produced, and thus spinal caries may be mistaken for hip disease. The pelvic cavity must, therefore, be examined as thoroughly in what is apparently hip disease as in spinal caries. Abscesses of the pelvic fossa, as we have already seen, consist of iliac and psoas abscesses. When there is extensive suppura- tion, it is not possible to draw a sharp distinction between the two forms, nor is it important to do so. The occurrence of clinically primary suppuration in the psoas muscle is exceedingly rare, and then it is generally to be attributed to some trauma. This condi- tion might justify the popular old term "psoas abscess" as a separate disease. Inguinal abscesses have been mistaken for inguinal hernia and hydrocele of the canal, especiallv in women. But these abscesses are situated more towards the side, and have a wide connection with the pelvic bone by broad processes, so that this mistake should be avoided ; the veiy rare bilocular hydroceles may, however, still give rise to ditficultv. 5i« SURGICAL DISEASES OF THE PELVIS AND SPIXAL COLUMX Abscesses of tJie fJiigJi may be mistaken for femoral herniae, if situated in the middle line immediately under Poupart's ligament ; if towards the side, for an enlargement of the sub-iliac bursa. If the pus can be displaced at all, it goes back gradually, a hernia goes back with a jerk. If it is not displaceable — this is the rule — its consis- tence is generally elastic or fluctuating, which, of course, excludes a r Fig. 230. — Burrowing abscess in the iliac fossa in a case of sacro-iliac tuberculosis. Fig. 231. — Caries of the dorsal spine with a transversely divided burrowing abscess sac. hernia. An enlarged bursa is i"ecognized by its deep situation under the iliacus, whereas an abscess, even if it descends Avithin the sheatli of the muscle, always has a tendency to reach the surface. Manv burrowing abscesses are distinguished by possessing a subdivided sac (fig. 231). If the femoral abscess is situated lower down, it ma\- INFLAMMATORY DISEASES OF THE SPINAL COLUMN 519 be mistaken for sarcoma of the femur, or of the adductor muscles. The flexion of the hip-joint may sometimes suggest hip chsease. Unless the hip-joint is itself secondarily affected with tubercle, a burrowing abscess due to spinal caries only prevents extension, whereas in true hip disease abduction and rotation are especially limited. In perineal abscesses the diagnosis has to be made from dermoids and the various forms of peri-proclitis. The most likely diagnosis in the rare cases of gluteal burrowing abscesses is hip disease, which can only be excluded by a careful investigation of the spinal column and the hip-joint. The origin of doubtful cases of suppurating tistulae is best ascer- tained by means of a skiagram, after they have been injected. The most useful preparation for this purpose is one composed of vaseline with 20 per cent, of zircon oxide, a modification of Beck's methods, as bis- mutli salts are not quite free from risk. (3) SPINAL CARIES WITH CURVATURE. Once the typical curvature is developed, a glance at the patient's back suffices for the diagnosis. It is usually very easy to avoid any confusion with spinal deformities due to other causes. As the kyphosis in spinal caries depends upon the destruction of one, or at most of two or three, vertebrae, it appears more or less in the form of an angular kink, the apex of which is formed by one spinous process. All other changes in the shape of the spinal column, except those which result from accidents, are not merely kinks but curves, because they concern several vertebrae. There should never be any confusion with scoliosis and kypho-scoliosis, because lateral curvature is so predominant in these, but is only very exceptionally present in tubercular disease. Even if a vertebra is diseased asymmetrically, as occurs occasionally, and therefore breaks down more on one side than on the other, there is no real scoliosis, but always an essentially anterior kink, a gibbus. In rachitic bending of the spine, the result is more fiequently pure or nearly pure kyphosis, and the deformity consists of a definite curve and not of kiiik. If a child, suspected of caries, is carefully suspended, by ail its limbs, with the abdomen downwards, the back will bend in rickets, but not in caries. (4) SPINAL CARIES WITH CORD SYMPTOMS. If a patient with spinal caries becomes affected with spastic para- plegia, it obviously indicates compression of the cord, but simple loss of power of gait is sometimes ascribed to the vertebral disease, although it is really the result of an early spastic paraparesis. We may even go further ; any definite increase in the tendon reflexes, in tlie parts supplied from below the lesion, must be regarded as a sign of commencing 520 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN pressure. Sometimes sv77//)/07/zs of pain predominate ; occipital neuralgia in " malum sub-occipitale," neuralgic pains in the arms in caries of the lower cervical vertebrae, crural neuralgia and sciatica when the lumbar spine is atfected — sometimes also in cervical caries. These symptoms point to compression of the roots and should prepare us for the rapid onset of cord symptoms, or compel us to try to avoid them by means of permanent extension. The absence of dislocation of a vertebra in no way negatives the diagnosis of damage to the cord, which is often involved in an actual extension of the disease to the membranes, and is not compressed by displacement of the vertebra. In such cases there is, of course, but little to be expected from extension treatment. In a case wherein all four extremities were completely paralysed, I found, at the posf-niorfcm, nothing but tubercular pachymeningitis of the cervical cord, and no displacement of vertebrae at all. 5.— NON-TUBERCULAR INFLAMMATION OF THE SPINAL COLUMN. We have, hitherto, been assuming that the spinal disease is of a tubercular nature, which, as a matter of fact, is true for the majority of cases. But there are various exceptions to the rule. Certain changes in the spine, for instance, follow injuries, and the significance of these has loomed large since the prevalence of insurance against accidents. An elderly man rolled down a small incline in his garden. He felt some pain in the lower portion of his cervical spine, but only kept his bed for a short time. Later on, his cervical spine began to bend forwards, and there developed a curvature which was something between an angular kink and a roundish kyphosis. There was no burrowdng abscess, no pyrexia, &c., and the vertebra which formed the apex of the curve was not tender on pressure. Did the patient suffer from tubercular caries of a traumatic nature, brought on by his fall ? It is possible, but experience shows that a similar clinical picture may develop without any tubercular change. The comparatively short period, during which pain w^as complamed of, is very unlike tubercle. It is much more likely that the patient sustained a compression-fracture of the spine, and that the damaged vertebral body gradually broke up and sunk in ; and we may be quite reassured as to the further progress of the case, even if a permanent protuberance remains on the back. The diagnosis may be very difficult in cases wherein the original trauma was slight, and the development of the curvature very slow, as previously mentioned (Chapter LXXVI). The cases in which the symptoms of pain persist for a long time also suggest spinal caries. INFLAMMATORY DISEASES OF THE SPINAL COLUMN 52 1 We either have to leave the diagnosis in doubt, or base it upon the presence or the absence of other tubercular manifestations, unless a skiagram or a burrowing abscess decides the matter. A kink or a bend is not always the most prominent result of an injury. In rare cases, rigidity of the spinal column is the chief symptom, which may be associated with an extensive but slight kyphosis of the major portion of the spine. Bechterew has described such a case, in which bony union of the vertebral bodies was found. The accompanying symptoms, due to the spinal cord and the nerve roots, should be distinctive of this condition. Another variety of vertebral disease may occasionally be confused with caries, namely ankylosis of the spine, better called arthritis deformans of tJie vertebral Joints. It manifests itself by gradual stiffen- ing of the spine, and by curvature. The disease has been especially described by Striimpell, and by Pierre Marie. This disease is characterized by the simultaneous ankylosing or deforming process in other joints, and is often the consequence of some infective malady. I have seen it in association with chronic ankylosing arthritis of the elbow, wrist, one knee and temporo- maxillary joint. Confusion with spinal caries is only likely to occur in the first stage of the disease, when the portion of vertebrae originally diseased — most frequently in the lumbar spine — is exceedingly painful. But the subsequent course of the disease, and particularly the involvement of various other joints, makes the diagnosis quite clear. Gummatous periostitis in tertiary syphilis, by destroying the affected vertebrae, may produce a clinical picture very similar to spinal caries. The diagnosis must be based on the history, or on Wassermann's test, and on the result of specific treatment. Finall}^, one should mention the rare occurrence of acute osteo- myelitis of the spine, and that metastatic inflammation of the spine that has been observed after acute infective diseases, such as pneumonia and especially typhoid fever. The course of these diseases depends upon the virulence of the organisms. It is the duty of the practitioner to detect abscess development as early as possible, but this does not, however, occur in all cases. 522 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN CHAPTER LXXIX. SPINAL CURVATURES. Orthop.-edics has, of late, become so much of a speciaHty, that not only the general practitioner but even the surgeon gladly leaves spinal curvature to this department. Expedient as this may be for therapeutics, because only an orthopaedic institute can possess all the mechanical apparatus for the treatment of scoliosis, it is not so as far as diagnosis is concerned. To detect the beginnings of scoliosis, nothing is required beyond an observant eye and a plumb line. Nevertheless the strictures applied by Albert years ago, in regard to overlooking scoliosis, are equally applicable to-day. Perhaps lady doctors would have the advantage in the diagnosis of this condition, because females possess a keener eye for deformity than males. It is for this reason that the mother first detects that the " child has one shoulder higher than another," or that " the back or hip sticks out." In considering the causes of spinal curvature, we must recollect, as Schulthesz has especially pointed out, that it is not a clinical and etiological entity, but is in most cases only a symptom. When the statics of the body are disturbed at any point, the spinal column provides for the restoration of the equilibrium. Shortening of one leg causes obliquity of the pelvis, and a corresponding scoliosis occurs to com- pensate for this disturbance (figs. 232 and 233). An abnormal in- clination of the pelvis, due to flexion of the hip, is compensated for by an increased lumbar lordosis. These are static curvatures, and are recognized by their disappearance as soon as the pelvis is restored to its natural posture (figs. 232 and 233). Temporary curvatures are often due to some painful condition, the best example of which is sciatica (fig. 234), a matter to which we shall again refer. In other cases the curvatures are due to disturbances in the supporting power of the muscles. Thus we find considerable lumbar lordosis in pro- gressive muscular atrophy (fig. 235) ; scoliosis in anterior polio- myelitis, in syringomyelia, and in Friedreich's disease (fig. 236). Diseases of the thoracic organs sometimes are at fault, as in the case of scoliosis which occurs in consequence of contraction after pleurisy, and especially after empyema. Heart disease with enlargement, by causing asymmetry of the thorax, may also lead to curvature of the spine. We should only look in the spinal column itself for the origin of the trouble, if we have excluded all these causes. Inflammatory diseases play their part among these spinal changes. Caries leads mainly to kyphosis, but occasionally produces a slight lateral curvature. SPINAL CURVATURES 523 Arthritis deformans of the lumbar spine may also cause lumbar kyphosis. Injuries may be responsible, for sometimes kyphosis is caused bv a compression-fracture. P'inally there is a group of cases in which the change in form is due to a congenital asyininetrical dcforniitv of the spine, such as a wedge- FiG. 232. — Lumbar scoliosis with con- vexity to the left, due to 4 cm. shortening of left leg. Fig. 233. — Same case, after compen- sating for the shortening. shaped outgrowth of a vertebra, with a supernumerary rib on the broad side, or fusion of two vertebrae on one side, with the absence of a rib on that side. If the cervico-dorsal portion is affected, the deformity manifests itself by one shoulder " standing out" (fig. 237). This congenital prominence of a shoulder may also be due to simple 34 524 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN muscular anomaly, or to a clasp-like bony communication between the scapula and the cervical spine. A skiagram is always required to elucidate these conditions. These deformities are mainly responsible for the so-called " numerical variations " of the spinal column, i.e., they interfere with the ordinary subdivision of vertebras and ribs into the separate segments (Dwight, Bohm). It still remains to indicate those forms of slight asymmetry which are responsible for ordinary scoliosis. Fig. 234. — Scoliosis due to sciatica. Fig. 235. — Progresfive muscular atrophy with lordosis. The further consideration of this subject comprises that which is usually understood by the term " airvatnres of the spine." These curvatures are (i) symmetrical or antero-posterior, (2) asvmmetrical or lateral. SPINAL CURVATURES 525 (1) ANTERO-POSTERIOR CURVATURES. These may either consist of an abnormal flatness, the bootmaker's type of spine, or of an increase in the normal curves, or, finally, of really abnormal curvatures. The increase of the normal curve in the lumbar region constitutes lordosis and in the back kyphosis. The mechanical and the nerve conditions already referred to are the principal causes, but rickets and osteomalacia should also be especially considered. Then there is the so-called " round back " which is Fig. 236. — Friedreich's ataxia with scoliosis. Fig. 237. — Congenital cervico-dorsal scoliosis with convexity to the right, and prominence of the shoulder, due to a symmetrical outgrowth of spine and ribs. iiereditary. Such abnormal curvatures as lumbar kyphosis usually depend upon rickets or osteomalacia. The diagnosis of these antero-posterior curvatures is easy. It only requires some slight appreciation of form, and we will therefore not dwell on it any longer. It is only necessary to remark that one must examine for lateral curvatui-e in all antero-posterior curvatures. Slight scoliosis with definite torsion is often concealed behind an ordinary round back. 526 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN (2j LATERAL CURVATURES. Lateral curvatures, or scoliosis, involve the practitioner in great responsibility, because they generally bring their own revenge for delayed treatment. The patient should stand for examination, completely nude, or at least undressed as far as below the hips ; the two feet must be held in the same posture, the arms must hang down loosely, and otherwise the whole attitude must be as unconstrained as possible. Then we look at him from the back, making an inspection from head to foot. We note whether the head is exactly over the mid-point of the feet, whether it is held obliquely or erect, whether the shoulders are at the same level, whether the scapulae are at equal distances from the spine and stand out equally from the thorax. Our eyes follow the line of the spinous processes, and we can at once detect, especially in thin subjects, whether the furrow between it and the transverse processes is equally developed on both sides, or whether it is somewhat obliterated on one side and deepened on the other. We compare the distance of the arms from the body, in other words the two triangles of the waist, i.e., the triangle formed by the arm with the outline of the body, and also the shape of the thorax, the position and shape of the hips, the level of the gluteal folds, and, finally, the shape and posture of the legs. Then the patient is directed to walk a few steps, in order to see whether he limps. After he has walked round the room, we tell him to resume his former position. This slight inter- ruption in the examination has the advantage of showing us whether the posture observed at first is really the normal posture of the patient. This is a precaution which should not be omitted even in slight cases of scoliosis which can easily be straightened out, and especially not in cases of complete scoliosis (figs. 241 and 242). We next proceed to a more careful examination of the spinal column. We drop a plumb line (fig. 238) from the seventh cervical spine, and note whether it falls midway between the buttocks, and lower down between the feet. We thus find to which side the thorax is displaced, and the extent of the displacement in relation to the pelvis, and also the distance by which the convexity of the curvature deviates from the plumb line (figs. 238 and 239). We then feel the spine and mark on the skin the position of each spinous process with a pencil. This also gives the opportunity of observing whether there is any tender- ness on pressure. We then proceed to test the movement of the spine, and we direct the patient to bend his back forwards, backwards, and to each side, with his knees close together. This examination, in the first place, will reveal any caries which may have been overlooked, for the movements are but slightly restricted and never painful in scoliosis, SPINAL CURVATURES 527 whereas caries may always be recognized by painfulness and the- limitation of movement by pain which bears no relation to deformit3\ But the examination of the back, when bending forward, teaches us something more. On inspecting the bent back from the nape of the neck downwards^ we may be struck with the fact that one side of the ^^ Fig. 238. — Rachitic, lumbar scoliosis with convexity to the lefr, and dis- placement of thorax to right, i.e., to the side of the concavity (through over- compensation). Fig. 239.— Dorsal scoliosis with convexity to left, and displacement of thorax to left, i.e., to the side of the convexity. thorax is higher than the other, that is to say, that there is protuberance of the ribs (figs. 243 and 245). This permits us to estimate the degree of torsion of the vertebrje, and the amount of the deformity. We can, however, usually detect the protuberance of the ribs when the patient is erect. Fig. 240. — Complete scoliosis with convexity to left, displacement of thorax to right. Right waist triangle enlarged. Right axillary fold shortened. Fig. 241. — Lumbar scoliosis with convexity to left, of very slight degree ; only recognizable by shape of waist triangle. Fig. 242. — Lumbar scoliosis of severe de- gree with convexity to the left, and dorsal scoliosis with convexity to the right. Despite an apparently slight curvature of the spine, the right waist triangle is deeply indented. Fig. 243. — Same case as fig. 242. Pro- nounced protuberance of ribs on right side, despite an apparently slight lateral curvature. Fig. 244. — Severe lumbo-dorsal scoliosis, with convexity to the left and compensatory dorsal set 1 Oils with convexity to the right. Fig. 245. — Same case as fig. 244. Lower protuberance of ribs to the left, upper pro- tuberance to the right. Fig. 246. — -Piimary dorsal scoliosis with convexity to the right. Mild case. Fig. 247. — Primary dorsal scoliosis, with con- vexity to right. Severe case. 530 SURGICAL DISEASES OF THE PELVIS AND SPIXAL COLUMX The inexperienced will, however, be astonished to see how pro- nounced it really may be, when the back, in the erect posture, appears to be fairly normal to the unpractised eye. Neither should we estimate the degree of change exclusively by the position of the spinous processes, because they always remain nearer to the middle line than the bodies of the vertebras. The deformity is always more noticable on the skeleton from a front view than from the back, and the vertebral spine may have undergone a pronounced lateral deviation before any marked displacement of the spinous processes can be detected. Fig. 248. — Primary dorsal scoliosis wilh convexity to the right. Very severe case. Fig. 249. — Primary dorsal scoliosis with convexity to the left. The examination of the functions of the spinal column indicates, fin.ally, the stage of the deformity. If all the movements are carried out symmetrically to the same extent, and if the deformity vanishes with the movements, or if it is only noticed occasionally, for instance when the muscles of the back are tired, the case is in an early stage, wherein no material changes in the spinal column have yet formed. Under appropriate treatment, this condition may be cured in a few weeks. If, however, the deformity is present in the same manner at every examination, but can be completely straightened out, actively by SPIXAL . CURVATURES 531 muscular exertion or passively by suspension, the case is one of iiiobile scoliosis (figs. 250 and 251). Immediate treatment promises good results even here. We must not be content, however, witln prescribing a tonic and giving general directions that the patient must not tire himself. We must either take the treatment in hand ourselves, energetically^and complicated apparatus may not be required in this stage — or we must send him to an orthopaedic institute. If the deformity can only be partially straightened out, it is in a. position of contracture; if it cannot be straightened out at all, the case is one of fixed scoliosis. Fig. 250. — Mobile complete scoliosis with con- vexity to the left. Muscles relaxed. Fig. 251. — Same case, with the muscles tense. We now have to consider tlie Jonii of the scoliosis. If the whole spine constitutes one carve, we speak of complete scoliosis, which is usually convex to the left. It is recognized by the fact that the waist triangle on the convex side is diminished with sharp angles above and below, whereas on the concave side the triangle is enlarged and more deeply indented (fig. 240). In early cases the back is usually displaced to the left in relation to the pelvis. In complete scoliosis the protuberance of the ribs is generally found on the concave side, i.e., towards the right, in contrast to the condition in partial scoliosis. 532 SURGICAL DISEASES OF THE PELVIS AND SPINAL COLUMN If the curvature is mainly localized in the lumbar region, we speak of hunbar or luinho-dorsal scoliosis. Here also the convexity is usually to the left (figs. 238, 240-245). The displacement of the back in relation to the pelvis is more pronounced than in the previous form, the waist triangle on the convex side is also diminished or filled out, the protuberance of the ribs is on the convex, i.e., the left side. In slight cases the shape of the w^aist triangle is the only indication of the curvature (tig. 241). This form has a great tendency to be followed, in the course of time, by a compensatory curvature of the dorsal vertebrae in the opposite direction, i.e. towards the right, and, of course, a second protuberance of the ribs develops on the right side. Fig. 245 illustrates this double protuberance of ribs in a severe case of dorsal scoliosis with the convexity to the right. This must be distinguished from primary scoliosis of the dorsal vertebrae, wherein the curvature has its convexity to the right (figs. 246-248), and which eventually becomes compensated by a lumbar scoliosis with its convexity to the left. The whole of the upper part of the body appears to be displaced to the right in relation to the pelvis. The right arm hangs free in the air, whereas the left is closely applied to the hip. The right scapula appears to project, because it is pushed forward by the protuberance of the ribs. On the other hand, the left scapula is reall}^ farther away from the body than the right one, because it lies over the flattened or retracted half of the thorax. Having correctlv ascertained the form of the curvature, our next task is to discover its cause. There is no difficulty in this if we are told by the mother that the child was late in walking and in talking, and that the teeth were late in appearing, and if we also find evidences of riclwts still persisting in the skeleton. We may also obtain some indications from the form of the rib protuberance, for if the ribs are bent close to the spine this points strongly to rickets. Some- times there are no indications of definite rickets, but other abnor- malities of the skeleton, such as flat-foot or knock-knee, show that the cause must be ascribed to late rickets. In other cases, the ■examination of the brothers and sisters, or even a glance at the mother's back, may show that there is a hereditary tendency, which cannot be identified with rickets. Finally, what is our position in regard to school scoliosis f There can be no doubt that the most frequent types of lateral curvature are commonest among school children, viz., lumbar or complete scoliosis with the convexity to the left and dorsal scoliosis with convexity to the right. On the other hand, we often see these types ■develop at an age before it is possible that the posture adopted in writing could have any effect. We must, therefore, assume that the SPINAL CURVATURES 533 scoliosis produced in school develops on some pre-existing tendency thereto. Not only do the cramped posture of writing, the position of the copy-book, and the shape of the letters contribute towards the development of the curvature, but also the bad habit of always carrying the school books home under the same arm. Worse than all this, however, is the practice, which was universally prevalent up to a few years ago, of making children sit up straight for hours on forms without adequate supports for the back. No wonder that weak muscles of the back become tired and the spine sinks into a posture to which a pathological predisposition inclines it. This predisposition probably depends upon an exaggeration of some slight asymmetry of the spine, normally present. But this must not be classed, without further consideration, with the condition previously referred to as ''numerical variation," depending upon an essential mal-development, the significance of which is not quite clear. PART VI. SURGICAL DISEASES OF THE EXTREMITIES. CHAPTER LXXX. FRACTURES AND DISLOCATIONS OF THE CLAVICLE. (i) If a patient is unable to raise his arm be3-c)nd the horizontal^ after a fall on the shoulder or a fall on the arm which transmits its force to the shoulder, if he inclines his head towards the injured side (fig. 252), and if the shoulder appears to be drawn forwards and inwards, we involuntarily look to the clavicle, in the anticipation of finding a fracture in its outer half (fig. 252). The patient suffers extreme pain when the fracture is manipulated. But this striking picture is not always in evidence. In children especially, the fracture is frequently sub-periosteal — green-stick fracture. The displacement is limited to a slight angular kink, or may be absent entirely ; while the power of movement mav suffer no definite interference, and the arm may be raised vertically without any hesitation. The careful observer will, however, notice that the child takes care of his injured side when playing, and that he does not willingly allow himself to be led by the affected arm. But if the child has not been carefully observed, as is so often the case, the doctor is not consulted by the parents until the thickening, due to callus, has made its appearance. (2) Injuries in the vicinity of the sterno-clavicular joint are equally easy to diagnose. These are, with few exceptions, disloca- tions, and are caused by dragging on the shoulder-girdle or pressure thereon. Inspection and comparison with the opposite side indicate without any difficulty whether the dislocation is forwards, as is most usual, or upwards, or inwards behind the sternum, which is the rarest variety. Dislocation of the sterno-clavicular joint is often FRACTURES AND DISLOCATIONS OF THE CLAVICLE 535 accompanied by other injuries, especially fracture of several ribs, when there has been severe compres- sion of the thorax. The dislocation may easily be overlooked in such cases, be- cause the fractured ribs and the contusion of the lung, which nearly always compli- cates these severe in- juries, concentrate all attention. (3) Injuries in the neighbourhood of the acromio-clavicular joint are more inter- esting from the dia- gnostic point of view, loecause they are more difficult to recognize. The differential dia- gnosis concerns con- tusion, sprain, and dislocation of the :j Fig. 252. — Fracture of the right clavicle. joint, fracture of the acromion, and of the extremity of the clavicle. (a) If there be no deformity, and pain is the only symptom, we have to distinguish between contusion and sprain. We may onlv assume the former when the joint has sustained a direct injury. We will probably find some evidence of this in bruising which has super- vened, or even in some abra- sions. If the injury was in- direct, the case can only be one of sprain. If the pain is mainly a pressure pain, affect- ing the whole joint, it strongly suggests contusion, whereas, if it is elicited mainly on Fig. 253. — Fractured clavicle. 536 SURGICAL DISEASES GF THE EXTREMITIES movement— raising the arm beyond the horizontal — and if the pressure pain is limited to the fold of the joint, it suggests sprain. {b) A slight deformity, consisting of a little step-like ascent from the acromion to the clav- icle, may be regarded as a sprain- — although the condition is one of loosening of the liga- ments which approxi- mates very closely to a luxation. There is no sharp line of demarca- tion between a sprain and a subluxation. On the contrary, fractures of the end of the clav- icle or acromin may be mistaken for sprains or contusions if they are periosteal, and there- fore produce no dislo- cation. If there is also no crepitus on move- ment, nothing but a skiagram can demonstrate the presence of the fracture. (c) If, however, we do find definite deformity — and this usually consists of a step-like drop of the shoulder (fig. 254), we must dis- FlG. 254. — Right acromio-clavicular dislocation. Fig. 255. — Skiagram of fig. 254 (taken from behmd, and therefore, apparently reversed). Fig. 256. —Detachment of distal end of clavicle. tinguish between (i) fracture of the outer end of ilie clavicle; (2) acromio-clavicular dislocatiou ; and (3) fracture of the acroniiou. Some indication is afforded by the position of the maximum pain FRACTURES AND DISLOCATIONS ABOUT THE SHOULDER-JOINT 537 on pressure and of the displacement. The palpation of both sides and comparative measurements will usually clear up the condition. In doubtful cases the irregular shape of the prominent edge and the crepitus permit of the distinction between fracture and dislocation. The differential diagnosis has usually to be made between dislocation and fracture at the end of the clavicle. In addition to the results of palpation and measurement, we must also take into consideration the visible external deformity. A very striking step-like formation suggests dislocation rather than fracture. The severity of the pain on pressure is also of some value, because it is more pronounced in fracture than in dislocation. The skiagrams are easy to interpret, and are conclusive (figs. 255 and 256). There may be some difficulty in interpretation in the case of children, because the lateral cartilaginous portion of the clavicle is transparent. A fracture of the cartilage may therefore be mistaken for a dislocation. This error may be avoided by controlling the skiagram by a comparative measurement of the median fragment. It may be noted finally that the distal end of the clavicle has occasionally been displaced under tlie acromion, and even under the coracold process. These rare injuries are quite recognizable by those who are skilled in palpation. CHAPTER LXXXI. FRACTURES AND DISLOCATIONS ABOUT THE SHOULDER-JOINT. A MERE glance and an examination of the power of movement usually suffice to make a diagnosis in the case of a patient who has fallen upon his shoulder, or upon his arm, the latter outstretched to avert the fall. If we employ palpation in addition, it is hardly possible to err, unless an unusually large haematoma renders an accurate ex- amination impossible. The fact that so many errors of diagnosis are actually made is due to a want of anatomical consideration. A skia- gram, which we may adopt as our last resource, ought only to confirm an already made diagnosis and reveal a few details, but should never be a substitute for diagnostic reflection. We place the patient before us, with the upper part of his body undressed, and direct him to slowly lift both arms from the side. If the injured arm can be raised perpendicularly, the shoulder-joint is 538 SURGICAL DISEASES OF THE EXTREMITIES free, and there is certainly no serious injury of the shoulder or shoulder- girdle. In the case of sub-periosteal fracture of the clavicle in children, free movement may still persist, as stated in the previous chapter. If the arm on the injured side can only be raised above the horizontal line in a hesitating manner, we should let it down again gradually. If the patient lets it drop from the horizontal position with a sudden grimace of pain, we may be almost positive that the collar- bone is broken. If the arm cannot be raised at all, or only very slightly, or if the L Fig. 257. — Sub-coracoid dislocation of humerus. Arm abducted. Axis deviated inwards. Shoulder i^attened. Fig. 258. — Axillary dislocalion of humerus. A greatly afjducted. Axis deviated inwards more ii in adjoining case. Shoulder bulged by a lai hiiemaloma. patient supports it with his other hand, it indicates the presence of a severe injury — a dislocation or fracture about the shoulder-joint. In dislocations it may be possible, in some circumstances, to raise the arm as far as the horizontal already on the second day, with a certain amount of pain. In these cases, however, it will be observed that the movement chiefly takes place at the clavicular joint. If the axis of the humerus is deviated inwards so that the continua- tion of its line would intersect the clavicle, and if the elbow is abducted from the side of the body, the case is either one of dislocation or of fracture. If the curve of the shoulder is flattened (fig. 257) it is a FRACTURES AND DISLOCATIONS ABOUT THE SHOULDER- JOINT 539 dislocation ; if tlie curve is retained, it is a fracture (fig. 259). This flattening may, however, be concealed by an extravasation of blood (fig. 258) ; but if dislocation be present in such a case, pressure with the finger below the acromion would show that the glenoid fossa is empty, in comparison with the other side. This sensation of the emptiness of the glenoid fossa is so unequivocal that if it is not present, we may positively exclude dislocation in any doubtful case. Unless a haematoma had attained an extraordinary size, it could not prevent the detection of the gap in the normal position of the head of the humerus. Should any doubt still remain, we must try passive movements. If these are limited in certain directions, the case is certainly one of dislocation ; if they are normal or unusually free, especially in the direction of adduction and outward rotation, the case is one of fracture. If the glenoid cavity is empty, but crepitus and preternatural mobility are present, the rare combination of fracture with dislocation exists. .4.— DISLOCATIONS. Having diagnosed a dislocation, we have next to decide whether it is of the axillary (sub-glen oid) or sub-coracoid variety ; other forms are exceedingly rare. If the arm is greatly abducted from the side (fig. 258) and the head of the humerus is distinctly felt in the axilla, the dislocation is axillary. If the arm is less greatly abducted and the head can be felt and seen under the coracoid process (fig. 257), the dislocation is sub-coracoid. The fact that the head of the bone can be seen and felt in Mohrenheim's fossa must obviously dispel any doubt about the presence of a dislocation. We purposely do not lay too much stress upon the demonstration of the head of the humerus in a misplaced position, because a disloca- tion can, and should be, recognized without this sign. When there has been much extravasation of blood with infiltration of the soft parts, especially in an axillary dislocation, it is often impossible to make this examination without an anaesthetic, and many a dislocation would be overlooked if the diagnosis depended upon the discovery of the head of the humerus in an abnormal position. In the absence of any considerable extravasation of blood, an indication for distinguishing between the two forms of dislocation may be obtained from the amount of increase in the circinnference of tJie shoulder-joint, as measured through the axilla and over the acromion. If the increase does not exceed 2 cm., the dislocation is sub-coracoid, but if it is as much as 4 cm. the dislocation is axillary. In these cases, however, palpation is quite easy, and if there is much extravasa- tion of blood the sign is of doubtful value. One who is able to recognize these two important varieties of disloca- tion of the shoulder will have no difficulty in detecting the rare forms, wherein the head of the humerus is in front, under the clavicle 35 ' - . ■ 540 SURGICAL DISEASES OF THE EXTREMITIES (subclavicular dislocation) or above the conicoid process (supra-coracoid dislocation) or upwards and backwards (sub-acromial dislocation) or backwards and downivards (infra-spinous dislocation). We must always be guided by the three above-mentioned cardinal signs, (i) absence of the head of the humerus from its normal position, (2) diminished range of passive movements, and (3) the presence of the head in an abnormal position, a sign which can, as a rule, be easily demonstrated in the forms last noted. 5.— FRACTURES. If the head of the hume- rus is in its normal position, and passive mobility is in- creased, or remains normal, while active movements are quite impossible, and the power of the shoulder is lost, we diagnose a fracture. This may be confirmed by feeling, or even by hearing crepitus on manipulation. This symptom is, of course, conclusive when present, but its absence is not in any sense an argument agaiust fracture. The lower frag- ment may be so much dis- placed that it no longer rubs up against the upper one, or the crepitus may fail owing to impaction of the frag- ments, or to the sub-perios- teal position of the fracture. In cases of separation of the epiphysis in young people, the crepitus is nothing more than a soft grating which may easily be overlooked. Disptaceuient of the lower fragineut often furnishes further confirma- tion of the diagnosis of fracture. This fragment may be in a position of abduction or of adduction, and mav also be completely displaced, either backwards or forwards. We have already studied the position of abduction, in which the elbow projects away from the side, and in which the axis of the humerus is directed towards the centre of the clavicle (figs. 259 and 263), because of its similarity with the usual posture of the arm in dislocation. The position of adduction is indistinguishable from the normal posture of the arm, and therefore can only be recognized on a skiagram (fig. 265). The forward Fig. 259. —Fracture through the tuberosities. Arm abducted, but curve of shoulder maintained (after Kocher). FRACTURES AND DISLOCATIONS ABOUT THE SHOULDER JOIXT 54I displacement of the shaft of the hunTierus is of greater importance. This displacement is recognized by the fact that the axis of the arm, when looked at from the side, does not go through the acromion, but in front of it. If there is any doubt about this, Ave can always feel that the margin of the lower fragment presses, as a sharp edge, against the anterior surface of the shoulder circumference. If the skin itself is impaled by the lower fragment, so that a dimple forms, there can be no possible doubt about the existence of a fracture. The same applies jjiiitniis nmtaiidis to the rarer forms, in which the humerus is displaced backwards. In some cases nothing abnormal beyond a diffuse swelhng is visible on inspection, and neither unnatural mobilitv, nor crepitus, can Fig. 260. — The most frequent varieties of fracture at the upper end of the humerus. T. Fracture of the anatomical neck. 4. Fracture of the great tuberosity. 5. Y-Fracture. ■a. Fracture through the tuberosities. 3. Fracture below the tuberosities. be detected, owing to the impaction of the fragments. Comparative measurements of the length of the humerus from the acromion to the external epicondvle may also fail to give any positive indication. If it were not that the persistent loss of power pointed to some severe injury, one would be inclined to be content with the diagnosis of contusion of the shoulder. In such cases we are assisted by the presence or absence of " fracture-pain." We press, with equal force, the tips of two or three fingers under each acromion. A circum- scribed severe pain resulting from this pressure points to fracture. Then we test whether axial pressure elicits pain ; this is done by pressing the elbow upwards, with counter-pressure over the shoulder. In recent cases, the presence or absence of pain on axial pressure is decisive, for or against fracture respectively. If there is no displacement, this pain on axial pressure may be v^ery indefinite, and disappear after twenty-four hours, although pain on local pressure continues. It is never justifiable to attempt any extensive movements under 542 SURGICAL DISEASES OF THE EXTREMITIES Fig. 261. — Shattering of head of humerus (patient was run over by railway carriage). Fig. 262. — Sub-coracoid dislocation. Fig. 263. — Fracture of humetus, through tuberosities, in position of abduction, as in dislocation {cf, fig. 262). Fig. 264. — Axillary dislocation with detach- ment of great tuberosity. FRACTURES AND DISLOCATIONS ABOUT THE SHOULDER-JOINT 543 Fig. 265. — Fracture of humerus through tuber- osities, in position of slight abduction. Also fracture of great tuberosity, indicating Y-fracture. Fig. 266. — Fracture of humerus through tuber- osities in position of adduction. Fig. 267. — Fracture of humerus, below tuberosities : (a) line of fracture ; (b) epiphyseal line. Fig. 268. — Fractured great tuberosity in a reduced sub-coracoid dislocaiion. 544 SURGICAL DISEASES OF THE EXTREMITIES an anaesthetic when the displacement is sUght or altogether absent. Such may result in causing a very undesirable amount of displacement. The diagnosis of fracture can be based upon the complete loss of power and the pain on pressure. The variety of the fracture can be ascertained by direct palpation and by noting whether the great tuberosity does or does not follow the movement of the bone on rotating it. We are now in a position to diagnose the precise form of fracture, if we take into consideration the typical lines of fracture shown in fig. 260. It is only possible actually to feel the fracture when it is extra- capsular. Therefore if the edge of a fragment is felt the fracture must either be through the tuberosities, or below the tuberosities. The distance of the edge of the fragment from the joint indicates which of these two varieties it is. If the edge cannot be felt, one must test whether the great tuberosity follows the movements of the bone. If the great tuberosity moves with the humerus on rotation, the fracture must be intracapsular — probably a fracture of the anatomical neck^ assuming that our diagnosis of fracture is confirmed by crepitus. But if we have not elicited any crepitus, and have only based our diagnosis on the presence of pain on axial pressure, there may be an impacted fracture between the tuberosities which is the more frequent event. But if the great tuberosity does not move when the humerus is rotated, the choice lies between the fracture which goes through the tuberosities, and the fracture which runs below them. Even if we can- not feel the edge of a fragment, the diagnosis can be made with consid- erable accuracy from the position of the maximum pain on pressure. Fracture of the metaphysis (between the epiphysis and the diaphysis) caused by sudden pressure, for instance, by a blow in the direction of the axis, produces the least symptoms. We will describe this form of fracture in connection with the radius, but Iselin has shown that this variety also occurs at the upper part of the diaphysis of the humerus. The diagnosis can only be made from the local pain on pressure. If the great tuberosity is detached as an isolated fragment, it naturally does not follow the humerus on rotation, but in such a case there is no pain on pulling or pressing on the axis of the limb. This detachment is usually a complication of a dislocated shoulder (figs, 264 and 268), and the signs of dislocation are therefore predominant. The complicating fracture can only be recognized, apart from a skiagram, if we obtain crepitus or are able to feel the detached great tuberosity through the skin. An isolated fracture of the great tuberosity, without dislocation, can be detected by the circumscribed pain on pressure if the displacement is slight. If the displacement is greater and the patient is thin, it can be seen that the shoulder is flattened out and broadened, as viewed from the front. There will FRACTURES AND DISLOCATIONS ABOUT THE SHOULDER-JOINT 545 also be two distinct bulgings — the one behind representing the detached tuberosity, the one in front representing the somewhat anteriorly displaced head of the humerus. As the external rotators (supra- and infra-spinatus and teres minor) are inserted into the great tuberosity, active external rotation becomes impossible, and the arm can, at most, be raised as high as the horizontal. This fracture sometimes occurs, indirectly, through muscular contraction. It is only in thin subjects, and when there has been little extravasa- tion of blood, that it is possible to suspect clinically a Y-shaped fracture, from the combination of symptoms of the lines of fracture I and 2, or 2 and 4 (fig. 260). The symptoms of separation of the epiphysis resemble those of frac- ture through the tuberosities. Fig. 269. — Fracture through the tuber- osities. Taken from the front. No apparent displacement. Fig. 270. — Same case. Taken from the side. Displacement evident. Special mention should be made of separation of fJie epiplixsis, in infants during delivery, and separation of the epiphysis in infants with congenital syphilis, owing to syphilitic osteo-chondritis. The loss of movement in the arm is the most striking symptom in these children — so-called " pseudo-paralysis." If the shoulder is flattened and the head of the humerus is approximated to the thorax, just as in the case of dislocation, but if, at the same time, there are increased mobility, crepitus and pain on axial pressure as in a fracture, though nothing can be found wrong in the humerus, we should think of a fracture of the neck of the scapula, more especially of detachment of the articular process and coracoid process. Confirmation of this diagnosis is furnished if the deformity is corrected by displacing the humerus to the side and pressing upwards, and by the return of the deformity immediately the pressure is relaxed. 46 SURGICAL DISEASES OF THE EXTREMITIES Figs. 261 to 268 indicate the skiagraphic appearances. The importance of taking a lateral view (if possible with the arm abducted) is shown by comparing Figs. 269 and 270. We should only be content with the diagnosis of contusion or sprain, if nothing is yielded by an examination, carried out as here directed, whether the injury be direct or indirect. We append to this chapter a summarized table which will facilitate diagnosis in any given case. ln^ „„-j f^„„„ u J 1 /Passive movements limited in /(jlenoia fossa can be deeply ^ ■ i- ,• / jj . - . -^ 1 certain directions (adduc- tion). pressed into ; bead of hu- merus to be felt in an abnormal position. Passive movements free. Curve of shoulder_/ flattened Shoulder curve re- tained Glenoid fossa cannot be ; Head of humerus shows no- where circumscribed pain on pressure (not even through the axilla), but the scapula is painful on pressure through - - --- __ the axilla. Coracoid process deeply pressed into ; head / follows the movements of the of humerus not felt in an \ arm. The whole shoulder abnormal position. region can be displaced up- wards, but immediately sinks ' downwards again. I Circumscribed pain in head of \ humerus on pressure. Curve over shoulder can be deeply pressed in ; pas- sive movements limited ; head of humerus can be felt in abnormal position Curve over shoulder can- not be pressed in ; passive movements free ; head of humerus not felt in ab- i normal position. No pain on axial pressure ; loss of power moderate ; no local pain in bone on pressure ; pain about the capsule. No pain on axial pressure. Severe circumscribed pain on pressure over great tu- berosity ; active outward rotation, nil. Rarely tuber- osity can be felt to be movable. Pain on pulling or pressure in long axis ; local pain on pressure, especially through axilla; great tuberosity fol- lows rotation ; severe loss of power. Ditto, but the pain on pressure through axilla is felt in scapula and not in head of humerus (see also above). Ditto, but pain on pressure at level of tuberosity, also de- monstrable from outer side ; loss of power slight or dis- appears rapidly. Ditto, but great tuberosity does not lollow rotation ; lower fragment often dis- placed anteriorly ; anterior margin can be telt through deltoid ; loss of power more than in lo, but in children may be slight. Ditto, but local pain on pres- sure below the tuberosities ; site of fracture clearly felt \ from the axilla ; loss of \ power very great. (i) Dislocation of hu- merus (usually axil- lary or sub-coracoid). (2) Dislocation with frac- ture. (3) Fracture of neck of scapula. (4) Fracture of humerus with position of ab- duction. (5) Dislocation of hu- merus with hsema- toma. (6) Sprain of humerus, (7) Fracture of tuberosity. great (S) Fracture of head or anatomical neck. (g) Fracture of neck of scapula. (10) Impacted fracture through tuberosi- ties. (11) Free fracture through tuberosities (separa- tion of epiphysis) either without displacement or in a position of ad- duction, or displace- ment anterior. (12) Fracture of humerus below tuberosities (surgical neck). INFLAMMATORY PROCESSES ABOUT THE SHOULDER-JOINT 547 CHAPTER LXXXII. INFLAMMATORY PROCESSES ABOUT THE SHOULDER-JOINT. Inflammation about the shoulder is situated, apart from rare exceptions, in the biirscv, the joint, or in the bones. ^.—DISTINCTION BETWEEN BURSAL AND JOINT DISEASE. The snbscapnlar bnrsa and the bursa bekveen the tuberosities are only dilatations of the capsule of the joint, and require no special attention, because they are never diseased independently. The sub- coracoid bursa is too small to be of any importance. The bursa under the deltoid is, however, of importance pathologically. It lies between the deltoid muscle, the capsule of the joint and the humerus, and is often subdivided into two parts, an upper, the sub-acrouiial bursa, and a lower, the sub-deltoid bursa proper. How can we distinguish between an effusion into this bursa and an effusion into the joint ? In the first place, by inspection. If the sub-deltoid bursa is filled up, it raises the deltoid muscle from off the joint and the humerus, especially at its external and anterior portions. Klister has pointed out that this bulging is best recognized by looking at the patient from behind and above, and comparing the two shoulders. On the other hand, an intra-articular effusion does not make the curve of the shoulder any more pronounced, because even a tensely filled capsule is unable, for anatomical reasons, to lift up the deltoid to any con- siderable extent. If the deltoid muscle bulges to a great distance downwards, an intra-articular effusion is at once excluded, and we must assume that the effusion is in the deltoid bursa. If the effusion in the joint is so great that it causes a visible swelling, this swelling will also manifest itself where the joint is least covered by muscles, i.e., in the posterior region, and also in the diverticulum of the capsule along the biceps tendon. This does not imply that the shoulder-joint which contains an effusion does not appear to project away from the body more than on the healthy side. But this is due to the fact that an extensive effusion presses the humerus and all that covers it somewhat away from the body. This broadening of the shoulder, as seen from the front is, however, quite different from the protuberant bulging just described in connection with effusion mto the bursa. The outline of the shoulder is otherwise retained. 54^ SURGICAL DISEASES OF THE EXTREMITIES If, on palpation, it appears that it is something Hke a tense cushion under the deltoid and over the bone which causes the enlargement of the shoulder, the case must be one of a bursal effusion. But if we at once come upon the humerus under a muscle of normal thickness, and the shoulder is nevertheless widened, as seen from the front, the humerus must be displaced by an articular effusion, A bursitis is only painful on pressure over the area of the bursa, but an arthritis is painful over the whole extent of the joint, especially if pressure is made directly over the capsule, i.e., at its posterior and inferior regions. Loss of power is another piece of evidence in favour of disease of the joint. In disease of the shoulder-joint, as in that of other joints, there IS always the reflex attempt to keep the joint at rest, and allow its function, as far as possible, to devolve upon some other joint. In the hip this "muscular fixation " is at once manifest as a limp, because the joints of the lumbar vertebra? only make a poor substitute for it. But in the shoulder, the joints at the two extremities of the clavicle are able to compensate for it, to a considerable extent, and thus conceal the loss of movement. We must, therefore, examine for loss of power, bearing in mind the behaviour of the scapula and clavicle. In the ordinary way, the scapula does not participate in the movement of the shoulder until the arm is raised above the horizontal. But if the scapula participates before the arm reaches this level, it is obvious that there must be some limitation of movement in the shoulder-joint. A steep position of the clavicle and the approximation of the shoulder to the middle line, also signify limita- tion of movement. Fig. 271 (left-sided muscular fixation of the shoulder-joint) illustrates this latter symptom very clearly. If this stiffness is only occasional, e.g., when the patient is tired, or if it disappears under anfesthesia, it is purely of a muscular nature. If some force is required under the anaesthetic to overcome the stiffness, it indicates that definite changes have already occurred, especially contraction of the capsule and adhesions between the head of the humerus and the glenoid fossa. If the joint remains entirely fixed, even under the anaesthetic, there are either very old-standing fibrous adhesions, or bony ankylosis exists. The patient chiefly notices this disability, whether it be due to the muscle or fibrous tissue, in the movements wherein the rest of the shoulder girdle cannot act as a substitute — e.g., in adduction of the arm to the middle line behind the back. Interference with this movement is sometimes the first complaint in tubercle of the shoulder- joint. There are three conditions which we must guard against, in •examining the function of the shoulder-joint. The first has been included under the general term of "joint neurosis," and usually occurs in the form of hysteria. A "neurosis of a joint" may occur in children, especially in little TXFLAMMATORY PROCESSES ABOUT THE SHOULDEK-JOIXT 549 girls. If the patient has sustained an accident and looks forward to compensation, it is dignified with the designation of "traumatic neurosis." We cannot investigate here the respective parts played ni this condition bv deliberate exaggeration and by involuntary auto- suggestion. These, no doubt, vary in different cases. But the fact is that many patients who assert that they can hardly lift their arm to the horizontal are often able, within a few minutes, to raise it quite vertically, provided that the neurotic habit is not too deeply rooted within "them. As a rule there is no interference with passive movements, and this, of course, excludes the possibility of any serious mjury to the joint. But we must be careful not to fall into the second source of error, viz., a genuine pavahsis. A workman dislocates his shoulder. It is promptly reduced by a doctor, but still remains powerless ; the patient cannot raise his arm. Fig. 271. — Approximation of the level of the shoulder to the middle line, and steep position of the clavicle, when the arms are raised, signs of stiffness of the shoulder (early stage of arthritis of shoulder). At first the doctor thinks of some damage to the joint through the injur}-. Then he thinks that the patient may be malingering, because the passive movements are quite free. Examination, however, shows that the deltoid does not contract at all when the movements are being tested, and that the reaction of degeneration is present. The patient has, therefore, sustained a paralysis of the circnintiex nerve, as a result of his dislocation. ^lalingerers and hysterical patients usuallv contract their muscle somewhat, in order to show their " good intentions " ; whereas in paralysis this is impossible. But paresis may cause great difficulty, because a certain amount of voIuntar\^ contraction occurs, just as in malingering. We can generally escape from this difficultv, however, bv examining with the faradic and galvanic currents, and by testing 55° SURGICAL DISEASES OF THE EXTREMITIES the sensation in the area supphed by the circumflex nerve — i.e., over the deltoid muscle. If we base our differential diagnosis between bursitis and arthritis of the shoulder-joint on what has already been said, it will follow that the only movement which is hindered in bursitis is the one wherein the inflamed bursa is compressed between the acromion and the humerus — i.e., raising the arm from the side ; the other move- ments are quite free. But when the joint itself is inflamed and its function is interfered with, all the movements are more or less limited, both active and passive. Finally, it should be mentioned that infiainuiatorx changes in the nxiila (lymphadenitis) may also interfere with the movements of the joint. i5.— DIAGNOSIS OF THE VARIOUS FORMS OF BURSITIS AND ARTHRITIS OF THE SHOULDER. (1) BURSITIS. In rare instances acute infections, like gonorrhoea, acute articular rheumatism and staphylococcic infections (furuncle), &c., may give rise to bursitis by metastasis. The most frequent forms are, however, the traumatic and the tubercular. If the disease appears directly after a contusion of the shoulder, or after the constant repetition of a slight trauma — including any unaccustomed work which involves the deltoid muscle — we may assume that it has a traumatic origin. But if there has been a considerable free interval between the injury and the onset of the bursitis, or if the disease has come on gradually and quite spontaneously, we must think of tubercle, especially if this is supported by a hereditary predisposition, and by the previous history of the patient. Occasionally the bursitis is not primary, but has been caused by the rupture into the bursa of an extra-articular focus in the bone. Positive information can only be furnished by a skiagram. (2) ARTHRITIS OF THE SHOULDER. In discussing the etiology of this condition, it is necessary to distinguish the acute from the chronic cases. {a) Acnte intlnniination of the shonlder-Joint may be one symptom of acute articular rheumatism. Such a case would be left to the physician, but we must remember that there is a complete chain of transitional forms — from the purely serous polyarthritis of rheumatism to the suppurative inflammation of pyaemia— which, under certain circumstances, may require surgical treatment. The most important of these is scarlatinal arthritis, which often attacks the shoulder; and IXFLAMMATORY PROCESSES ABOUT THE SHOULDER-JOINT 55 1 we must be careful lest we compromise the functions of the joint by delaying incision too long. Gonorrheal arthritis is another transitional form between rheumatism and pyaemia, and is usually recognized by the fact that only one joint is affected. This variety should be thought of, if the patient has outgrown the stage of children's ailments, but has not yet learnt how to avoid the gono- coccus. But one must never forget that this micro-organism may occur in childhood (especially in little girls) — Gonococciis insontinm. Pyaemic arthritis of the shoulder is mostly met with in puerperal infections, but may occur in any pyaemic disease. (/)) The diagnosis is much more difficult in cliroiiic artliritis of the sliouldcr. It is most important, from the therapeutic point of view, to decide whether it is tubercular or not. In the first place one has to consider traumatic arthritis of the shoulder. The histories of these cases are very similar, with slight variations. A middle-aged or elderly man has sustained a sprain of the shoulder, or some severe injury, such as a dislocation, which has been properly reduced. The patient may, of course, be a female, but the condition rarely happens in this sex. The original pain dis- appears quite normally, but there is no restoration of the power of the joint. Attempts at movement remain painful, and they are often attended by creaking and grating. Pain frequently radiates towards the back of the neck and the elbow. On examination, it will be found that the joint is more or less stiff, and that the capsule is distinctly painful on pressure ; but there is not sufficient effusion to permit of recognition. If untreated, the condition may persist for weeks and months, but in slight cases it rapidly yields to proper treatment, especially if the patient is otherwise well, and has not instituted a claim for damages. In old people, in rheumatic and gouty subjects this traumatic arthritis of the shoulder may develop into one of the varieties of "chronic rheumatism," which proves refractory to all treatment. If this disease has not followed the injury, but has come on gradually some time after the subsidence of the immediate effects of the accident, we should think oi post-irauiuatic tuberculosis. The more trifling the injury, and the more pronounced the inflammatory symptoms, the more naturally will this diagnosis suggest itself. Sometimes we can do nothing but give a test injection of tuber- culin, or wait and watch the case — which is equally good. A skiagram can only help the diagnosis if changes in the bone have alreadv occurred, but as these changes can never be excluded, this method of examination should never be neglected. In such cases, we may assume with the greatest probability that the injury has merely caused a latent tuberculosis to assert itself. The diagnosis is easier if there has been no antecedent injury, for 552 SURGICAL DISEASES OF THE EXTREMITIES then it is only necessary to decide between tubercle and chronic articular rheumatism. The anatomical changes which occur in this latter include pro- cesses of serous effusion, fibrous adhesions, proliferation, and destruction — indeed, any morbid change which may occur in a joint. Their etiology includes injuries, toxic processes (lead), infections (an original acute infective rheumatism), and finally neuropathies (tabes, syringo-myelia) apart from cases which we cannot account for at all. It must be stated, however, that none of the anatomical varieties presupposes any definite etiology ; one and the same cause may be responsible for the most differing anatomical forms. The tendency towards the affection of many joints in a symmetrical manner is an important diagnostic sign, common to all varieties, whatever be their causes — even if traumatic. This circumstance permits the diagnosis to be made at once in a large number of cases. It is true that tubercle often affects many joints, but, as a rule, there is at any rate one focus so much involved that there is no difficulty about the diagnosis. It is more difficult to diagnose the cases of subacute or chronic rheumatic polyarthritis, wherein several joints are attacked at long intervals. If only one joint is diseased, we may remain long in doubt. Early muscular atrophy, progressive deteriora- tion — even if slow — depression of the general health, and possibly also a slight rise in temperature, would point to tubercle ; but a variable local condition with good general health would indicate a " rheumatic " affection. Some weight in making a diagnosis may also be attached to the success or failure of spa-treatment All these difficulties apply to those frequent forms of shoulder-joint tubercle, wherein there is neither effusion nor any demonstrable swelling of the capsule, wherein the morbid process manifests itself by slow destruction and simultaneous absorption of the articular ends of the bones — a clinical picture which used to be termed " caries sicca." On the other hand, there can be no doubt about the diagnosis of tubercle if a localized swelling gradually forms, even at the posterior region of the joint, with suppurative softening of the tissues, and the formation of sinuses which discharge their pus and pieces of caseous material. Gummatous disease of the shoulder-joint may occur, but it is so rare that it does not enter into practical consideration. We may now briefly summarize the foregoing : — // the signs of infiamniation of the shoulder — loss of power, spon- taneous pain, tenderness on pressure — coiiie on immediately after an injury, we may assume the presence of a purely traumatic arthritis of tJie shoulder-joint, even if the malady persists for weeks or months. But if these symptoms come on spontaneously, or supervene a few weeks after a slight injury, we should think of tubercle, especially in young patients. If INJURIES ABOUT THE ELBOW-JOINT 553 in addition to the slwnlder, other joints become affected with inflaui- niatory symptoms at longer or shorter intervals, hut witliout, anyivhere, presenting the classical signs of a tubercular focus, the case probably represents one of the forms of chronic articular rheumatism, and the older the patient is, the more probable is this diagnosis. C— PRIMARY DISEASES OF THE BONE. We have referred to the bones as the third source of inflamma- tion in the neighbourhood of the shoulder-joint. So far as the bone disease manifests itself in the form of in/ianiniation of a joint the foregoing remarks will apply. The involvement of the bone, or the presence of the primary focus within it can only be demonstrated by a skiagram. But the bone may be diseased, and the joint itself not be involved. This condition will be suggested, when there are pain and swelling in the neighbourhood of the joint, while its movements remain free. The localization of the changes will, at once, enable us to distinguish wdiether the disease originates in the scapula or the humerus, and its course generally enables us to determine whether it is acute osteomyelitis, tubercle or gumma. In its early stages, a sarcoma may be confused with a chronic inflammatory disease. CHAPTER LXXXIII. INJURIES ABOUT THE ELBOW-JOINT. Although the elbow-joint is superficial in position and easily felt, injuries thereof are a source of great perplexity of diagnosis. There are two reasons for this ; firstly, the fact that three bones participate in the construction of the joint, and secondly, the extensive swelling of the soft parts which occurs — much more extensive, for example, than in the case of the wrist. But if we accustotn ourselves to draw logical conclusions from what is actually felt, we shall find that the undiagnosable injuries about the elbow will tend to become fewer and fewer. Having decided from the loss of power and deformity that some severe injury to the elbow has occurred, we must first d termine whether a fracture or a dislocation is present, and then the variety of the one or the other. Some indications are furnished by the ^^6' of the patient. 554. SURGICAL DISEASES OF THE EXTREMITIES Fractures and separation of the epiphyses, with secondary disloca- tions, are more apt to occur m early childhood, whereas adults are more subject to pure dislocation, because of the relatively greater firmness of their bones. We will now proceed to detail the method of examination. /!.— INSPECTION. Sometimes a mere glance suffices for the diagnosis. If the out- lines of the sigmoid fossa are visible through the skin of a thin individual and the head of the radius projects behind, no one can doubt the existence of a dislocation (fig. 272). If the axis of the fore- arm, as seen from the front, instead of deviat- ing slightly externally is directed internally, we immediately think of certain forms of fracture (fig. 287), &c. On inspection, we note the following points, which we shall make further use of, in the course of examina- tion. (i) Position of the elbow (flexion or ex- tension, abduction or adduction, pronation or supination, abnormal position of the axis of arm or forearm). (2) Degree of the swelling. (3) Prominence of the bony parts. (4) Ecchy- moses. (5) Impalement of the skin. (6) Posture of the hand (paralysis of the radial nerve). 5.— EXAMINATION OF ELBOW MOVEMENTS. We first ask the patient to carry out a few movements in various directions. If he complies with our request, and the move- ments attain the normal range, he has neither a dislocation nor a fracture which interferes with the mechanism of the joint. If active movements are restricted, we must endeavour to ascertain the icxtent Fig. 272. — Backward dislocation of elbow. INJURIES ABOUT THE ELBOW-JOINT 555 of the passive movements, at first, gently without anaesthesia, and then, if necessary, under an anaesthetic. The following possibilities have to be considered : — {a) If there be an excessive amount of movement in one definite direction, while movement in the opposite direction is restricted by the tension of the uninjured ligaments, we may conclude that a sprain has occurred. In posterior or postero-external dislocations, which constitute the majority of these cases, it is possible to over-extend the elbow, but it is not possible to flex it beyond a right angle. In pure lateral dislocations flexion is indeed possible, but the aspect of the joint, as seen from the front, with the lateral displacement of the forearm in relation to the humerus (the bay- onet shape of the arm) is so striking, that the dis- location of the joint can- not be missed. We must, however, decide whether it- is a complete or in- complete backward dislo- cation, or a dislocation backwards and outwards, or the rare backward and inward form, or the still more rare backward dis- location of the ulna only. Careful palpation of the projecting bony land- marks will furnish infor- mation on all these points. Fig. 273. -Dislocation of elbow backwards. Skiagram of fig. 272. (6) If our examination has showai that there is no interference witli passive extension and flexion, thus excluding the possibility of any ordinary dislocation, the case is one of fracture, or there may be no severe injury at all. Before coming to any definite conclusion and diagnosing the exact form of fracture, it is desirable to recall the possible varieties by a glance at the accompanying diagrammatic illustration (fig. 274). The skiagrams which follow illustrate again the most important and typical fractures,mostly of children. Owing to the epiphyseal cartilages, the interpretation of their skiagrams often presents great ditificulties. 36 556 SURGICAL DISEASES OF THE EXTREMITIES The examination of the power of the elbow and the testing for false mobility m.ay yield the following possibilities : — (i) // all passive niovenients are free, and the only derangement consists of the ■unpossihility of active extension, it is obvious that some break has occurred in the continuity of the extension apparatus, and experience shows that this usually indicates a fracture of the olecranon (fig. 277). If, anticipating the order of the examination, we palpate its surface, and come upon a gap in the bone, or find thereon a trans- verse, sensitive groove, the diagnosis is confirmed. If doubt still remains, the attempt should be made to displace the tip of the olecranon from the ulna — a manoeuvre which is very painful for the patient. It is obvious that the examination for active extension must be conducted in such a way that the drop of the forearm by its own Fig. 274. --Course of the lines of fractures at the lower end oi the humerus. 1. Fracture of the external epicondyle. 2. Fracture of the rotula. 3. Fracture of the external condyle. 4. Fracture of the internal condyle. 5. Fracture of the internal epicondyle. 6. Fracture through the condyles. 7. Fracture above the condyles. 8. Y-shaped fracture. weight should not mislead the observer into thinking that active extension has been performed. (2) If the olecranon is uninjured, the forearm, which is usually flexed to a right angle, should be moved backwards and fonvards in relation to the humerus. If this is possible, and if the epicondyles are felt to move witJi the olecranon, there must be a break in the continuity above the joint, i.e., a supra-condylar fracture. If, on displacing the olecranon backwards, it gets into the position of a posterior dislocation, hut the epicondyles do not follow it, and if it can easily be replaced into its normal position, we should think of fracture of the coronoid process of the ulna, especially if these movements are associated with some crepitus. Tliis fracture was rarely recognized before the advent of X-rays, but the light now INJURIES ABOUT THE ELBOW-JOINT 557 shed thereon renders the diagnosis possible in the future even without the rays. The signs just noted ought always to raise the suspicion of the very rare fracture of the base of the coronoid process. We shall describe a somewhat more frequent form later on. (3) If we cannot move the fore- ' ! arm backwards and forwards in I relation to the humerus, we must examine for another important sign, Fig. 275. — Normal elbow taken from behind. Boy aged 11. ^.?'. = centre of ossification of epicondyle. C£. = exlernal condyle. The centre of ossification of internal condyle is not yet present. Fig. 276. —Normal elbow taken from the side. Boy aged 11. References as in previous figure. i.e., for abnormal lateral mobility, in the sense of adduction or abduction. As there is always a certain amount of abduction atid adduction normally possible in children, it is necessary to compare the injured side witli the uninjured one. The forearm makes an obtuse angle with the arm, the angle being open outwards, thus constituting a slight degree of valgus, as in the knee. This valgus posture is more pronounced in females than in males. If, on comparing the two sides when both arms are kept in the same attitude, it is seen that the normal abduction is lost on the injured side (fig. 284), or, indeed, replaced by a position of adduction. Fig. 277. — I^'raclure of the olecranon. 558 SURGICAL DISEASES OF THE EXTREMITIES Fn Oe. Fig. 278. — Supracondylar fracture with- out dislocation (/^.r.). Boy aged 12. The internal epicondyle has fused wiih the humerus (unusually early). The centres of ossification for the internal condyle {C.i.), and the olecranon [O.I.), have appeared. Fig. 279. — Same case as previous figure, from the side. F.r. i=r line of fracture with small piece separately broken off at the back. Fig. 280. — Supra-condylar fiacture (hyperexten- sion fracture) in a girl aged 3, taken from the side, showing the backward displacemen'. 281. — Same case, taken from the side, showing, lateral displacement (bayonet shape). INJURIES ABOUT THE ELBOW-JOINT 559 we can at once conclude that there is abnormal lateral mobility. Passive movements will show whether this increased mobility is present in both directions, or only in one direction. In the former case the condition must be one of supra-condv- lar fracture, which we have already recognized by the fact that the fore- arm can be displaced from before backwards. In the latter case the condition must be one of damage to the liga- ments of one side, not, as a rule, merely a simple rupture of a lig- ament, but a fracture of the portion of bone into which the ligament is inserted, i.e., the in- ternal or external condyle or the epicondvle. If ulnar adduction is in- creased, the external radial lateral ligament must have given way, or the external condyle may have been torn off with it (figs. 289 and 290). On the other hand, increased abduction signifies the tearing off or the internal epicondyle (figs. 285, 286, 287), or the much rarer fracture of the internal condyle. (4) But even this examination may fail to give us an unequivocal result. It may be possible to displace the forearm to some extent, both back- wards and forwards, there may be increased mobility in the direction of abduction and adduction, but not one of these signs may be sufificiently pronounced to base a diagnosis thereon. We must therefore make one final test by firmly grasping the humerus at the epicon- dyles, and attempting to move the bones of the forearm, at the elbow joint, in a lateral direction. The object of this manoeuvre is not to bring the forearm to an angle with the humerus, but to displace it into a direction parallel therewith. If we can do this, it is very probable that a piece of bone consisting Fig. 282. — Supra-condylar fracture (flexion fracture), in a boy aged lo. Lower fragment displaced to the front. Fig. 283. — Piece of cartilage bone broken off the rotula ((/". fig. 291). 560 SURGICAL DISEASES OF THE EXTREMITIES of the trochlea and rotnla has been broken off ; in other words, that a fracture through the condyles has been sustained. It is very Hkely that this movement may be effected in the case of other fractures which extend into the joint, especially in fractures of the condyles ; but these have already been recognized by the abnormal degree of adduction or abduction of which they are capable. (5) Even if this test is negative, we cannot definitely exclude injury of one of the bones forming the joint. There still mav be a circuui- scrihed piece of bone broken off, iviihin ilie Joint, which does not interfere with passive movements. Two symptoms will lead to this assumption : (i) the presence of crepitus when free movements are made, and (2) sudden temporary interference wiLh these movements. We conclude irom the crepitus that something is broken, and the sudden inter- ference with movement, as occurs Avhen a loose bodv is in a joint, shows that some solid substance becomes incarcerated between the ends of the bones (fig. 283). Further conclusions may be drawn from palpation. C— PALPATION. This will aid us in solving the problems which have not been cleared up by inspection and by testing the movement of the joint. Palpation is easy when the case is recent and the swelling is slight ; but it may be quite valueless if some time has elapsed since the accident, and the joint has become tense with effused blood and its whole neighbourhood extensively infiltrated. In these circumstances we must have recourse to anaesthesia, and massage the oedema awav as far as possible, before making the examination. It is most important to determine whether the swelling is situated within the joint or out- side the capsule. If the latter be the case, it is in favour of a para- articular fracture (supra-condylar). This happened in the case illustrated in ligs. 278 and 279. There was no false mobility and it was only the circumscribed swelling and pain on pressure which made one suspect a " fracture of the bone above the joint." We have next to feel the three well-known bony landmarks, viz., the tip of the olecranon and the two epicondyles. We know from anatomy that these three points form an equilateral triangle (fig. 288 (b) and (c)) lying in the same plane as the humerus, when the arm is flexed to a right angle, whereas they are all at the same level, or, mathematically speaking, in a plane vertical to the humerus (fig. 288 (a)), when the arm is extended. It is always advisable to compare the injured with the uninjured side, while making! the examination, in order the better to appreciate slight changes in these relations. The following possibilities must be taken into consideration : — INJURIES ABOUT THE ELBOW-JOINT 561 (i) If the tip of the olecranon is displaced iipivavds when the arm is extended, or displaced backwards when the arm is flexed, i.e., has shifted from the plane of the humerus, whereas the epicondyles retain their relation to this bone, the case is either one of backward disloca- tion or fracture through the condyles. Marked projection of the olecranon, combined with limitation of movement — impossibility of complete flexion — points to dislocation. Slight projection with free passive movement indicates fracture through the condyles, which is rare, or detachment of the coronoid process, which is equally rare. If the projecting olecra- non, notwithstanding its backward displacement, still remains midway between the external and internal epicon- dvle, the case is one of simple posterior dislocation. If we can distinctly palpate the sig- moid fossa and the head of the radius, the dislocation is complete ; in other cases it is incomplete. If the head of the radius remains, how- ever, in its normal position, or slightly displaced inwards, the case is an example of the rare posterior dislocation of the ulna alone. (2) If the tip of the ole- cranon ami epicondyles are together displaced hackivards in regard to the plane of the shaft of the humerus, so tiiat the relation of the epicon- dyles to the shaft of the hu- merus is altered, and so that they are movable against the humerus, the case can only be a supracondylar fracture— a hyper- extension fracture, whose course runs from forward and below to behind and above (lig. 280). (3) If the olecranon alone, without the epicondyles, is displaced fonvards and movement is limited it must be one of the rare cases of anterior dislocation ; if passive mobility is free, and the epicondyles are displaced forwards at the same tune, the case must be one of Fig. 2S4. — Rijiht supra-condylar fracture, in a boy aged ii. The normal cubitus valgus is straightened out (angle very definite on left side). Shortening. 562 SURGICAL DISEASES OF THE EXTREMITIES supracondylar fracture, arising through flexion (fig. 282). In the latter case it may be possible to feel the pointed end of the upper fragment of the humerus through the soft parts above the olecranon, if there is not too much swelhng, and we may also be struck by the unusual rotundity of the elbow in profile. (4) If the olecranon appears to be displaced laterally in relation to the epicondyles, we must note whether this displacement is in relation to both condyles. If it is so, there must be an incomplete or complete lateral or postero-lateral dislocation, according to the degree of ligamentous rupture and displace- ^ ment. (5) If the tip of the olecranon 1 only preserves its normal relation Fig. 285. — Detachment of internal epicondyle and its displacement to- wards \he forearm. Fig. 286.— Detachment of internal epicondyle without displacement. The slight indication of callus shows, apart from the age of the patient, that it is not merely physiological cartilage. in regard to one epicondyle, we must assume that the other condyle or epicondyle has been broken off and displaced. The epicondyle is usually broken off by itself on the inner side, whereas on the outer side it is generally a matter of fracture of the condyle. The symptoms, in regard to false mobility, are, in principle, the same in both cases; hyperabduction when the fracture is on the inner side, and hyper- adduction when the fracture is on the outer side. If the swelling is not too great, palpation is quite conclusive. On the outer side INJURIES ABOUT THE ELBOW-JOINT 563 we often find the detached condyle rotated to the extent of 90° or even 180°. In fracture of the internal epicondyle the detached piece of bone is sometimes found hanging from the lateral ligament in its normal position, but often towards the anterior surface, and displaced even as far as the level of the fold of the joint (fig. 285). (6) If we feel the three chief points in their proper position, but the head of the radius is displaced, there must be a dislocation of tiie radius alone. The radius usually deviates forward (fig. 293) or outwards, rarely backwards, and the injury generally oc- curs in children as a result of extreme pronation combined with abduction. The so-called subluxation of the radius forwards, which is also fre- quent in children, must be distinguished from complete dislocation of the radius. This is at present looked upon as an mter- position of the posterior wall of the capsule between the radius and liumerus. This injury often occurs to children, when they are dragged by Fig. 287. — Detachment of internal epicondyle, and its rotation to the extent of 90°. $h^ Fig. 288. — Relative positions of three bony projections on elbow, which serve as landmarks, (a) Extension. (b) Flexion as seen from Ijeliind. (c) Flexion as seen from the side. 564 SURGICAL DISEASES OF THE EXTREMITIES the arm. On palpation nothing can be found, in striking contrast to the incapabiHty of performing anv movement. The accuracy of the diagnosis is proved by the result of treatment; power of movement is at once regained if the normal conditions are restored by supination and flexion. (7) There may be pronounced posterior displacement of the fore- arm, when considerable passive movement is applied to it. At the same time each separate condyle can be displaced from the shaft of the humerus. The movements are accompanied by a sound of crackling like a bag of nuts, in the joint, which is filled with blood. In these circumstances there can be no doubt that there is a supra- condylar fracture, combined with fracture of both condyles — in other words, a T- or Y-shaped fracture (fig. 292). ] (8) If the ordinary signs of a ^ c. Fig. 289. — Fracture of external condyle. Seen from the side. Fig. 290. — Fracture of external condyle. From behind. posterior dislocation exist, and if in addition crepitus and abnormal mobility of the external condyle or internal epicondyle are noted, it is obvious that the dislocation is associated with a fracture. This latter combination is a very typical occurrence. (9) Sometimes, nothing may be recognized at first on passive movement and palpation ; nevertheless, a suspicion of crepitation being present, we cannot exclude a fracture. In some cases, prona- tion and supination are deranged, in some flexion is painful, and in INJURIES ABOUT THE ELBOW-JOIXT 565 others the derangements vary so much that they suggest a " derange- ment interne" — although this is not a diagnosis. (a) If there is locaHzed pain on pressure over the head of the radius, if it is thickened and abnormally prominent, with a circum- scribed effusion of blood in its vicinity, if pronation and supination are painful and if thev are accompanied by rotation of the head of the radius, the case is one of fracture of the head itself (chisel fracture, Bniiis ; fig. 294). But if the pain on pressure is mainly limited to the neck, there is probablv a fracture of the neck, whether the head moves on rotation or not (hg. 295). The detached head is sometimes turned to an angle of 90°, so that its depression can be felt. {h) If the symptoms of a foreign body in a joint are the most prominent combined with some limi- tation of extension, we should think of an abra- sion fracture of the emi- nentia capitata humeri, Fig. 291. — Detachment of cartilage and some bone (X) from the eminentia capitata humeri (see corresponding fragment in fig. 283). Fig. 292. — T-fracture of lower end of humerus. which was first carefully described by Kocher. In this fracture, only a localized piece of cartilage with a small fragment of bone are broken off (fig. 283). This piece may sometimes be felt as a loose body, between the external condyle and the head of the radius, as soon as the arm is extended. On flexion, the piece of cartilage disappears within the joint. If some bone is detached with the cartilage, the diagnosis can also be made by X-rays (fig. 291). (c) But if nothing is found, except that there is localized pain on 566 SURGICAL DISEASES OF THE EXTREMITIES pressure and ecchymosis of the elbow, we may assume that there is a detachment of the coronoid process. As soon as callus develops, it is very easy to detect this injury by palpation (ng. 296). The diagnosis of " sprain " is only justified if an exhaustive and systematic examination fails to elicit anything definite. Fig. 293. — Forward dislocation of radius alone. Fig. 294. — Chisel fracture of head of radius. Fig. 295. — Detachment of head of radius. Fig. 296. — Detached fracture of the coronoid process of ulna, (c) Prolifera- tion of callus visible above the fragment. INJUKIES ABOUT THE ELBOW-JOINT 5^7 D.—ROKTGEK RAY EXAMINATION. We must never be content merely with a screen examination. The clearest picture on a screen fails to exhibit the details which a moderately good skiagram shows. It is impossible to avoid over- looking on a screen, subordinate, though important, injuries which may accompany the chief injury, e.g., a dislocation — an injury whicli is recognizable even without X-ray examination. Another precaution which must be observed, especially when dealing with growing individuals, is always to take a control picture of ilie unhijured side, in the same position as that in which we have examined the injured side. If this is neglected, we are liable to interpret the cartilaginous ends between the various centres of ossification as fractures of the external condyle, the olecranon, &c., and in all probability we will overlook actually existing injuries. It is also indispensable to examine the joint in two directions perpendicularly to one another, from the front and from the side. The X-ray examination of an elbow injury is therefore not always an easy task, and the correct interpretation of the skiagram may be just as difficult as the accurate appreciation of what is found on palpation. We may summarize the above in the following scheme — /Moderate and transitory loss of power ; nothing severe ; pain on pressure ; usually a little effusion- Ditto, but severe pain on pres- sure over the head of the radius or its neck. The head often appears to be somewhat thickened ; localized ha;ma- torna in its neighbourhood. As in I, but severe pain on pressure in the flexure of elbow ; possibly also swell- ing and crepitus therein ; loss of power of active flexion (brach. internus muscle). No displacement of the cardinal landmarks I Joint free, but pain on pressure (except sometimes in 7, when the olecranon ; transversely above it. is movable). Loss of power variable ; sym- ptoms of foreign body in joint ; loose body to be felt between rotula and head of radius, on extension. Severe loss of power and effu- sion ; forearm can be dis- placed somewhat, forwards and backwards (in position of dislocation). Some lateral displacement also possible. Passive movements free ; active movements restrained ; ole- cranon mov-able, sometimes proximally displaced. (i) Sprain. (2) Fracture of the capl- tulum of the radius (or detachment of the head). (3) Fracture of coronoid process of ulna. (4) Supracondylar frac- ture without displace- (5) Abrasion of emin- entia capltata. (6) Fracture through the condyles. (7) Fracture of ole- cranon. 568 SURGICAL DISEASES OF THE EXTREMITIES Olecranon displaced in relation to the axis of ! the humerus, but not j movable in relation tO( the ulna. The epic&n-\ dj'les not movable in relation to one another. Displacement back-^ wards. Displacement wards. for- /Epicondyles not displaced ; passive flexion restrained. Epicondyles share in displace- ment, and movable in relation to shaft of humerus; passive movements free, or more e.\-- tensive than normal. I Epicondyles not displaced. I j Epicondyles share in displace- I ment forwards ; passive move- V ments iree. Internal epicondyle movable; I usually displaced distally and dorsal ly. Internal condyle movable. Epicondyles or condyles separately displace- able in relation to the shaft of the humerus. External epicondyle movable. External condyle movable, usually' rotated about go° to Both condyles separately mov- able, in relation to one another and to the shaft of the hu- ^ merus. (S) Posterior dislocation. (9) Supracondylar frac- ture in hyperexten- sion. (10) Dislocation forwards (rare). (11) Supracondylar frac- ture in flexion. (12) Fracture of internal epicondyle. (13) Fracture of internal condyle (verj- rare). (14) Fracture of external epicondyle (very rare). (15) Fracture of external condyle. (16) Y and T Fractures. INFLAMMATORY PROCESSES ABOUT THE ELBOW. (1) ACUTE INFLAMMATORY PROCESSES. Acute inflammation of the soft tissues about the elbow may resemble an acute arthritis, just as in other joints. One should first think of phlegmon of the forearm, originating from a lymphangitis, which is so frequently the result of infected wounds of the hand. The etiology — i.e., a peripheral injury — at once indicates the correct diagnosis. It is not often that the elbow-joint is involved after these injuries. Apart from other symptoms, their chronological order serves to differentiate a superficial phlegmon from an acute arthritis. In the latter, pain and difficulty in movement appear first, and the superficial changes follow ; in the case of a phlegmon, swelling and redness of the skin appear first, and the difficulty of movement later on. If the inflammation is limited to the antero-internal side of the joint, or at least has arisen in this situation, we may conclude with great prob- ability that the phlegmon or the abscess has originated in the glands of tJie dhoiv. If the phlegmon has started behind, we look to the INFLAMMATORY PROCESSES ABOUT THE ELBOW 569 olecranon bursa for its origin. This bursa, like the pre-patellar, has a great tendency to inflammation, and the sHghtest skin abrasion in its vicinity suffices to afford entrance to the cocci and to cause an extensive phlegmon of the whole of the back of tiie elbow region. The more acute the process, the further it encroaches beyond the immediate hmits of the bursa, and extends to the front and to the upper arm. In contrast to this superficial inflammation, which at any rate at first leaves one side of the joint free, in acute arthritis the entire circumference of the joint is painful on pressure. The swelling is most evident where the capsule is most superficial, namely, about the radius and at both sides of the triceps tendon. But the soft parts in front soon swell up, and the whole region of the joint finally becomes Fig. 297. — Tubercle of the elbow. Spindle-shaped swelling 01 the joint. Slight depression at the site of the triceps tendon. red and oedematous. Reference should be made to the remarks on the shoulder-joint for the causes of the inflammation. Let us begin with the soft tissues. There are certain chronic in- flammatory processes on the arm, the diagnosis of which is not clear at first sight. Examination shows that there is no primary disease of the underlying bone, and no portal of entry for organisms is evident. The changes consist of swelling and purulent infiltration of the subcutaneous tissue and of the skin, the brunt of the aft'ection falling either on the one or the other. If any tubercular change, e.g., caries, disease of the tendon sheath, or lupus, be found on the hand, we diagnose the condition of the arm as one of tubercular lyuiphangitis, with its sequelje, tubercular abscess of the soft tissues or tubercular destruction of the skin. Individuals suffering from this form of 570 SURGICAL DISEASES OF THE EXTREMITIES Fig. 298. Tuberculosis of the elbow. (a) Diseased side. Cartilage has disappeared ; bone eaten away, especially on the ulna. Fig. 299. (b) Healthy side. Fig. 300. — Tubercular focus in ulna. Fig. 301. — Chronic inflammation of olecranon bursa. INFLAMMATORY PROCESSES ABOUT THE ELBOW 57 1 tubercle have very little resistance to the bacillus, and we therefore frequently find other foci of the disease present. If there is no indication of this kind, we should think of the purely metastatic tubercle of the soft tissues, which is a rare form, or of syphilitic gumma, which is more likely, or of actinomycosis, which is, however, very rare, in the extremities. Until quite recently our diagnosis might have ended here. But within recent years it has been shown that a special variety of mycelial fungus {Sporotrichiim Beurmanni) may cause persistent changes in the skin, the deeper tissues and even the bones, with signs intermediate between gumma and tubercle. This diagnosis of sporotrichosis has been made in many countries in isolated instances ; but it can only be based on bacteriological examination of the pus — another reason for examining pus, the origin of which is not quite clear. (2) CHRONIC INFLAMMATORY PROCESSES. Chronic inflammation of the elbow depends upon the same causes which we have encountered in chronic disease of the shoulder-joint. If several other joints are involved, we find in the term chronic articular rheumatism, discussed in that connection, a convenient diagnosis rather than a clear conception. If the elbow alone is diseased, it can hardly be anything but tubercle. Careful palpation, comparing both sides, will generally detect the capsule, even if only slightly distended or swollen, in the form of two symmetrical pads (fig. 297) on both sides of the triceps tendon, and as a transverse pad at the level of the head of the radius. If the capsule is definitely thickened, the case must be regarded as one of tubercle, even if there be not much interference with movements. The axilla must always be examined for enlarged glands, although they may be less frequent in tubercular arthritis than in tubercular disease of the skin. Whereas tubercle usually appears in the shoulder-joint in the form of a dry caries, without swelling of the capsule and without effusion, the fungating and caseous-suppurative forms occur most frequently in the elbow, both being accompanied by a moderate amount of effusion. The joint soon assumes a spindle-form shape, and the tendon of the triceps stretches at a slight depth between the two pads of capsule at the back of the joint. It is but rarely that the skiagram indicates any osteoporosis (the purely synovial form). Definite foci in the bone (fig. 300) or superfi- cial portions of the joint eroded away, are usually seen (fig. 298). In exceptional cases I have seen a certain amount of peri-articular formation of new bone, especially when fistulse are present. If the 37 572 SURGICAL DISEASES OF THE EXTREMITIES bone formation is very extensive, it should raise the suspicion of syphihs. A harmless chronic inflammation of the olecranon bursa, corre- sponding to the same condition of the pre-patellar bursa, must not be confused with a localized tuberculosis of the olecranon (fig. 301). Occasionally one comes across persons who complain so per- sistently of pain in the region of the internal epicondyle, that one is inclined to think of tubercle. Sometimes a history of slight injury is given, but more often not. Nothing is to be detected, either by ph3^sical examination or by a skiagram. These cases have been termed epicondylitis (Francke) and the symptom has been attributed to traumatism of the insertion of the ligament and of the peri- osteum ; and to slight inflammatory changes, e.g., after influenza or rheumatism. CHAPTER LXXXV. TUMOURS AND ALLIED SWELLINGS ON THE UPPER ARM AND FOREARM. We encounter the same tumours and swellings in the upper extremity as we shall come across in discussing the lower limb, especially the thigh; but they are rarer in the arm. There is nothing characteristic about the tumours of the skin and the subcutaneous tissue of the upper limb. Only lipoma of the shoulder (fig. 302) and the pendulous lipoma of the axilla (fig. 303) merit special mention. Spindle-shaped tumours, following the course of a nerve, and originating in the deeper soft tissues, are usually neuromata or neuro- fibromata, but may be sarcomata. If the tumour becomes fixed on muscular contraction, we may assume that it has an iniraninscular origin, in which connection we should think of an angioma of the muscle, of a sarcoma, of a gumma or of tubercle. If the swelling can be emptied on pressure, or by elevating the arm, and fills up again when the arm is dependent, it is suggestive of an angioma of the muscle. These signs, however, only apply if the angioma is definitely of the cavernous type. But most of these tumours contain a large amount of connective tissue and of fat, and smooth muscular fibres proliferate therein, so that they feel firm and even hard. The cavernous type is badly defined and extends in a TUMOURS AND ALLIED SWELLIXGS 573 diffuse manner ; but the hard variety is definitely circumscribed and could easily be taken for sarcoma or early tubercle, if it were not for two contra-indicating circumstances — the long duration of the disease, and the attacks of acute swelling (thrombosis) which the patients frequently describe. Tubercle of the muscle appears first as a small oval swelling which is definitely painful on pressure. As long as no suppurative softening and abscess formation bursting through the muscle occur, the diagnosis can only be one of probability, supported by a previous history of tubercle. If an abscess has formed, it is easier to recognize the nature of the disease ; but never- theless it may be impossible in some Fig. 302. — Lipoma of the upper arm. Fig. 303. — Pendulous lipoma of the axilla. circumstances to exclude primary disease of the bone before the operation and without a skiagram. A young man showed me a swelling, which had arisen a few weeks previously, on the anterior surface of the left forearm, in a position where there were no glands. Examination showed that the swelling was either intermuscular or intramuscular ; family history revealed tubercle in a brother. Diagnosis : tubercle of muscle. The operation showed that the major portion of the palmaris longus 574 SURGICAL DISEASES OF THE EXTREMITIES had been converted into a tubercular area, which had not yet sup- purated. If the tumour appears to be neither an angioma nor a tubercle, the question of gumma and of sarcoma, which are rare, will arise. If we find a tumour over the biceps, resembling a pad transversely to the muscle, appearing when the muscle contracts and vanishing when it relaxes (fig. 304), it can only be a hernia of muscle, i.e., a firmly contracted mass of muscle projecting through a space in the aponeurosis. This defect mav be of trau- ' ' 1 i If i Fig. 304. — Hernia of biceps muscle. Fig. 305. — Intramuscular osteoma after a contusioi a, Connected with the periosteum, b. Lying free i the muscle. matic origin ; but it is occasionally bilateral and is probably then a congenital peculiarity. This was the case in the subject depicted in fig. 304, in whom the change was equally pronounced on both sides. If a tumour of bony hardness has developed after an injury — contusion of muscle, laceration of muscle after dislocation — we may assume the case to be one of traumatic osteoma, a circum- scribed ossifying myositis. This is a process intermediate between new growth and inflammation, and occurs mostly in the brachialis intei'nus muscle (fig. 305). TUMOURS AND ALLIED SWELLIXGS 575 Fig. 306. — Gummatous periostitis and ostitis of the humerus and end of the ulna. Fig. 307. — Chronic localized osteomyelitis of the humerus (abscess of bone and sequestrum). Fig. 308. — Old diffuse osteomyelitis of humerus. Fig. 309. — Myelogenous tubercle of lower end of the humerus and of the ulna (in a child). Club-shaped deformity of bone. 57^ SURGICAL DISEASES OF THE EXTREMITIES If a tumour is connected with the bone, and is increasing some- what rapidly, it is necessary to differentiate between tubercle, gumma, osteomyelitis and sarcoma ; if the growth is slow, the diagnosis will lie between sarcoma, fibroma, and chondroma. We should especially think of tubercle of the dinpliysis in children. This condition can easily be mislaken for a chronic osteomyelitis, unless the pus is examined bacteriologically, both in its perioste^d and m37elogenous forms. Aguninia is diagnosed by the history of its comparatively painless course and by a skiagram. I once saw a gummatous swelling which had existed for two years, and which I definitely looked upon as a sarcoma before ascertaining the history and having a skiagram taken. The patient, however, told me that he had had syphilis fifteen years before, and he himself attributed the swelling to this cause. He was right ; the skiagram confirmed his diagnosis (fig. 306), and the swelling vanished after specific treatment. A sarcoma is usually first recognized when its circumference shows that it cannot be either tubercle or gumma. If the, patient consults the doctor soon enough, it is quite possible that a skiagram would enable an early diagnosis to be made. Distension of the bone, if very circumscribed, points to tubercle, but may also indicate sarcoma. Periosteal deposits in children occur in tubercle and in comparatively recent osteomyelitis ; • in adults almost exclusively in the latter condition and in gummata. Diffuse, smooth induration (fig. 308) or slight spindle-shaped distension points to old osteomyelitis which has run its course. The distension may still be concealing a sequestrum (fig. 307). Irregular proliferation of the periosteum must be ascribed to a gumma (fig. 306). A nebulous transparency of the bone in its entire thickness with the loss of details of its structure suggests a sarcoma. CHAPTER LXXXVI. INJURIES OF THE WRIST AND HAND. (1) RADIUS AND ULNA. The diagnosis of injuries of the wrist was a very simple matter before the time of X-rays. Anything which was not a fracture of the radius was a sprain, and vice versa. Dislocation of the wrist was looked upon as a curiosity, and it was asserted that the injury was so rare that it could not be diagnosed. The X-rays have shed some light upon this comfortable simplicity, but at the same time have INJURIES OF THE WRIST AXD HAND 577 raised new problems of diagnosis. In addition to fracture of the radius there are also numerous injuries and displacement of the carpal bones and their combinations. If these could only be recognized by X-rays, the matter would be no more difficult in practice than heretofore. Cases previously diagnosed as sprains would now be sent straightway to the radiographer as "injuries to the wrist," and nobody would take the trouble to attempt to diagnose a fracture of the radius. But fortunately these injuries can be diagnosed without X-rays if they are properly examined. Fracture of the radius with pronounced fork-like posterior displacement need not detain us. It cannot be mistaken for any- thing else, if the classical symptoms are present, viz., displacement of the antei-ior fragment with the hand posteriorly and towards the radial side, freedom of the wrist-joint (fig. 311) and deviation of the styloid process of the radius with the wrist away from the axis of the radius (fig. 312). Fig. 310. — Sub-periosteal green- stick fracture. Fig. 311. — Fork-like posterior displacement, withfraclure of radius (case of detachment of epiphysis with great displacement). The styloid process of the ulna is usually broken off in distal fractures (fig. 314, &c.), and the entire lower end of the ulna in more proximal fractures (fig. 319). This latter variety usually occurs in children and in old people with weak bones. Further back, there occurs the greenstick fracture which is so common among children (fig- 310)- If the fracture involves the joint, and the displacement is not very pronounced, the diagnosis is more difficult, for we have to take into consideration both sprains and injuries to the carpus. If the movements of the wrist-joint are free and painless, there can be no damage therein, so that if there be an injury at all it must involve the radius at some distance from the joint. If the movements 578 SURGICAL DISEASES OF THE EXTREAIITIES are painful or cannot be carried out, it is obvious that the joint is affected. If, after fixing the joint so as to prevent any movement therein, pressure in the axis of the forearm causes no pain, we may exclude a recent transverse fracture oi the radius. But, on the other hand, if it does cause pain, we may only attribute it to a fracture if it is distinctly localized on the elbow side of the wrist-joint. After this preliminary examination, we proceed to a more accurate palpation. If the styloid process of the radius or ulna is very painful on pressure, and if it is also somewhat thickened, we may conclude that there is a frac- ture, even if it is not possible to feel a movable fragment distinctly. We then feel the radius carefully from before back- wards, and as a control from behind forwards, ascertain- ing, point by point, the amount of pain on pressure. If there is no very pro- nounced pain, it is certain that there is no fracture. But if there is a position, on the elbow side of the end of the radius, wherein a definite and circumscribed pain on pressure exists, we must as- sume that there is a fracture of the radius, even if there be no visible displacement, which may, of course, be concealed by the general swelling. If this circum- scribed pain on pressure can be traced over the whole width of the radius, the case is an ordinary transverse extra-articular fracture (figs. 315 to 318) ; but if the pain is only pronounced at the outer side and if, at the same time, there is some effusion into the joint, the case is one of an oblique fracture involving the joint (fig. 321). This variety of fracture, described by Baiton some seventy years ago, w^as at that time the subject of considerable controversy. We now know, thanks to the X-rays, that this fracture is not at all rare. The presence of articular effusion, or at least of hampered activity *& .1 fjQ_ 212. — Deviation of hand from the radius in a case of fractured radius. INJURIES OF THE WRIST AND HAXD 579 of the joint, in association with more or less pain on pressure in a transverse direction, should raise the suspicion of a combined fracture, the ordinary varieties of which are illustrated in figs. 322 and 323. These fractures also occur more frequently than was previously thought. On the other hand, an isolated fracture of that portion of the end of the radius which is turned towards the ulna is very much rarer. Such a fracture may be suspected when there is a locahzed pain on pressure between the radius and ulna, and when the movement of rotation is painful. A separation of the epiphysis must be thought of if the fracture is situated in the vicinity of the epiphyseal line in a young person. These injuries are often accompanied by damage to the bone itself, in that the line of the transverse fracture only corresponds partially to the cartilaginous end, or by the existence of a longitudinal fissure in the bone — which, however, is rare (fig. 313). We must refer to another variety of fracture, which occurs mostly among young people. This is illustrated in figs. 317 and 318, wherein the fracture is caused by sudden axial pressure, for instance, a fall on the palm of the hand. In this case there is neither false ixiobility nor displacement. The loss of power is often so slight that no fracture is suspected. But careful examination will show that there is a sharply defined transverse area of pain on pressure, above the edge of the radius over the whole extent of the metaphysis. The skiagram reveals on either side a slight roof-like projection of the bone, showing that the radius has been compressed and that the crushed bone has been pushed out laterally because of the msufficient strength of the bone in its long axis. If it is certain that a fracture of the radius is present, we must examine for the injuries which so often accompany this accident, namely, detachment of the styloid process of the ulna and fracture of the scaphoid (see below). (2) WRIST-JOINT. If nothing is found in the radius, we must consider whether the carpal bones have sustained any injury, or whether the case is one of a simple sprain. The typical examples of the former consist of palmar dislocation of the semilunar bone, fracture of the scaphoid, and a combination of the two. (a) If we find, under the flexor tendons, a bony protuberance projecting towards the palm, or even only a marked thickening of the skeleton of the wrist in an antero-posterior plane, in a case wherein the joint is very painful and has lost its power, we must assume that there is probably a palmar dislocation of the semilunar bone. This diagnosis would be confirmed by the subsequent onset of neuralgia in the terminal fibres of the median nerve. These injuries are nearly always recognizable in skiagrams taken 58o SURGICAL DISEASES OF THE EXTREMITIES Fig. 313. — Commencing separation of the epi- physis of radius, wilh a longitudinal fissure. Fig. 314. — Transverse fracture of radius, with detachment of styloid process of ulna. Fig. 315. — Separation of epiphysis of radius, with displacement of radius backwards. Patient aged 19. (Case of fig. 311.) Fig. 316. — Same case, from the side. INJURIES OF THE WRIST AND HAND 581 Fig. 317- — Fracture of radius, caused by axial pressure, in a boy aged 10. Fig. 318. — Same case, from the side. Fig. 319. — Fracture of radius far back, with detachment and partial shattering of lower end of ulna. Fig. 320. — Same case, from the side. 582 SURGICAL DISEASES OF THE EXTREMITIES Fig. 321. — Oblique fracture of lower end of radius. Fig. 322.— Combined fracture of radius. (Oblique fracture on the radial and ulnar side.) Fig. 323. — Combined fracture of radius. (Transverse fracture, with oblique fracture on the ulnar side.) Fig. 324. — Dorsal deviation of the distal frag- ment in a case of fractured radius. (An old case, in which line of fracture is still clearly recognizable.) INJURIES OF THE WKIST AND HAND 583 Fig. 325. — Normal wrist-joint. Fig. 326. —Palmar dislocation of the semilunar bone. Fig. 327. — Normal wrist. C = Os magnum. N = Scaphoid. L = Semilunar. Fig. 328.— Palmar dislocation of the semilunar. References as in previous figure. 5S4 SURGICAL diseasp:s of the extremities in the dorso-palmar position. The semilunar is somewhat obHquely directed towards the scaphoid, and its distal articular surface look- ing towards the radius is easily detected (c/. figs. 325, 326). A skiagram taken in the lateral position always exiiibits these injuries very clearly, and this measure should never be neglected in any obscure injury of the carpus. Such a skiagram shows the semilunar bone deviated towards the palm, with the head of the os magnum lying upon its dorsal surface {cf. figs. 327 an d 328). In these cases the os magnum might be looked upon as dislocated just as well as the semilunar. {h) If in addition to a moderate amount of palmar projection, there is definite pain on pressure over the scaphoid with shortening of the carpal region, and probably also some radial displacement of the hand, we must assume ! : '^ f'^M i ^^^^^ ^^^ wrist has sus- "^ tained a combined injury. This combined injury usually consists, as I have shown, of fracture of the scaphoid with palmar dis- location of the semilunar and the proximal fragment of the scaphoid attached to it. We term this for convenience the typical intercarpal dislocation fracture. Fig. 330 is taken from the case, in which both sides were affected, which first suggested to me the typical character of this injury. Sometimes there is a transverse fracture of the os magnum combined with tlie injury ; the styloid process of the radius or of the ulna may also be broken off occasionally. A definite fracture of the radius may even be present. (c) If there be no abnormal bulging we must dift'erentiate mainly between a simple fracture of the scaphoid and a pure sprain— apart from anything^exceptional. If both fragments of the broken scaphoid retain their normal position, as is often the case, the only sign of fracture of the scaphoid may be a narrowly circumscribed and per- sistent pain on pressure over the broken bone, i.e., in an area distal and internal to the easily felt styloid process of the radius. This pain on pressure sometimes permits us to suspect this fracture long after the infliction of the injury. The diagnosis is easier Fig. 329. -Transverse fracture of the scaphoid without displacement. when the INJURIES OF THE WRIST AND HAND 585 proximal fragment is displaced towards the palm, because a careful comparison of the two hands would probably show that there was a projection towards the palm on one radial side. A skiagram usually demonstrates a fracture of the scaphoid at the first glance (fig. .329). Doubt can only arise if the scaphoid is placed steeply, so that its distal portion overlays its proximal portion. The skiagram is then liable to erroneous interpretation, as occurred so often when X-ray diagnosis was in its infancy. When the scaphoid is in such a position it is not possible to recognize fracture thereof at the first glance (see, e.g., the scaphoid in fig. 323). A control skiagram must therefore be taken with the wrist slightly flexed and adducted towards the ulna. If there is no local pain on pres- sure over the scap- hoid, we are justified in limiting the clin- ical diagnosis to that of a sprain. But if pain persists after an injury which has been assumed to be a wrench, or if any doubt exists from the first, we must resort to an X-ray examination. This will probably show that we have missed some injury which is not palpable, e.g., a contused fracture of the semilunar bone which can hardly be detected without an X-ray examination, and which may lead to atrophy or to the partial formation of a sequestrum. I have seen such an injury occur as a result of an indirect trauma. It is most important to make an X-ray examination in all injuries resulting from accidents, which we may be inclined, perhaps unjustifi- ably, to attribute to malingering and exaggeration. If the skiagram fails to reveal anything, we may then definitely speak of a sprain, and make our prognosis accordingly. We have hitherto confined ourselves to injuries which frequently occur in practice, and the diagnosis of which is important for the general practitioner. But there are, in addition, rare dislocations in the radiocarpal joint, in the intercarpal joints and carpo-metacarpal Fig. 330. — Typical intercarpal dislocation-fracture. (Frac- ture of the scaphoid, with palmar dislocaiion of the semilunar, L, and of the proximal fragmtnt of the scaphoid, N2-) 586 SURGICAL DISEASES OF THE EXTREMITIES joints, some of which can be diagnosed by careful palpation, taking into consideration the position of the styloid processes, but which can all be definitely diagnosed by means of X-rays. (3) THE METACARPUS AND FINGERS. Fracture of the metacarpals can easily be distinguished from simple contusions bv traction and pressure on the corresponding fingers. Only a longitudinal fracture would remain painless on such manipulation. Fracture of the base of the first metacarpal may be mentioned as a typical, though not as a frequent injury. It is usually regarded as a sprained thumb, but the persistent pain shows that some more severe injury is present. The skiagram shows Fig. 331. — Contusion fracture of semilunar X (trau- matic softening). Fig. 332.- -Fracture of the base of first metacarpal. either a transverse fracture of the upper end of the base (fig. 332), or a piece of bone broken off its palmar surface (Bennett's fracture). The circulatory disturbances which follow injuries of the bones and soft parts are "^most pronounced on the back of the hand, just as in the case of inflammation. They are liable to persist in this position for a considerable time, even if they are not kept up by the manipulation of the patient who is insured against accidents. This condition has been termed " hard traumatic cedema of the back of the hand " (Secretan), but it has also been shown to be the result of percussion, practised by those who shirk work while seeking compensation. INJURIES OF THE WRIST AXD HAND 587 Fractures and dislocations of the fingers are so easy to recognize that they need not detain us. The same apphes to dislocation of the thumb, so well known, because of the difficulty of its reduction. It is an injury which cannot be mistaken for anything else. The following scheme summarizes the foregoing remarks on injuries of the wrist : — No deformity of bone, evident on inspec- tion or palpation. ' Radius nowhere showing any localized pain on pressure ; carpus usually somewhat swollen ; loss" of power always pro- nounced ; Rbntgen rays always required. , Radius painful on localized pressure, behiyid the line' of the wrist-ioint. Pain on pressure diffuse. Localized pain on pressure in the tabatiere. Localized pain on pres- sure over the semilunar (middle of the back of carpus). Wrist free ; the pain on pressure runs in a trans- verse direction. Wrist swollen ; loss of power ; pain on pressure close to dorsal edge of ' radius. (ij Sprain of hand. (2) Fracture of scaphoid. (3) Contused fracture of the semilunar. (4) Extra-articular trans- verse fracture of the radius, (5) Fracture of radius ex- tending into joint. Definite deformitj' cf wrist. Shape of wrist like the back of a fork, with the bend more towards the elbow. , Joint free. Shape of wrist like the back of a fork, with the bend-{ near the carpus. (6) Extra-articular fracture of radius, 3-4 cm. or more behind the joint ; usually with detach- ment of lower end of ulna. (7) Extra-articular fracture of radius near joint : often with fracture of stj-loid process of ulna (also separation of epi- physis). (3) Intra-articular fracture of radius (oblique frac- ture or transverse and oblique fracture). , Xo definite shortening of (9) Dislocation of the hand ; localized promin- semilunar. I ence of bone under the Dorso-palmar thickening of ! fle.xor tendons, the joint without definite-? fork shape of wrist. ! Shortening of hand ; large (10) Inter-carpal disloca- ■ mass of bone imder the tion - fracture (frac- I flexor tendons; pain on ture of scaphoid and ^ pressure over tabatiere. dislocation of semi- lunar) ; not rare. Joint swollen, tender and stiff. 38 -588 SURGICAL DISEASES OF THE EXTREMITIES CHAPTER LXXXVII. INFLAMMATORY PROCESSES ABOUT THE WRIST. (1) ACUTE INFLAMMATIONS. We need only briefly refer to the severe inflammatory oedeixia of the back of the hand, which may follow any infected wound of the skin, either on the palm or on the dorsum. We must, however, deal in more detail with inflammations of the tendon-sheaths, wherein there may be some doubt at first as to the primary seat of the in- flammation. If the patient states that the swelling has followed a perforated wound of the finger, or a bite, &c., we should at once think of the tendon sheaths, because such insignificant peripheral wounds frequently lead to acute suppuration within them. The character of the loss of power furnishes an important differen- tiating sign. Inflammation of the tendon sheath especially interferes with the movements of ilie fingers, whereas disease of the joint affects the movements of the wrist. An inflamed wrist is painful all over, whereas in inflammation of the tendon sheaths the aft'ected side only is painful. In acute arthritis, traction and pressure in the axis of the wrist is painful, but this is not the case when the tendon sheaths are inflamed. Finally, teno-synovitis always spreads in a longitudinal direction, whereas arthritis remains limited to the neighbourhood of the joint. It sometimes happens that the joint becomes secondarily involved after a primary inflammation of the tendon sheaths. We may assume that such an event has occurred if pain, oedema and pyrexia persist, despite the opening of all superficial areas of pus, or if we feel and hear a sound of grating on moving the joint. This latter sign indicates that the articular cartilage has been partially separated or destroyed by the inflammation. On the other hand, the tendon ■sheaths may become secondarily involved as a result of disease in the joint or in the bones. If the teno-synovitis has extended to the forearm, and is accom- panied by fever, oedema and pain, we must carefull}'- search for suppuration in order to make a timely incision into the abscess. As this is often situated deeply on the interosseous ligament, we must not wait for fluctuation before making a diagnosis. Having diagnosed an inflammation of the joint, we must next determine its natnre and its canse. If other joints are also affected, and the inflammation subsides after the administration of salicylates, we may assume that the case is one of acute articular rheumatism. If only one joint is aft'ected, and -the salicylates are ineftective, gonorrhoea is the most probable INFLAMMATORY PKOCESSES ABOUT THE WRIST 589 •cause, even if an injury is invoked as a pretext, or has aclually happened. An hotel servant sought to claim his accident compensation because •of an acute swelling of his wrist, having sprained it in lifting a portmanteau. When asked whether he had had gonorrhoea, he at once gave the desired reply. The lifting of the portmanteau was merely the occasion of the first appearance of symptoms of inflam- mation ; although, of course, the sprain may have favoured the attack of the gonococci on the joint. The patient should produce the most irrefutable evidence of an accident before an injury can be made responsible, even in a limited manner, for such an arthritis. For the rest we may refer to what has already been said in connection with the shoulder-joint. In a few cases the diagnosis must be made by the course of the disease. Acute articular rheu- matism runs a rapid course and does not usually impair the power of the joint ; gonorrhoea takes a long time to recover, often lasting for months. In some cases it leaves the joint free, in others stiff. Staphylococci and streptococcic infection lead, as a rule, to suppuration and to partial stiffening. (2) CHRONIC INFLAMMATORY PROCESSES. No difficulty usually attends the diagnosis of inflammation of the wrist, which is chronic from the start. If several joints have been affected symmetrically, the case is one of chronic articular rheu- matism, the varieties and causes of which have already been dis- cussed in connection with inflammations of the shoulder-joint. If, on the other hand, only one wrist is affected, there is no alterna- tive but to assume that the case is one of tubercle (fig. 334). It is most important to recognize this condition in its early stages. If the extent of the movements at the wrist gradually becomes restricted, if those which are executed are painful, if there is also slight pain on pressure, and some muscular atrophy supervenes in the forearm, we should think of tubercle, even though there be no visible swelling. If there is swelling, the question as to its differeiitia- tion from tubercular teno-synovitis may arise. The clinical pictures of the two diseases are, however, quite different. In tubercle of the joint the whole wrist is thickened in a spindle-shaped manner, in advanced cases the hand is in a position of slight palmar dislocation with complete extension of the fingers (fig. 334). The pain on pressure is equally pronounced on both sides of the joint, and there is also pain on traction or pressure in the axis of the wrist, as well as on any attempt at active or passive movements of the joint. In teno-synovitis, however, the swelling is only on one side, generally 590 SURGICAL DISEASES OF THE EXTREMITIES Fig. 333. — Wrist in arthritis deformans. Fig. 334. — Tubercle of the wrist. Fig. 335. — Tubercular leno-synovitis of the flexor tendons. Fingers slightly contracted in flexion. INP^LAMMATORV PROCESSES ABOUT THE WRIST 591 Fic. 336. — Arthritis deformans. (Skiagram of fig. 333.) Fig. 337. — Tubercular arthritis. Fig. 338. — Acute maculated osteoporosis in a case of complicated fracture of the elbow. Fig. 339. — Rickety changes in bone. 592 SURGICAL DISEASES OF THE EXTREMITIES on the palmar surface, and its maximum degree is not at the level of the wrist, where the tendon sheath is firmly bound down by the- strong anterior carpal ligament, but either proximally or distally thereto (see fig. 335). The fingers are not extended, but are slightly contracted in fiexion, and there is no palmar subluxation of the hand. If there be any pain on pressure, it is limited to the aft'ected surface.. The movements of the joint are only mechanically hindered by the swelling, but are scarcely painful. Pressure on the joint causes no pain. If the joint is stiff and the movements of the fingers very restricted, and if fistulas are present, it is neither necessary to inoculate guinea- pigs nor to take a skiagram in order to establish the diagnosis of tubercular arthritis. A skiagram gives valuable information in all stages of the disease concerning the site and extent of the affection of the bone, and of the condition of the articular cartilage. In the early stage of synovial disease, X-ray examination only shows a diffuse osteoporosis, which differs by its greater uniformity from the acute maculated osteo- porosis which occurs in acute inflammatory processes and in fractures (t^g-33S). If the disease starts in the bone, it can be recognized very early,. In both forms the cartilage disappears in the couise of the disease, and the individual bones come into direct contact. In the later stages the bones appear merely as shapeless and nebulous structures (fig- 337)- The extreme degree of bony changes which may exist in arthritis- deformans is shown in fig. 336. It is interesting to compare with it a. skiagram of a case of rickets (fig. 339). CHAPTER LXXXVIII. ABNORMAL POSITIONS AND POSTURES OF THE HAND AND FINGERS. ^.—RESULTS OF INJURIES TO NERVES. We have already referred on various occasions to paralytic con- ditions of the upper limb, which are of surgical importance. But it may not be superfluous to briefly summarize what has already beert said, and to make a few amplifications. Two questions arise in every case of paralysis : — (i) Which muscles are paralysed ? ABXORMAL POSITIOXS AND POSTURES OF THE HAXD AND FINGERS 595 (2) Where is tlie interruption in the conducting path of the nerve ? The reply to the first question only demands a knowledge of muscular function and a careful examination. Often a mere glance at the patient suffices for an approximate diagnosis, when the limb is held m a characteristic posture. If the hand hangs prone and lax, and the fingers cannot be extended, it is obvious that the case is one of radial nerve paralysis. If the thumb is extended against the index finger and cannot be moved away from this position, we should think of paralysis of Hie median nerve, and should test the power of abduc- tion and flexion of the index and middle fingers especially. If this, power is lost, and if at the same time the sensibility of the dorsal surface of the terminal phalanges is abolished, there can be no doubt about the diagnosis. If, on the other hand, the thumb cannot be- actively approximated to the hidex finger, if the basal phalanges of the second and fifth fingers are slightly over-extended while the middle and terminal phalanges are slightly flexed, we should at once suspect paralysis of the nlnar nerve. It is easier to diagnose this condition at a first glance in the later stages, when the thumb, hypothenar eminence, and interossei are atrophied and the fingers have assumed the well-known posture of "main en grift'e," i.e., over-extension of the basal phalanges with severe flexion of the middle and terminal phalanges (fig. 346). If the patient cannot actively raise his arm at the shoulder, though the movement can be performed passively without difficulty, we should thhik of paralysis of the circumflex nerve, and should test whether there is any loss of sensation in the area to which the sensory branches of the nerve are distributed (over the deltoid muscle). The second question, relating to the site of the damage, is, however, of greater importance from the point of view of surgical treatment. This is frequently quite clear from the original cause of the disturb- ance {e.g., aneurism, tumour, &c.), or from the position of an injury, such as a cut, stab, or fracture of bone. Cuts over the wrist, which frequently involve the ulnar or even the median nerve, and fractures of the humerus, which may sacrifice the radial nerve, are mainly responsible. At the level of the shoulder-joint the dislocated head of the humerus may bruise the circumflex nerve, or, more rarely, one of the lai-ge cords of the brachial plexus. In the supraclavicular region the plexus may be directly injured, or mdirectly, by means of a. fragment of a broken clavicle. In the absence of any such indication, or in cases wherem the- injury involves simultaneously several sections of the limb, we should always give the preference to the causation which is able to attribute all the paralysis to one individual lesion. An example wiU make this clear. 594 SURGICAL DISEASES OF THE EXTREMITIES A workman was hit on the head and shoulder by a large block of stone. When we saw him a few weeks subsequently, we were particu- larly struck by the posture of the left hand, which corresponded to that of radial paralysis. A fracture of the upper third of the humerus, which had healed somewhat at an angle, appeared at first sight to furnish the required explanation. But further examination showed that not only did the paralysis concern the extensors of the fingers and wrist and the supinators, but that it also involved the deltoid muscle, and that there was loss of sensation over the area supplied by the circumflex nerve. All this made it evident that the circumflex nerve was damaged when the fracture of the upper arm occurred. But this did not explain the paralysis and atrophy of the supra- spinatus and infraspinatus muscles, which were no less striking than the other paralysis. There must, therefore, have been some injury higher up, and, as a matter of fact, there was a badly united fracture of the clavicle, the peripheral end of whose ceritral fragment exactly corresponded with the position of Erb's point. We were obviously not dealing with separate paralvses of the radial, circumflex and suprascapular nerves, but with a contusion of the nerve cord composed of the fifth and sixth roots, between the clavicle and the first rib — the so-called Erb's point. The accuracy of this assumption was proved by the fact that the muscles whose nerve supply corresponded exactly with the fifth and sixth roots were com- pletely paralysed, i.e., the supraspinatus, infraspinatus, deltoid, coraco brachialis, brachialis anticus, supinator longus and brevis. The nerve fibres to the long extensors of fingers, which are given off much lower down, were, however, evidently less directly involved, and the corresponding muscles therefore suffered less damage. Just as damage to the upper roots of the brachial plexus, causing Erb's paralysis, produces a fairly uniform clinical picture, notwith- standing certain irregularities, a similar result follows from damage to the lower roots, causing Klumpke's paralysis. In this condition, the paralysis of the small muscles of the hand, and the disturbed sensation in the region of the median and ulnar nerve, are combined with oculo-pupillary derangements, such as miosis, narrowing of the palpebral fissure and retraction of the eveball. The more protected position of the lower roots usuallv prevents their exposure to injury, and therefore Klumpke's paralysis is more frequently encountered as a result of tumours or inflammatory diseases of bone {e.g., spinal caries). The patient has not always paratysis when he consults the surgeon. The latter often has more occasion to see paralyses of the upper ex- tremity arise as a result of treatment. These include aucvsthesia paralysis, Esumrch's paralysis and crutch palsw The first condition usually represents paralysis of the circumflex or radial nerve, and depends upon compression of the nerve-roots between the humerus and thorax, or between the humerus and the edge of the operating table, when the arm is raised. The mechanism ABNORMAL POSITIONS AND POSTURES OF THE HAND AND FINGERS 595 of the two other forms of paralysis requires no further explanation. In all the three forms the motor fibres are usually alone affected, and spontaneous recovery occurs in a few weeks, or at latest in a few months. The course of ischaemic paralysis which comes on after too tight an application of a firm bandage, is quite different, because in such a case there is direct damage to the muscle in consequence of the deficient blood supply. The final result is not one of recovery but a fibrous degeneration of the muscle with contracture, in other words a permanent damage. Fig. ^40. — Manus vara. Absence of radius and of thumb. Fig. 341. — Skiagram of same case. ^.—ABNORMAL POSTURES OF THE WRIST-JOINT. Abnormal postures of the hand are less frequent than those of the foot. Apart from ordinary traumatic deformities we distinguish congenital manus vara and acquired manus valga. Manus vara, clubbed hand, which is generally seen in infants, always indicates a partial or complete defect in the radius. The thumb is often absent in these cases (figs. 340 and 341). 596 SURGICAL DISEASES OF THE EXTREMITIES Fig. 342. — Manus valga. Madelung's deformity or the hand. Fig. 343. — Radio-ulnar skiagram of the same case. Fig. 344. — Dorso-palmar skiagram of the same case. ABNORMAL POSITIONS AXD POSTURES OF THE HAXD AND FINGERS 597 M a n u s valga, " ^la- delung's de- form i t \' o f the hand," occurs, not very infre- quently, in females. The hand looks as if it had sus- tained a pal- mar sublux- ation. The lower end of the ulna is entirely dis- placed from its normal connections and projects m.arkedly towards the dorsum. There is pain for a certain period of the disease, just as in genu valgum and pes valgus, and then it completely disappears. The cause of this condition is not so much the result of occupation, as was originally thought, but is due to some change in the bone, depending upon curvature of the whole radius, resulting from late rickets. Its distal articular sur- face inclines towards the uhia and towards the palm, and thus allows the whole carpus to glide palmwards, causing a subluxa- tion (figs. 343 and 344). The diagnosis is made at first sight. It is but rarely that separa- tion of the epiphysis due to injury Fig. 345. — Bilateral Dupuytren's contraction. Fig. 346.— Contracture in ulnar paralysis. ives rise to this kind of deformitv. A traumatic origin might. be suspected if the manus valga were distinctly unilateral. 598 SURGICAL DISEASES OF THE EXTREMITIES C— ANOxMALIES IN THE POSTURE OF THE FIXGERS. We mention first among the anomalies of posture of surgical interest, the bent little finger which is sometimes hereditary, but is a cosmetic fault rather than a deformity. The anomalies of posture which may supervene after trauma and after tubercle of the bones are both innumerable and irregular. Dupuytren's contraction of the palmar aponeurosis forms quite a characteristic picture. At first the patient merely notices that he can no longer fully extend his fourth and fifth fingers. On examina- tion there will be found a localized remarkably hard thickening of the palmar aponeurosis running towards the affected fingers. The •skin also exhibits swellings alternating with retracted areas. The disease usually involves both hands symmetrically, or one becomes affected soon after the other. Extension of the affected fingers becomes more and more difficult ; the thick swelling continues to ■extend towards the hand and the fingers, the process involving one finger after another, sometimes even the thumb. The posture of the fingers is so striking that it cannot be overlooked or mistaken for anything else. In rare cases an injury has been suggested as the cause ; in other cases, a tendency to gout and nervous influence have been blamed, and I have seen alcohol suspected in more than one instance. In the majority of cases the etiology is quite obscure. It occasionally happens that a contracture, which we must regard as Dupuytren's, is said to have come on after an injury in a case where there is some prospect of compensation. If the other hand also shows the beginning of a contracture we must not then attribute much significance to the unilateral injury. We may also refer incidentally to the trigger fmger. This symptom -consists of the arrest of the movement of the finger in a certain position and its sudden advance with a jerk as a further effort is made. The ■symptom may depend upon some joint disease, e.g., on some abnor- mality in the shape of the articular ends due to injury or inflammation. I3at the cause is usually to be found in the tendon or tendon-sheath, and consists of a localized thickening, which produces mechanical •obstruction in one definite position of the finger. TUMOURS OF THE HAND AND FINGERS 599 CHAPTER LXXXIX. . TUMOURS OF THE HAND AND FINGERS. ,4._IXX0CEXT TUMOURS. The most frequent tumour-like swelling is known as a ganglion. As we now know that these structures represent areas of gelatinous degeneration in the connective tissue of the joint capsule, and arise independently of the synovial sheath of the tendons and of the joint, we no longer trouble ourselves to difi'erentiate between tendo- genous and arthrogenous ganglions. They have nothing to do with tendon sheaths, but are closely related to the joint capsule, because they arise within its tissue. If there is any communication present, it must have arisen secondarily. It follow^s from the origin of the ganglion that its cavity is only separated from the joint cavity by a thin layer of connective tissue, which lies directly upon the synovial membrane. Unless, therefore, we proceed with the utmost care in extirpating a ganglion, we must be prepared for opening the joint over a limited area. There is, of course, no harm in this, if asepsis is maintained. Some quacks tell their patients that a " nerve is displaced," in order to impress them with the belief that they are able to replace it, I know of a quack who provided every disease or injury of the limbs with this diagnosis, and nevertheless, or perhaps because of it, had a large clientele. Voltaire says, quite justly, that quackery started when the first swindler discovered the first fool. One point is of diagnostic interest. It sometimes happens, in cases of tubercular wrist, that granulation masses of tubercle protrude betw^een the tendons as far as the skin, as visible, separate tumours. Oilier has described cases wherein only a localized protrusion of the capsule has become affected with tubercle (tuberculomes juxtasynoviaux). I had such a case, in which the wrist movements were perfectly free, and 1 proceeded to operate in the belief that an ordinary ganglion was present. 'Sly mistake only appeared during the operation. Cystic tumours of the hand and fingers are either sebaceous cysts, w^hich are usually situated on the dorsum, or traumatic epithelial cysts, which are always found in the palm. The latter are generally considered to be due to some trauma which has displaced some epithelial cells into the deeper tissues. Franke thinks that some of these cysts are of congenital origin. Lipomata are generally on the palmar surface, but they may grow between the metacarpal bones and appear on the dorsum. Like tuberculosis of the tendon-sheaths, they may spread towards the 6oo SURGICAL DISEASES OF THli EXTREMITIES fingers, but in contrast thereto they always come to a termination at the carpal ligament. Fibromata always present their usual characters : they are well encapsuled, are hard, and grow slowly in the tissue of the true skin, the palmar aponeurosis, the tendon-sheaths or the tendons. They frequently cause neuralgic pain. Angiomata occur in every variety, as telangiectases, cavernous angiomata, and as circinate angiomata. They are situated in the skin, in the subcutaneous connective tissue or in the muscle. Sometimes an injury appears to be the cause of the origin of an angioma. Chondromata have a very characteristic appearance. They occur as hard nodulai- growths of the fingers, and are often multiple, just as those which occur in connection with the toes (which see). Fig. 347. — Ganglion of wrist. Finally, one should refer to a small inflammatory tumour, which is .occasionally found on the hand or fingers. It is about the size of a -pea, or somewhat larger, resembles a raspberry in appearance, has a -thin stalk and is surrounded by a collar of epidermis. It is a granuloma, first described by Poncet and Berard as botriomycosis, and is essentially a disease of horses. The one observer attributed it to a definite variety of Staphylococcus botriouiyces ; the other, to the Stapliylococcns aureus. The appearance of the tumour is so charac- teristic that it cannot be mistaken if once seen. Histologically, it is a telangiectatic granuloma. B.— MALIGNANT TUMOURS. The principal malignant tumours which occur on the hands and fingers are sarcomata and cancer of the skin. Sarcomata have been seen on all parts of the hand, but most ACUTE IXFLA-MMATORY PROCESSES OF THE HAND AND FIXGERS 6ol frequently on the fingers. They may arise in the skin, in the tendons or tendon-sheaths, or in the bones, in which latter case they may be mistaken for chrondromata. Cutaneous cancer always occurs on the back of the hand. It appears at first as a flat, more or less warty growth, which subse- FlG. 348. — Cancer of the back of hand. quently ulcerates extensively and assumes the usual characters of cancer (see fig. 348). Cutaneous cancer, arising from chronic X-ray dermatitis, or from localized hyperkeratosis independently thereof, deserves special mention, as many well-known radiographers have fallen victims to it. CHAPTER XC. ACUTE INFLAMMATORY PROCESSES OF THE HAND AND FINGERS. .4.— INFLAMMATORY PROCESSES OF THE FIXGERS. Although inflammatory processes of the hand and fingers are routine matters of minor surgery, they do occasionally raise interesting problems. If a patient comes with a swollen and inflamed finger, as a rule we diagnose a whitlow forthwith. But this does not complete our diagnostic task. Several diseases sail under the flag of whitlow, and we shall deal with them briefly. We must anticipate, by insisting upon a careful examination for lymphangitis of the arm, and enlarged glands of the axilla, in every case 602 SURGICAL DISEASES OF THE EXTREMITIES of infective disease of the fingers. A trifling wound of the finger, which may have been healed within a few days, can lead to enlarged glands of the axilla and subsequent suppuration. (a) Dermatitis. — A patient consults us for a severely swollen and inflamed middle finger, which looks more hke a beetroot than anything. else. He states that he had sustained a slight injury to the skin, which he treated by lysol fomentations on the direction of his doctor. The finger became swollen, and as the swelling increased, the more- assiduous was he with the lysol fomentations. It is clear on examina- tion that the two contiguous surfaces of the neighbouring fingers are inflamed, in addition to the middle finger. There is no extension of the inflammation to the hand or the arm in the form of lymphangitis ;. neither are there any general symptoms of infection. There is no sign of disease in the bone or tendon sheath, and the original wound is almost healed. Considering the entire condition, and especially the involvement of the two contiguous surfaces of the adjoining fingers, we are bound to assume that the case is one of drug" dermatitis. The abandonment of all disinfectants and a dressing of simple ointment soon caused all the symptoms to disappear. A similar condition may attend other disinfectants, for instance corrosive sublimate, and especiallv iodoform. Iodoform dermatitis- was a very common occurrence when the practitioner used to think that he had not discharged his duty adequately unless his patient reeked of iodoform. Where the infective inflammation is deeply seated, the skin is tense and elastic, the epidermis smooth and shining. In drug dermatitis the superficial epidermis is infiltrated, uneven and rather rough, and is often raised by numerous little definite vesicles, or even by large blebs. I once saw a slight wound of the finger, treated by sublimate compresses to prevent infection, which resulted in bulbous der- matitis reaching to the shoulder. The whole arm resembled an enormous sausage and was covered all over with blisters. In this case also the patient applied the compresses the more diligently as the dermatitis mcreased. If the infection is deeply situated the patient complains of a stabbing, boring, aching pain, which prevents any rest, either by day or night ; in dermatitis, however, the complaint is rather of a trouble- some irritation and burning. In the former case local pressure causes great pain, in the latter case very little. (b) Primary inflammations of the bed of the nail. If the in- flammation starts superficially at a circumscribed spot and gradually spreads to the whole phalanx, the case is one of infection of the nail- bed, even if the bone necroses subsequently. If the inflammation does not involve the bone, and nevertheless fails to subside in the ordinary manner, w^e should remember that a primary chancre has often been mistaken for a whitlow, and also that ACUTE INFLAMMATORY PROCESSES OF THE HAND AND FINGERS 603 there is such a condition as paronychia syphilitica, in the secondary stage. If the patient exhibits a striking tendency to whitlows, although his occupation does not predispose towards them, we should examine for syringo-myelia (fig. 352), Raynaud's disease, and diabetes. An ordinary whitlow, which runs a particularly severe course, is always suggestive of diabetes. (c) An inflammation situated in the subcutaneous cellular tissue is distinguished from one due to primary disease of the bone by the fact that it is of very limited extent at first. If the accumulation of pus is not incised early, the inflammation may attack the tendon- sheaths and then rapidly extend. (d) We must also refer to erysipelatoid inflammation of the finger, which was described by Rosenbach and more recently by Tavel, cases of which we have ourselves observed. Redness and hard swell- ing of the skin develop as a result of some insignificant wound of the skin, and the condition slowly spreads towards the hand, without leading to suppuration or causing general symptoms. In other cases lymphangitis, painful swelling of the axillary glands, and pyrexia occui". The disease is very liable to recurrence, and people who are occupied with meat, or animal oft'al, are the most frequent sufferers. (e) We now come to acute inflammations of the tendon sheaths. These do not usually arise spontaneously, but follow some injury, extending as far as the tendon-sheath. Perforating wounds and bites are especially dangerous in this respect, because if they introduce septic organisms in deep situations, they are not easily dislodged, and have abundant opportunity of developing undistiu-bed. If swelling of the finger occurs after such a history, the course of the tendon-sheath should be noted and an rmmediate opening made, without waiting for definite fluctuation, if there is pain on pressure along the sheath. Teno-synovitis is distinguished in its early stages from ostitis and periostitis by the fact that the inflammation is not limited to the course of one phalanx, and that the pain on pressure and the swelling are more pronounced on one side of the finger than on the other. The distinctness of the clinical picture often becomes obliterated in the more advanced stages, because a periostitis may develop from a teno-synovitis, and a secondary inflammation of the tendon-sheath mav follow primary disease of the bone. If an injury can be excluded, gonorrhoea should be thought of. Gonorrhoeal teno-synovitis usually begins very acutely, almost like a phlegmon, and then proceeds to a' ■quiet chronic stage. Suppuration occurs especially \n mixed infections. If a manual labourer complains of a slightly painful swelling over the long extensor of the thumb, which has come on alter hard work, and we feel distinct crepitation over the tendon and muscle, the 39 6o4 SUR(}ICAL DISEASES OF THE EXTREMITIES diagnosis is crepihiiit tciio-s\'iioviti<, a tibrinous inflammation of the tendon-sheath, the tissue around the tendon and the muscle. (/) Suppurative inflammation of the bone, whether primary or secondary, can be recognized : — (ij By tlie diffuse swelling and tenderness of the entire circum- ference of the finger, in the extent of one phalanx. (2) By pain on axial pressure. (3) By false mobility and crepitus in the adjacent joint, as the disease progresses. A skiagram is of no assistance in the initial stage, but is yery yaluable later on, when the course is protracted and there is a deyelop- Fjg. 349. — Whitlow causing secondary disease of bone. Infection of extensor tendon sheath by prick of a needle. Fig. 350. — Skiagram of same. X =^ part of bone which has formed a sequestrum. ment of new periosteal bone, or an inyolucrum begins to form, or if the case is somewhat more acute and the dead bone becomes divided from the heahhv part by a light zone, even without the formation of any new bone (tig. 350). {g) It is important to know something about acute inflammation of the finger joints. The first interphalangeal joint is most fre- quently affected. It acquires a spindle-shaped thickening and looks somewhat like a radish in form. It is usually the consequence of some injury, and I have seen it particularly in butchers. The joint may remain distended with clear fluid for weeks after the subsidence of acute symptoms, even in mild cases. If the disease lasts for a long time, the cartilage finally disappears, as may be demonstrated by X-rays, before the joint yields any crepitus on movement. Conor- CHROXIC IXFLAMMATIOX OF THE HAND AXD FINGERS 605 rhoea should be thought of if only one joint is afiected, and if the disease has had a sudden and spontaneous onset. The finger-joints may be involved secondarily in cases of suppurative teno-synovitis and ostitis. The clinical picture is, however, dominated in such circumstances by the primary disease, and the arthritis is merely a complication. Z?.— ACUTE INFLAMMATORY PROCESSES OF THE HAND. These arise from three different causes, leaving out of account the rare cases of primary periostitis and osteomyelitis of the metacarpal bones. They may originate as an extension from the fingers, as a result of injuries to the hand, or from suppuration of the bursa, which exists so frequently in the case of manual labourers, under the callosities of the palm. The diagnosis is usually very easy, but one must remember that even if the site of inflammation be in the palm, the oedema is most intense in the dorsinn, because of the greater laxitv of the skin. This peculiarity often leads the beginner to make his incision in the wrong place. The practitioner often has to decide whether suppurative inflam- mation of the bursa beneath callosities is the result of an accident or not. If a wound of the skin, however minute, has led to infection, the decision is clear enough. But suppuration occasionallv occurs without it being attributable to such a cause, and we are bound to regard it as a malady arising from occupation, and not as the conse- quence of an accident. It should be mentioned that an acute attack of gout mav excep- tionally occur in the hand. I have seen such a case incised as phlegmon — a mistake which may be pardoned owing to the rarity of the incident. CHAPTER XCI. CHRONIC INFLAMMATION OF THE HAND AND FINGERS. The skin, the tendon sheaths, the bones or the joints may be the seat of chronic inflammation in the hand or fingers. (1) THE SKIN. Chronic inflammatory conditions of the skin and subcutaneous tissue include primary chancre, lupus, leprosy, syringo-myelia, the trophic disturbances associated with Raynaud's disease, in addition to 6o6 SURGICAL DISEASES OF THE EXTREMITIES chronic eczema and to gumma, which latter is, however, of rare occurrence. A chancre may be diagnosed by the history, early enlargement of the glands, and possibly by the secondary symptoms. Many a prac- titioner has fallen a victim to a primary sore of the hand in the course of his profession. Practitioners who cannot restrain themselves from touching every wound or ulcer with their lingers, may be reminded that, even if they do not fear the organisms of suppurations, they may still be in dread of the spirochcctes. A well-known dermatologist says, not unjustly, " Whoever touches ever}^ ulcer with his fingers, shows that he does not know what it may be, or that he has already had syphilis." If the ulcer must be touched, an india-rubber finger-stall should be used, for the protection of oneself and other patients. Fig. 351. — Lupus of back of hand. (Tuberculosis verrucosa cutis.) Lupus, in its various forms, is mostly situated on the back of the hand or fingers. It is recognized by its usual characteristics, and we would especially refer to what has already been said in connection with lupus of the face, for the points of distinction between it and tertiary syphilitic lesions. Lupus may, in rare cases, ulcerate very deeply and even destroy the tendons, eventually causing severe con- tractures. If the tubercular process attacks the bones and joints, there may ensue an amount of destruction which is suggestive of leprosy. Post-mortem tubercle and skin tuberculosis of butchers should also be thought of, if the appropriate causes exist. Leprosy of the fingers is chiefly recognized by the fact that it leads to their spontaneous amputation. If this condition exists we must at once ascertain whether the patient has lived in a leprosy district. In addition to the well-known regions of leprosy, there are CHROXIC INFLAMMATION OF THE HAND AND FINGERS 607 numerous scattered centres of leprosy in rarely visited districts, which should be taken into consideration. In doubtful cases, we must search for traces of macular leprosv in persistent, atrophic, superficial and cicatricial cutaneous changes in various parts of the body, and in thickening of the large nerves, especially the ulnar. The mutilation in syringo-myelia and Raynaud's disease compete with that in leprosy. The symmetry and the associated nerve symptoms are always conclusive. The latter must, however, be carefully sought for, because the patient is often quite unaware of them (see fig. 352, which is taken from a patient who had no intimation of his syringo-myelia). (2) THE TENDON-SHEATHS. Inflammation of the tendon- sheaths, which is chronic from the start, and which is accompanied by swelling, is, practically without exception, of a tubercular nature. The flexor tendons are most fre- quently affected. I once saw a case of extensive tubercular teno - synovitis of the extensor tendons in a butcher, who had wounded himself on the cor- responding place fifteen years pre- viously with a splinter of bone of a tubercular cow. An old scar still remained in evidence of the wound. Tubercular teno - synovitis is easily recognized by the puffy induration in the region of the tendon-sheath and by the stiffness of the corresponding finger on slight flexion (fig. 335). The common tendon-sheath under the anterior annular ligament is occasionally affected, and the disease extends therefrom in four processes to the second, third, fourth and fifth fingers. There is frequently no fluctuation, or it may be more or less clearly recognizable in the palm only. If there is any considerable effusion the sac is subdivided, being constricted by this ligament just mentioned. The fluid can be displaced from the palm to the forearm and vice versa. Crepitation indicates the formation of melon-seed bodies. At first, the tendon sheaths only are affected, but spindle-shaped areas of granulation tissue with separation of the tendon-tissue into brush- like masses, may develop in course of time. Chronic enlargement of the Fig. 352. — Mutilation of hand, due to syringo-myelia. 6o8 SURGICAL DISEASES OF THE EXTREMITIES axillary glands confirms the diagnosis, if confirmation should be necessary. Tubercle could only be mistaken for the subacute stage of gonoi'i'ha'al tenosynovitis ov for the much more rare lipoma of the palm. The former would be indicated by a sudden onset with severe pain ; the latter by a painless onset. We must still refer to another malady, which mav cause the patient much agony, although it is trifling, and easy to relieve. This consists of the relative narrowness of the compartment of the tendon-sheath, lying on the styloid process of the radius, which transmits the extensor pollicis brevis and the abductor poUicis longus — a condition which I first described sixteen years ago, at Kocher's suggestion, as contracting teno-synovitis. It is not an inflammation in the strict sense of the term. The patients, who are mostly females, coinplain of pains radiating towards the thumb and forearm on any effort. On physical examination, the only thing to be noted is a striking tenderness on pressure, and sometimes a slight swelling in the vicinity of the above- mentioned compartment of the tendon-sheath. If the tendon-sheath is exposed under local anaesthesia, the tendons are seen to be constricted within it. The sheath should be split, which may also be done subcutaneously with a tenotome, and the patient is immediately and permanently cured. Histological examination merely shows thickening of the wall of the sheath, without an}^ inflammatory changes. (3) THE BONES. A spindle-shaped swelling of a metacarpal bone or a phalanx, which has developed gradually and with little pain, and which eventually suppurates and forms a sinus, is almost always tubercle. We say almost, because there is a very similar condition of the phalanx, which is due to syphilitic dactylitis. But the mere diagnosis of tubercular disease does not exhaust all that is necessary to know. From the point of view of prognosis, it is important to ascertain whether the disease has started in the medulla or in the periosteum. In adults the origin is usually periosteal, but in children almost exclusively medullar3\ My impression is that children who are the subject of congenital syphilis also display the periosteal variety of tuberculosis more frequently. Whether this is actually a fact must, however, remain an open question. The fate of the finger difters in the various forms of the disease. In tubercle arising from the medulla, ordinary tubercular dactylitis (fig. 354), the bone becomes more and more distended, or, to put it more accurately, becomes destroyed internally and is replaced by new bone from the periosteum. In this condition, the periosteum may remain CHKONIC INFLAMMATION OF THE HAND AND FINGERS 609 at least partially healthy. The spongy tissue becomes absorbed, or forms a sequestrum which is either expressed spontaneously or removed surgically. The phalanx becomes bent to one side, but practically the whole of it remains. In the periosteal form, however, the whole diaphysis gradually becomes deprived of its nutrition (fig. 353), necroses, and is expressed or removed surgically after pro- longed suppuration. But as the periosteum itself is tubercular, no healthy involucrum is formed as in the case of staphylococcic osteo- myelitis, but the linger becomes shortened by about the length of the ■:'% Fig. 353. — Tubercular dactylitis of periosteal origin. Fig. 354. — Tubercular dactylitis of medullary origin. diaphysis, after a few splinters of bone, formed from the periosteum, have been removed as sequestra. The differential diagnosis between these two forms cannot be made clinically, at any rate as long as there is no fistula. It can, how- ever, be made by a skiagram, upon which we must always base our treatment. If there is a history of congenital syphilis or a positive serum 6lO SURGICAL DISEASES OF THE EXTREMITIES reaction, the probability of syphilitic dactylitis is indicated. There is, however, no certain clinical symptom, and every case, which is not clearly one of tubercle, but in which there is some suspicion of syphilis, should have specific treatment before any other course is undertaken. CHAPTER XCII. DISLOCATIONS AND FRACTURES OF THE HIP. There is no joint which presents so much difticulty to the beginner, and sometimes also to the experienced, as the hip, because of the inaccessibility of the articular ends both to sight and to palpa- tion. All conclusions relating to the joint are, therefore, necessarily based on indirect signs, and the hip thus places a severe tax on the diagnostic powers of the examiner. The most striking symptom of all hip diseases is limping ; and we shall therefore briefly consider the most important forms of this symptom. The simplest variety is that which follows shortening. In this condition, the body inclines towards the diseased side at every step ; not because the limb gives way, but because it is too short. The leg is by no means spared, but still serves as a normal support. If the shortening is slight, the complete sole is planted down, but if it is extreme, only the toes reach the ground. The limp becomes noticeable in adults if the shortening exceeds i^ cm. (f in.). The paralytic limp, in the widest sense of the term, is very similar. The limb is insufficiently supported, either because of muscular weakness or because of dislocation. The patient supports himself vigorously on the affected leg, evidently experiences no pain therein, but inclines with each step towards the diseased side, and then supports himself the more firmly on the healthy leg for the purpose of throwing the diseased leg forwards for the next step. If this variety of limping is due to congenital dislocation, the head of the thigh bone may be seen to move upwards, under the gluteal muscles, towards the pelvis. If the disease is bilateral, the gait is waddling, like that of a duck. Painless stiffness of one hip produces quite a different kind of limp. The entire extremity, includmg the half of the pelvis, is moved forward as a whole, because a normal function of the other joints is not conceivable if one joint is stiff. But as there is no pain, the limb is not spared as a means of support, and the weight of the body is equally received by both legs. If the patient walks slowly, he is therefore able to render his disability less noticeable. The gluteal fold is obviously obliterated on the diseased side. A peculiar gait is DISLOCATIONS AND FRACTURES OF THE HIP 6ll produced by bilateral stiffness of the extremities as in cases ot severe double coxa vara. The patient wearily moves forwards, first one half and then the other half of the pelvis alternately, and there- with the corresponding limb. The pelvis rotates around a vertical axis, and not around a sagittal axis, as in cases of bilateral dislocation. In cases of painful limping, the movement of any joint is painful, and as all the joints of the lower limb are interdependent — for instance, a twisting movement of the foot is impossible without the participation of the knee and hip joints — the patient stiffens all the joints by muscular action, and avoids, as far as possible, putting any weight on the diseased limb, and inclines his body towards the healthy side. This latter circumstance distinguishes painful limping from limping due to painless rigidity, for otherwise most of the symptoms are common to both conditions, including especially the obliteration of the gluteal fold. There are several types of disturbance in gait. In unilateral congenital dislocation, it depends upon shortening and laxity of the joint ; in old hip disease, it depends upon shortening and stiffness. Doubt should rarely arise as to whether an injury to the hip-joint consists of a dislocation or a fracture. As a rule, such doubt indicates that the examination has not been conducted properly, or that the physical condition has not been correctly understood. In order not to fail in the appreciation of indispensable anatomical points, every practitioner should possess a skeleton, and he should consult it frequently. Expenditure on this is by far more advisable than on instruments which the practitioner purchases on the recommendation of manufacturers, but rarely, if ever, uses. .4.— METHOD OF EXAMINATION. We begin with inspection, and note the position and posture of the injured limb as well as the external visible injuries, extravasations of blood and swellings. The experienced observer will often be able to make a diagnosis from the posture of the injured extremity, or at least will narrow down the possibilities to a very limited extent. Thus, if the injured person lies helpless and motionless, with his leg in a state of complete external rotation, he will at once think of a fracture below the neck of the femur. A flexed thigh, rotated internally and adducted, will suggest a dislocation. He will also notice whether the region of the hip, on the injured side, is drawn in, or whether it projects unnaturally. A roundish bulging in the inguinal region is not likely to escape him any more than the fact of the one patella being higher than the other - — a condition which indicates shortening. We next proceed to what is for the patient the least painful pro- cedure of examination, the measnrenient of the length of the limb, and 6l2 SURGICAL DISEASES OF THE EXTREMITIES tor this purpose, it is necessary to bring both Hmbs into exactly the same position, to avoid mistakes. We measure on both sides the distance (i) between the anterior superior spine of the ihum and the tip of the external malleolus (c in lig. 355) and (2) the distance between the tip of the trochanter and the malleolus (b). (In cases of extreme external rotation the first measurement is also taken to the internal malleolus.) If the measure- ments are equal on both sides, we may, as a rule, exclude anv change in the bone, provided that the limb used as the standard for comparison has not been shortened by a previous accident. If one or other of these measurements, or both of them, be shortened, there is certainly either a dislocation or a fracture, unless the shortening be due to some previous injury or disease. If the distance between the anterior superior spine and malleolus (c) is alone shortened (supra-trochanteric shortening) the case is either one of dislocation or fracture of the neck of the femur. If both measurements b and c are shortened, the -reparation of continuity must be below the tip of the trochanter (infra- trochanteric shortening), and the case can only be one of fracture below the tip of the trochanter. We next determine the relation of the trochanter to the pelvis, in order to control the measurements previously obtained. It is generally said that for this purpose the most important thing is to ascertain Roser-Nelaton's line. Unfortunately, it is very difficult to do this when the injury has been severe. It is better to make use of this line in cases of abnormal positions, of iion-irauniatic origin. In recent injuries we should adopt other measurements which are equally reliable and easier to carry out, and which do not demand any change of posture in the injured person. These measurements consist of Bryant's triangle andthe trochanter — anterior superior spine — umbilicus line, which will be referred to in detail in the next section. The determination of Bryant's triangle is of special significance because the measurement of the horizontal base line of this triangle intimates t(j us the alteration in the position of the trochanter, and gives its level, and thus enables us, by comparing the two sides, to ascertain how far tlie trochanter has been displaced upwards. If the trochanter is abnormally high, there is either a dislocation or a fracture of the neck of the femur. If it is in a normal position the injury is not associated with any displacement, or, if there be any, it must be below the trochanter. In slight bending of the neck of the femur, or in fractures which are slighth' impacted, the shortening may be so small in amount as to come within the ordinary limits of errors of measurement. In anterior dislocations the trochanter is not displaced upwards in any marked degree. But in these cases, its definite approximation to the mid-line of the body shows that some anatomical damage has been sustained. We also find a certain amount of approximation to the middle line in impacted fractures of the neck of the femur. But, as we shall see later on, there are other definite signs which distinguish these fractures from anterior dislocations. DISLOCATIONS AXD FRACTURES OF THE HIP 613 •S "O c = S = -ff '-> .■J.__- u u rt v^' o'^ ^^ 5 g £ o-g S =« ^ = ■S S :,, -a ^ 2 « t - "2 c ="2 S'o l!.S jf-g r/~ = St; o"^ "-^ S u rt-OiJ otS o- •s_^t;-= 5 « °^ § « 5 ^ '-'no) -wCni rrv-o a%° ^ ^ J 4J rita 3J= J„- c C^ y'y.— ^ — oj '. is normally an isosceles triangle, whereas the base line formed by the prolongation of the axis of the femur is shortened, compared to the opposite side, when the level of the trochanter is raised (figs. 372 and 373). Shoemaker's method is even more simple, and it consists of pro- longing the line joining the trochanter icith anterior superior spine, on to the abdomen. This prolonged line normally meets the median line at the level of the umbilicus or above it; but when the level of the trochan- ter is raised it intersects this line below the umbilicus (fig. 374). The head of the femur does not leave the capsule in cases of congenital dislocation. The cap- sule becomes dragged out, in the shape of a pocket, and is displaced posteriorly with the head. The thigh does not, therefore, assume the typical, mathematically fixed position in relation to the pelvis which it presents in cases of traumatic dislocation. Indeed the drawn-out capsule permits abnormally free play for the move- ments of femur. Congenital dis- location of the hip is therefore characterized by remarkably great acrobatic niobilitv of the thigh, and there is no pathognomonic position in cases of congenital dislocation of the hip in young children. Freedom of movement only diminishes after the lapse of years, but even then, abnormality of position is much less pro- nounced than in cases of trau- matic dislocation. Another important sign, con- nected with this defective fixation of the head, is the possibility of moving it backivards and forwards on the pelvis tion of the hip, if they are not too old, but it can only be demon- strated in refractory children when the muscles are relaxed by anaesthesia. Before proceeding to this test, we must endeavour to Fig. 374. — Same case. Determinalion of level of trochanter by prolonging towards the umbilicus the line which joins the tro- chanter to the anterior superior spine. This sign is never absent in cases of congenital disloca- 634 SURGICAL DISEASES OF THE EXTREMITIES show that the licad is in an ahuoiinal position, and we shall generally find it above or behind the acetabulum. In the case of thin girls it is quite possible to see the head of the bone moving about, with every step, in the gluteal region. But it is not evident externally in very small fat children, nor can it be readily felt, especially if it is not fully developed. Sometimes anaes- thesia is indispensable for the examination, but whether employed or not, we proceed in the following manner, as taught by Malgaigne (fig. 375). The child is laid upon the healthy side ; the leg of the deformed side is flexed to a right angle, and, if necessary, is somewhat Fig. 375. — Palpation of the head of the bone in congenital dislocation of the hip. adducted. Attempts are made by pressiu-e on the femur from the knee, with one hand, to press the head of the bone as far as possible awav from the pelvis. At the same time movements of rotation are made with the same hand, while the upper end of the femur is. being palpated by the other hand. If only one protuberance is felt, this is the trochanter, and there is no dislocation present. But if kvo protuberances are felt, one must be trochanter, and the other is the head of the bone, and a dislocation does exist. Children who have alreadv walked for some time present another important svmptom, especially when the dislocation is bilateral, i.e., a NOX-TRAUMATIC DEFORMITIES AT THE HIP-JOINT 635 great degree of lumbar lordosis, which depends upon the rotation of the pelvis forwards, upon its transverse axis. The dislocation causes the centre of gravity of the back to fall along a line anterior to the points of body support, and the endeavour to bring it back again over the feet is the cause of the lordosis. The diagnosis of congenital dis- location of the hip is established if there is sJiortening, with abnormal mobility of the thigh, elevated level Fig. 376. — Congenital dislocation of the hip. (Lordosis !) L__ Fig. 377. — Lordosis in progressive muscular atrophy. of the trochanter and displaceability of the femnr on. the pelvis, and if a protuberance is felt besides the trochanter, and if, in addition to all this, liunbar lordosis is also present. A skiagram can only add a few details to the diagnosis, in regard to the shape of the acetabulum and the head of the bone. 41 636 SURGICAL DISEASES OF THE EXTREMITIES "1 We have not vet referred to the history, which usually relates that nothing was noticed in the first year, but that a slight lameness was observed as soon as the child attempted to walk. If the dislocation is bilateral, the gait will be described as waddling, and it will have been attributed to weakness; but the disability will be said to be constantly increasing. As we have already seen, the signs are so striking, and can usually be demonstrated with so much ac- curacy that it is hardly possible to overlook a definite case, and the favourite diagnosis of a past genera- tion — " weakness of the muscles and bones " — ought never to be made by a modern practitioner. An error in regard to a slight degree of bilateral dislocation is perhaps excusable. In such a case, we are unable to judge of abnormal mobility and shortening by comparison with the healthy side. We are only able to diagnose the dis- location, apart from the lordosis and the duck's gait, by the movability of the femur on the pelvis, the elevated level of the trochanter, and the detec- tion of the head of the bone, above or behind the acetabulum. Both types of cases sometimes require examination under an anaesthetic. The only affec- tion with which confusion is conceiv- able is a rachitic curvature of the femur, especially if this is accompanied by a bilateral coxa vara. Such children often present a pronounced lordosis, i.e., they protrude their abdomen for- wards, in order to regain the equi- librium, which is disturbed by the curvature of the femur (fig. 378). The gait is often awkward, and resembles the waddling in the case of congenital dislocation of the hip. The similarity of the conditions is enhanced by the fact that the level of the trochanters is raised in coxa vara and because they project abnormally far at the sides (see shape of hips in fig. 379). But an important difference is afforded by the abnormal mobility in congenital dislocations, m contrast to the restricted movements in Fig. 378. — Rachitic coxa vara, with simultaneous bending of the shaft of femur and tibia outwards and for- wards, and compensatory lordosis. NON-TRAUMATIC DEFORMITIES AT THE HIP-JOINT 637 coxa vara. There are, however, cases of coxa vara wherein the restric- tion of movements is but shght, namely the coxa vara of Httle rachitic children, and, on the other hand, there are cases of congenital disloca- tion — mostly in older children — wherein the abnormal mobility has become diminished. If, finally, the head of the femur is only slightly developed, and is therefore difficult to feel as a separate structure, and if the dislocation is not definitely of the iliac variety, but of the supra- cotyloid varietv, which, exceptionally, may remain in that position until an advanced age, it is quite conceivable that the case may be obscure until an examination is made under an anaesthetic. Trendelenburg has indicated a sign which may be valuable in such a case. He points out that when a normal individual stands on one Fig. 379. — Congenital dislocation of right hip (seen from behind). foot, the opposite half of the pelvis is raised, on account of the muscular fixation of the joint. In an individual with congenital dislocation, this fixation of the joint is absent, and therefore the opposite half of the pelvis sinks. However, if there be a dislocation, anaesthesia will enable the head to be felt, and the oscillating move- ment to be detected. If doubt still remains, it can be finally cleared up by X-ray examination. Infantile paralysis, once affecting the gluteal muscles, may involve the beginner into difficulty. The lameness is very similar to that of dislocation (paralvtic limp). The trochanter becomes so prominent, owing to the atrophy of the gluteal muscles, that the inexperienced is apt to mistake it for the head of the femur. Owing to the muscular paralysis the passive movements of the limb are very extensive, and in 638 SURGICAL DISEASES OF THE EXTREMITIES old cases there may b paralysis is that the he became ill with spread paralysis wh examination at once pelvis, and that the pr Fig. 380. — Bilateral rachitic coxa vara. Extreme projection of the e some shortening. But the history in infantile little patient previously walked quite well, that infective symptoms, and had, at first, wide- ich gradually subsided somewhat. Physical shows that the femur is not displaced on the ■ominence seen under the glutei is not the head of the femur, but an abnormally evi- _ dent trochanter. Although the limb may be shortened, the level of the trochanter is not raised, showing that the whole femur is shortened and not merely displaced upwards, as in dis- location. Sometimes genuine dislocations are associated with paralysis — not congeni- tal, but acquired ^flr<7/v5/s. In infantile paralysis they are unilateral, and depend upon the traction of the unparalvsed, but un - antagonized adductors. In trochanter region. Fig. 381. — Rachitic coxa vara. (Skiagram of fig. 380.) congenital spastic paraplegia — Little's disease — the dislocations may be bilateral, due to spastic contraction of the adductors. The paralysis may predominate the clinical picture so that the dislocation may be entirely overlooked, especially in bed-ridden children, although, owing to the muscular atrophy, tlus could easily be detected on grasping the hip. XOX-TRAU^IATIC DEFORMITIES AT THE HIP-JOIXT 639 Progressive muscular atrophy (fig, 377) is a disease which at first sight may suggest congenital dislocation of the hip because of the lordosis. A careful examination will, however, quickly expose the error. Congenitally dislocated hips are frequently affected in the course of time with inflammatory processes of the nature of arthritis deformans, causing considerable pain. This may impel the patients to seek advice, rather more than for the deformity — a circumstance which may be of diagnostic significance. A female patient, aged 24, sought advice for " rheumatic " pains in the right hip. She was of normal girth, but short in stature, and she had a striking stiff, peculiar measured gait. She had suffered with her hips from infancy, and had always been treated for '' general weakness." Examination showed a congenital bilateral dislocation of the hip, with arthritic changes on the right side. The skiagram showed that the heads of the femora were displaced to the extent of 9 cm., and that a new joint had developed on either side of the pelvis. The slow stiff gait was very remarkable in this case. Her aesthetic taste had unconsciously and gradually adapted it to such an extent as to completely conceal the waddling. Some female patients entirely lack this compensatory influence, and the term "duck's gait" hardly does justice to what is seen in some advanced cases. The following case is equally significant. A female patient, aged 36, in whom some " weakness " of the left leg had already been detected in childhood, began to suffer pain in the left hip and to limp when she w-as 31. She went from one practitioner to the other, and was considered to be a case of " rheumatism." This diagnosis did not, however, explain the shortening of li cm. Palpation did not reveal anything definite, because of the patient's stoutness. A skiagram had to be made in order to distinguish between the results of an old hip disease, or of an injury, and congenital dislocation. The skiagram was in favour of the latter. It was not the dislocation which caused the patient to seek advice but the secondary arthritis. B.— COXA VARA. If the head of the temur is not in an abnormal position, and if the bone cannot be displaced on the pelvis, there cannot be any dis- location. But if, despite these circumstances, the level of the trochanter is raised, it must be caused by the bending of the neck of the femur. In some cases coxa vara depends upon the diminution of the obtuse angle at the neck of the femur, and, finally, its decrease to a right angle (fig. 381), or even to an acute angle {coxa adducta of Kocher). In other cases the head of the bone is bent downwards 640 SURGICAL DISEASES OF THE EXTREMITIES and backwards, while both the head and the neck undergo a spiral twist backwards, when the neck is in a normal position. {Coxa vara in the strict sense of the word according to Kocher). The causes of this bending are the same as in the case of other bony deformities — i.e., rickets in infancy, the strain of abnormal weight during the period of growth, and in rare cases osteomalacia in later years. In addition, there are cases of false coxa vara, due to osteomyelitis, tubercle and injury, and, finally, very rare examples of congenital coxa vara. If the cause is rickets the disease is usually bilateral, but if the condition has been caused by abnormal weight-bearing (coxa vara of adolescents), it may be either unilateral or bilateral. But even in this case we must assume some abnormality in the constitution of the bone. It matters very little whether we classify it with late rickets or desig- nate it in some other way, because we are not fully acquainted with the nature of late rickets. Let us first consider in detail a case of rachitic coxa vara in a child. The posture of the leg and foot is as normal as the rachitic curvature permits, but we are struck by the extreme pro- jection and the great elevation of the trochanters. The gait of the little patient is exceedingly clumsy, and may sometimes be characterized as slightly waddling. The movement of the projecting trochanter, which is visible under the skin, resembles somewhat the movement of the head of the femur under the gluteal muscles in congenital dislocation of the hip. But, as already stated, the resem- blance is merely superficial, for in coxa vara there is only one pro- tuberance, whereas in dislocation there are tivo. On examining the individual movements we find that there is freedom of flexion, that external rotation is normal or only slightly restricted, but that abduc- tion is diminished or almost impossible. The only abnormality shown Fig. 382.— Left sided coxa vara in a youth. NON-TRAUMATIC DEFORMITIES AT THE HIP-JOINT 641 by the skiagram (fig. 381) is adduction of the neck of the femur towards the shaft, usually to an angle of about 90° — coxa addiicta. If we examine the rest of the skeleton we are almost sure to find other signs of rickets in the bones (fig. 378). The restriction of abduction varies. In young children it is slight, but later on, between the eighth and tenth year, it may be very pro- nounced and constitute the most troublesome symptom. In unilateral coxa vara the distance between the anterior superior spine and the malleolus is shortened in the affected limb, and there is corresponding luiilateral lameness. This is, however, a condition which is much rarer in rickets than the coxa adducta which occurs after fractures of the neck of the femur, osteomyelitis, or tubercle. Fig. 383. — Severe bilateral coxa vara, patient, aged 15. Rachitic form. A more complicated clinical picture presents itself in children, in cases of coxa vara in the strict sense of the ivord, i.e., bending of the head downwards and backwards, often with simultaneous twisting of the neck. For the head to retain its normal relation to the acetabulum, the shaft of the bone, and therewith the whole limb, would have to assume a position of adduction, external rotation and hyperextension. In order to improve upon this impossible position, the limb — head and shaft — executes a movement which is composed of abduction, inward rotation and flexion. The more pronounced the deformity, the more IS the whole range of the movement in these directions taken up in merely attaining a normal posture, and the less is it possible to abduct, 642 SURGICAL DISEASES OF THE EXTREMITIES invert or flex the limb any further. These simple considerations explain the disturbances of function, which we meet in this form of coxa vara. The gait of a patient with a unilateral affection presents the same lameness as a case of painless stiffening and shortening of the limb. The pelvis is pushed forwards at each step and the limb proceeds as a rigid whole with the pelvis. When the affection is bilateral, there is the peculiar gait wherein the pelvis oscillates around a vertical axis with every step. We will also notice that the affected limb is always held in a position of eversion, an obvious result of the downward inclination of the head, which is no longer fully compensated for. The skiagram shows mainly a downward displacement of the head, in the epiphyseal line, on a normally placed neck (fig. 384). EiG. 384a. — Coxa vara in a youth. Bending in the vicinity of the epiphyseal line. Fig. 384b. — Healthy side in same patient. We may summarize what has already been said, in regard to coxa addiida, as follows : Proininence and elevation of the level of the trochanter, restricted abduction, and shortening if tlie affection is uni- lateral. In regard to coxa vara in the strict sense of the term, we may summarize thus : Prominence and elevation, of tlie level of the trochanter with external rotation and restriction of abduction. Internal rotation and flexion, and shortening with lameness of one side if the affection is imilateral. These points should facilitate the differential diagnosis from other diseases of the hip. We have already discussed the differential diagnosis from congenital dislocation of tlie hip. ACUTE INFLAMMATORY DISEASES OF THE HIP-JOINT 643 Sometimes unilateral coxa vara in a youth is mistaken for coui- ■mencing Iiip disease. Coxa vara has, like flat foot, a painful stage which may easily be regarded as some inflammatory affection. A young man (fig. 382) sought advice for commencing "hip disease." He limped slightly towards the left, but two facts were noticeable at first sight: the limp was not painful, as he planted his left foot down quite firmly without any special care. It rather appeared to be due to shortening. In addition, the foot was con- siderably everted. This, of course, excluded hip disease. The stage wherein eversion exists is accompanied by some abduction and apparent lengthening. This stage is also so painful that it is im- possible to bring the foot down to the ground, without special care. Our thoughts, therefore, proceeded in another direction. We measured the leg and found 2 cm. of shortening, which is hardly possible in early hip disease. The level of the trochanter was definitely raised. On testing the movements it was found that abduction, flexion and inward rotation were restricted. This established the diagnosis of coxa vara, and the skiagram could do nothing but confirm it. Complete rest with the .application of an extension apparatus relieve the painful symptoms much more quickly than in the case of hip disease, which affords a further proof of the accuracy of the diagnosis. If a young man presents the symptoms of a unilateral coxa vara, we must, as we have already seen, investigate his clinical history for an injury, before attributing them to a deformity produced by mechanical conditions. If, however, such an injury cannot be recalled by the patient, we must not endeavour to persuade him of its occurrence. CHAPTER XCIV. ACUTE INFLAMMATORY DISEASES OF THE HIP-JOINT. A PATIENT is suddenly seized with severe pains in the hip, and is unable to move his leg with freedom. We have excluded acute disease of neighbouring structures, such as phlegmonous inflamma- tion of the crural or inguinal glands, or an acute abscess of the pelvic fossa. It therefore only remains to decide whether the case is one of acute arthritis of the hip-joint, or osteomyelitis of the shaft of the femur, or even of the pelvis. It is true that there is pain with every movement in osteomyelitis, just as there is in hip disease, but nevertheless passive movements 644 SURGICAL DISEASES OF THE EXTREMITIES may be carried out within certain limits, if due care is exercised. The local pain on pressure does not correspond to the region of the joint^ but has its highest point at some distance from it below the trochanter, at the extreme limit of the osteomyelitis — or, on the other hand, up- wards towards the pelvis. If there is secondary involvement of the joint the symptoms of the two diseases coalesce, but we ought to be able to decide the sequence of events by the fact that the pain on pressure extends comparatively far either upwards or downwards, and by the thickening of the bone. In acute hip disease, however, in- cluding a circumscribed osteomyelitis of the head and neck of the femur, we are struck from the very beginning with the intense pain- fulness of any passive movement of the joint, if not by its complete muscular fixation, no matter in which position this fixation has taken place. The maximum pain on pressure is in the vicinity of the head of the bone, i.e., beneath the middle of Poupart's ligament. On inspection and palpation it may be noted that this region is fuller than on the healthy side. The pyrexia proves that some acute inflammatory disease exists. What is the nature of this inflammation? If several other joints are involved simultaneously, or in rapid succession, we should think of acute articular rheumatism — but one must be sure that only the joints are affected. If the disease is limited to the hip, and the patient is young, the condition is most probably one of acute osteo- myelitis of the neck and head of the femur, involving also the joint. This diagnosis becomes quite certain if other areas of bone disease exist, or if some suppurative inflammation is actuallv present at the time, or has recently subsided. If the patient is a child convalescent from scarlet fever, we know that the case is one of scarlatinal arthritis, which may recover without incision, and with complete restoration of function, or which may rapidly destroy the joint. Similar forms of inflammation of the hip may more rarely come on, after typhoid fever, small-pox or measles. The hip is sometimes involved in puerperal articular disease. In default of any of these more frequent causes, we must seek other possible portals of entry for organisms of inflammation, and we should not forget gonorrhoea. Subacute inflammation of the hip may occur in secondary syphilis and in the congenital disease, but it is rare. Some- times it is quite impossible to determine how the infection entered, or to discover any cause. This is especially true of certain cases of acute hip disease in little children, who recover after simple evacuation of the pus, sometimes without leaving any serious derangement. Bacteriological examina- tion should never be neglected in this type of case, lest one overlooks an acute onset of tubercle. ACUTE INFLAMMATORY DISEASES OF THE HIP-JOINT 645 The organisms of acute suppuration sometimes give rise to a form of inflammation which is mistaken for tubercle, because staphylococcic and streptococcic infections of the neck of the femur do not always produce their familiar clinical picture. On the contrary, the disease may run such a mild course, despite its acute onset, that it easily suggests tubercle, unless a very reliable history is at hand. The records of von Brun's clinic have shown that this mistake is by no means rare. The following is a typical case : — We were consulted about a lad aged 12, who presented all the symptoms of early hip disease — moderate pain on axial pressure, and on pressure over the trochanter, fixation, of joint in a position of slight flexion, adduction and inversion ; temperatvn-e practically normal. This condition had existed unchanged for several weeks. Had we had no reliable history, we might have assumed that the case was tubercular. But as a matter of fact, the patient had been admitted to hospital with the diagnosis of acute osteomyelitis of the upper end of the femur. The disease had started suddenly, with severe, though transitory, fever. We accepted the diagnosis of the family practitioner, and it was confirmed during the course of the next month by the development of osteo- myelitis of the shaft of left humerus, with sequestrum formation. The lad had complained of pain in the left arm from the beginning, but he laid no stress on it, as his hip symptoms were much more distressing. One word in reference to the results of these inflammations. As long as the measurement between the anterior superior spine and malleolus is of normal length, having regard to the position of the leg, and the tip of the trochanter is at the correct level, the case is one of pure arthritis. But if there is sudden shortening, or if the trochanter becomes displaced upwards, there must be some pathological disloca- tion, usually backwards, or a separation of the epiphysis. The former is more frequent after typhoid or scarlet fever ; the latter, after osteo- myelitis, in which condition a fracture near the shaft may occur. The actual state of affairs can be determined by careful examination. If the limb is slightly everted and can be moved hither and thither on the pelvis, and if soft crepitus can be felt, a separation of tlie epiphysis is present. If the leg is in the position of a posterior dislocation, i.e.^ flexion, adduction and inversion, and if the head of the femur is felt under the gluteal muscles it is obvious that a dislocation is present. There is another, a further, possibility, which is, however, rare in acute arthritis, but may lead to an error of diagnosis. A little girl was suffering from scarlatinal hip disease and her limb was shortened and in a position of eversion. It was possible to move the femur on the pelvis, and soft crepitus was felt. We diagnosed inflammatory separation of the epiphysis. The skiagram, however, showed severe destruction of the upper border of the acetabulum and partial destruction of the head of the femur, which was not detached. 646 SURGICAL DISEASES OF THE EXTREMITIES The case was really one of pathological dislocation in which there was no pathognomonic malposition, and in which there was no possibihty of successful reduction, in consequence of the destruction of the joint. As soon as the residue ot the head was brought into a normal position, it glided backwards again, because of the destruction of the upper border of the acetabulum. An operation was performed subsequently -and this confirmed the X-rav diagnosis. CHAPTER XCV. CHRONIC INFLAMMATORY DISEASES OF THE HIP. Chroxic mflammatory diseases of the hip are mainly comprised within two groups. The one includes tubercular coxitis, the other embraces all that is understood by the term chronic rheumatic arthritis. There are other rare conditions, which will be referred to when discussing differential diagnosis. An approximate distinction is furnished by the circumstance that the tubercular disease affects growing individuals, while the non-tubercular arthritis affects adults ; but the borderland cases which lie between the two, cause difficulty in diagnosis. A.— TUBERCULAR HIP DISEASE. The diagnosis of tubercle is forced upon us if a child begins to complain of feeling tired and has a painful limp after walking for some distance, if the gluteal fold is obliterated and some muscular atrophy on the affected side is also possibly noticeable. As the limp is not permanent at first, but only comes on when the patient is tired, and as it can be suppressed when an effort is made to do so, it has been called a " voluntary limp" — an expression which constitutes an unjustifiable reproach. The progress of the case is a comment on its "voluntary" nature. Sometimes the child complains more about the knee than about the hip, but a cursory examination will show that the knee-joint is free. Having examined the gait of the child with his clothes off, we lay him upon a flat table and direct him to extend both legs completely. A hollow is observed to form in the back, so that the hand can be passed flat under the lumbar region. If we make the back fit closely against the table, the knee of the affected side becomes slightly raised. This preliminarv examination suffices to show that the hip is held in a CHRONIC INFLAMMATORY DISEASES OF THE HIP 647 constrained position of slight flexion, although otherwise the limb may either be abducted and everted, or adducted and inverted, both positions being met with in the early stages. If we cannot get the back to lie close against the table, we may adopt the simple and painless method of Thomas, i.e., we flex the healthy hip as much as possible in order to throw the pelvis backwards,, and thus the spinal column will certainly be forced close against the table. If there is the slightest degree of flexion on the diseased side,, the knee will then be raised, so that, at any rate, the hand can be passed under it (figs. 385 and 386). Fig. 385. — Lefl-sided hip disease. The position of slight flexion compensated for by the lumbar lordosis. Fig. 386. — Same case. The flexion demonstrated by Thomas's rnanceuvre. We then proceed to a careful examination of the separate move- ments, as compared with the healthy side. The more limited flexion,, extension, adduction, abduction, external and internal rotation are, the more does the patient endeavour to transfer these movements to the lumbar spine, and he moves his pelvis and leg as one fixed whole. In other words, the pelvis participates in the movements. We must then inquire whether this fixation depends upon pure muscular spasm, or upon any organic changes in the joint. If the degree of fixation after a long rest dift'ers from the degree present when the patient is very tired, it would indicate a muscular origin, but if there is no difference, the rigidity must depend upon causes within the joint. An absolute 648 SURGICAL DISEASES OF THE EXTREMITIES decision can only be arrived at by examination under an anaesthetic, when muscular fixation vanishes forthwith without any forcible manipulation. Abduction and rotation are the movements which are generally first interfered with. If the adductors become tense on attempting to perform abduction rapidly, the hip-joint is certainly involved, even if extension and flexion remain perfectlv free. Fig. 387. — Early stage of hip disease on right side, with external rotation ^ Jlexton and abduction. Fig. 388. — Early stage of hip disease on right side, ivith flexioi, adduction and inward rotation. It may happen in this stage that all s^-mptoms disappear after a few weeks' rest in bed, so that one thinks an error in diagnosis has been made. But the symptoms return in a few months, or even after a few years, and the classical picture of hip disease develops. If we are not quite clear about the limitation of abduction we direct the patient, after taking off his clothes, to spread out his legs as inuch as possible while standing. Any asymmetry which then exists CHRONIC INFLAMMATORY DISEASES OF THE HIP 649 in the posture of the leg or back is an indication that abduction is interfered with. A certain amount of importance attaches to the division of hip ■disease into stages, in accordance with the posture of the hmb. As Konig has shown, the patient endeavours to spare his hip-joint as much as possible in all stages of the disease. For this purpose the position of slight abduction and external rotation, with a little flexion, is the most useful, as long as the patient walks without crutches (fig. 387). But if the patient does go about on crutches, he raises his Fig. 389. — Advanced hip disease of left side with extreme flexion and abduction. Fig. 390. — Advanced hip disease of left side, with internal rotation, adduction and flexion. diseased leg, that is to say, he flexes it more, but still holds it in abduction. If the patient takes to his bed in the earlier stage of his disease, he supports his flexed, diseased leg on the healthy one, thus bringing it into the position of adduction and internal rotation (figs. 389 and 390). >-^ There is an anatoiuical cause for this position, if the head of the bone has left its normal situation and has become displaced posteriorly, or backwards and upwards, either through destruction of the capsule or gradual destruction of the posterior border of the acetabulum (so-called displacement of the acetabulum [Pfannenwanderung] 650 SURGICAL DISEASES OF THE EXTREMITIES fig- 391)- The position then assumed is one of subluxation or even of dislocation. After testing the power of movement we proceed to palpation^ which, combined with inspection, will show v;hether any abnormal swelling exists. The principal swellings to be thought of are enlarge- ment of the inguinal glands and abscesses which have made their way to the surface. These usually appear in front (see fig. 385, where there is an abscess below the anterior superior spine), but also occur on the outer and on the posterior surface of the hip. We next examine for pain. Fig. 391. — Hip disease with "displacement of acetabulum" and coxalgic peh (Skiagram of fig. 385.) Small sequestrum at x. We test for pain on direct pressure, where the joint is most accessible, ?'.^., in the front, just below the middle of Poupart's ligament. This pain is often an early sign of hip disease, although it is not so significant as loss of power of movement. Importance also attaches to indirect pain, elicited by force applied in the long axis of the femur or to the trochanter. We have already seen that any movement, carried out to an extreme degree, is painful. The differential diagnosis raises the following considerations : — {a) If it is quite evident that there is actual disease of the hip-joint CHRONIC INFLAMMATORY DISEASES OF THE HIP 651 itself, we must first exclude the subacute foruis of iufectivc hip disease. For this purpose it is necessary to give due weight to all the points advanced in the previous chapter, and only diagnose tubercle in the absence of any other cause. As already remarked in the previous chapter, an acute onset of hip symptoms indicates an acute infective origin, even if the disease develops into a chronic condition. The sudden rupture of a tuber- culous periarticular focus into a joint also causes acute symptoms, including fever, but as a rule this event would have been preceded by slight articular symptoms, pointing to tubercle. A rigor, or herpes labialis, accompanying the acute exacerbation, are indications agaiust tubercle. If the onset is very gradual, the possibility of tubercle must be entertained even if the hip symptoms have followed some acute infec- tious disease. A child who begins to limp in the slightest degree a few weeks after measles is probably the subject of early hip disease, the measles having prepared the soil for the tubercle. We must next exclude the so-called chronic rheum at ic arthritis, which we shall deal with at the end of the chapter. We have already seen that congenital dislocations of the hip and that coxa vara are subject to irritative stages, wherein some confusion with hip disease is quite conceivable. But such an error can be avoided by careful examination. The same applies to the hip symptoms which eventually arise in fracture of the neck of the femur, and which belong to coxa vara traumatica. We should think of primary or secondary malignant growth, including hydatid cyst, if the features of the case do not completely accord with hip disease, especially if the slight limitation of move- ment and its relative painlessness present a striking contrast to the severe and spontaneous radiating pains. (6) Diseases, independent of the joint, may simulate hip disease, by causing flexion of the hip and pain in its vicinity, leading to a painful limp. The most frequent cause of spastic flexion of the hip, not due to joint disease, is a burrowing abscess from a tubercular spine, or pelvic tubercle. This condition may resemble hip disease so closely that examination of the spinal column and palpation of the pelvic fossa are always essential in cases of spastic flexion of the hip. The diagnosis is easy if a dorsal curvature is evident, or if an abscess is found filling up the iliac fossa. But matters are not always so simple. The curvature may be quite absent in adults, and the connection of the abscess with the spinal column may be limited to a narrow sinuous track. In abscess due to spinal disease, however, abduction and rotation are usually free at the hip, whereas these movements suffer first if the joint itself is affected. A conclusion may also be based on a skiagram. 42 652 SURGICAL DISEASES OF THE EXTREMITIES In rare cases, a paranephritic or appendicular abscess may cause spastic flexion of the hip, and an inadequate examination may lead to a wrong diagnosis. Effusion into the iliacns bnrsa may also lead to a wrong diagnosis because of the spastic flexion and the swelling immediately over the hip-joint. But as abduction, adduction and rotation are quite free, despite the spastic flexion, such an error ought not to be made. Unless attention is paid to the free mobility of the joint, sciatica and periarticular neuralgia are liable to be mistaken for early hip disease, more especially in connection with gynaecological conditions. In some cases of hysteria there appears to be a real contracture at the joint ; but symptoms usually vanish on correct treatment by suggestion. It is sometimes difficult, in the case of a young girl, to decide at the first examination whether the condition is hysterical or the early stage of hip disease. The family history as well as the previous history must be taken into consideration. I have seen a girl simulate several tubercular joints in the course of a year, but the contractures rapidly disappeared after appropriate psychical treatment. In another case, I was at first inclined to diagnose hysteria, because the symptoms disappeared at times ; but the sequel showed that hip disease really existed. The foregoing considerations having led us to the diagnosis of tubercular hip disease, we must next endeavour to determine the variety and degree of the disease. It would be interesting to know whether the case is one of pure synovitis, or whether there has been a primary focus in the pelvic bone or femur. A diagnosis of pure synovitis can only be made, as in other joints, by the exclusion of primary bone disease. But as this usually causes no special clinical signs, and cannot as a rule be directly demonstrated, owing to the inaccessibility of the joint, we must remain uncertain of this point unless a skiagram is taken. If, however, acute exacerbations occur, and subside rapidly on complete rest, we may suspect the presence of diseased bone close to the joint, which has not yet extended into it, but is nevertheless capable of producing slight attacks of serous coxitis. If a tubercular abscess appears in the neighbourhood of the joint, which, however, remains free, we should think of the possibility of a para-articular focus of disease which has penetrated externally. Such a case is not really one of coxitis, as the joint is free. If severe pain is felt when force is applied to the joint, one may be tempted to diagnose primary disease of the bone ; but such a con- clusion is not reliable because the same pain would be elicited if the bone disease were secondary. Pain caused by putting weight on the joint only indicates that the bone is involved in the general condition, but one cannot even be quite certain of this. CHRONIC INFLAMMATORY DISEASES OF THE HIP 653 An X-ray exainination is the best method for the early diagnosis of a diseased area in bone. If the bony outhne is normal, and the gap representing the cartilage is of the ordinary size, but the bone itself is abnormally transparent to the rays (osteoporosis), and the shaft of the femur is narrowed, we may conclude that there is atrophy from disuse, as is usual with tuberculosis. It is, however, impossible to decide whether a primary synovitis exists, or whether a small focus of disease is present in the bone. If the transparent streaks corresponding to the articular cartilage are narrower than on the healthy side, but the picture is otherwise as just described, we must assume that the cartilage has already become partially absorbed. If the sharp edge of the ^^Hi^^^^^^^^^^^HnB^BK' 1 head of the bone or of the acetabulum is replaced by a rough irregular border, it means that the cartilage has been destroyed and the ad- jacent bone eaten away ; but even this condition does not exclude a primary synovitis. But whatever the aspect of the outline of the bone may be, there can be no doubt about the existence of a pri- mary focus of bone disease if there is a transparent area, in the head (fig. 392), the neck, or in the pelvis. This area may either be sharply defined or confused in outline, and is sometimes surrounded by a thick zone (osteosclerosis) with a more opaque structure in the centre (sequestrum). In the later stages it is necessary to diagnose the secondary changes, viz., displacement of the acetabulum, spontaneous dislocation, and separation of the epiphysis. The differentiation of these various processes possesses a certain therapeutic importance. If the displacement has occurred suddenly, or, at any rate, has been aggravated suddenly, for example, as the result of a slight injury, it indicates either a spontaneous dislocation or a separation of the epiphysis — or even fracture of the neck in the vicinity of a large area of disease. The diagnosis, as between fracture and dislocation, is made on the ordinary principles. It should, however, be noted that when the joint capsule is severely affected, the displacement is less and the mobility is greater than in a traumatic dislocation. If the Fig. 392. — Tubercular focus and sequestrum (x) in head of femur. 654 SURGICAL DISEASES OF THE EXTREMITIES displacement occurs gradually, it means that the capsule has worn away by degrees, and the head of the bone has escaped unnoticed, or that the acetabulum has been gradually changing its position, its upper border being displaced upwards, or upwards and backwards by pressure atrophy (fig. 391). The acetabulum thus loses its circular shape, and assumes that of a fish dish. In either case the limb takes up the position of adduction, flexion, and internal rotation. It is quite impossible clinically to distinguish between a severe degree of dis- placement of the acetabulum and a dislocation of gradual onset. This is, however, of no importance, because such dislocations, unlike those which occur suddenly, are incapable of reduction. The distinction may, however, be made by means of a skiagram, which will show at the same time the changes which the entire pelvis has undergone (coxalgic pelvis, fig. 391). The diseased side of the pelvis is inclined considerably forwards in relation to the other side, having rotated on a frontal axis (Hofmeister). One point in conclusion : A tubercular abscess, which is not secondarily infected, should never be opened in hip disease. If the pus is required for examination, it must be obtained by an aseptic exploratory puncture, and if it is desired to empty the abscess this must also be done by puncture and aspiration. B.— NON-TUBERCULAR CHRONIC HIP DISEASE. If a patient of advanced years comes complaining of his hip, our thoughts will run in a totally different direction. We must first make sure that the hip is really affected, and that the case is not one of sciatica. If, on testing the movements of the limb with the patient in a recumbent position, we find that their extent is restricted and painful at their extreme limits, we should think of one of the various forms of non-tubercular chronic arthritis. Of course these con-ditions may occur in young people, but they are as rare as tubercular hip disease is among adults. We then determine the degree of limitation of movement, just as in a tubercular hip, and endeavour to find the cause. If some move- ment still exists, we must note whether it is accompanied by grating. A skiagram will show the presence and degree of osseous changes, and indicate whether the arthritis is merely the result of some other skeletal deformity, such as congenital dislocation, or coxa vara, &c. We then examine to see whether the hip is the only joint affected, ' and we must take a careful clinical history with special reference to the various forms of " chronic articular rheumatism " mentioned in Chapter LXXXII. We will onlv now, however, refer to the conditions which especially affect the hip-joint. Anatomically, the most important are those processes which pro- CHRONIC INFLAMMATORY DISEASES OF THE HIP 655 cluce dcfonnitv, partially destructive and partially proliferating in character. The next in h-equency are the forms which produce ankylosis. As far as etiology is concerned, the cases wherein the disease remains permanently, or at any rate for a long time localized to one joint, are of more interest to us than those cases wherein the multi- plicity of the affected joints facilitate the diagnosis. In the former cases the disease often originates in an injury, sometimes a simple contusion. The younger the patient, the more likely this causation. On the other hand, elderly indi- viduals may suffer from arthritis of the hip with deformity, in the absence of any demonstrable in- jury, i.e., senile disease of the hip. In these cases, however, the disease does not always remain limited to one joint. In the absence of a history of injury, an examination should be made for nervous diseases, especi- ally tabes and syringo-myelia. Although we have regarded adult age as a contra-indication of tubercle, it may still be necessary to fall back upon this diagnosis in cases which are otherwise insuffi- ciently explicable, especially if the patient has a tubercular heredity, or has already suffered from some tubercular condition, and if the pain is very severe, and the disease progresses somewhat rapidly without any temporary improvement. Tubercular hip disease has exceptionally been met with, even at the age of 80. The diagnosis is sometimes rendered difficult by the fact that tubercle may occasionally affect several joints, and thus completely resemble a non-tubercular chronic arthritis. Unless some typical sign (osseous focus, sequestrum, abscess) occurs in one joint, the case may remain obscure for years, and even for a lifetime. Fig. 393-- Chronic hip disease with deformity. 656 SURGICAL DISEASES OF THE EXTREMITIES CHAPTER XCVI. SWELLINGS AND TUMOURS OF THE THIGH. If we see a patient who has suffered a severe injury, lying with his thigh abducted and the knee shghtly flexed, and the whole limb in a position of complete eversion, there is only one diagnosis possible, fracture of the shaft of the femur; if, on closer observation, we see that the thigh is thickened and its axis slightly bent (fig. 394), all doubt is dispelled. Fig. 394. — Fracture of the shaft of the right femur. Fig. 395. — Acute osteomyelitis of the right femur. If a little child, who can give us no history, and whose mother does not know whether it has had a fall, presents a swelling of the thigh and cries when touched, avoiding any movement with the leg, the question of fracture or of the early stage of acute osteomyelitis will at once pass through our mind (fig. 396). But we should be relieved from doubt by finding either false mobility on the one hand, or general and local rise in temperature on the other hand. If the swelling is only slight, but bilateral, the case is neither fracture nor osteomyelitis, but is probably one of Barlow's disease, in which very painful subperiosteal effusions of blood occur over SWELLINGS AND TUMOURS OF THE THIGH 657 the femur. This diagnosis is verified by dark bhiish swelKng of the gums where the teeth have erupted. If a young person becomes ill with high fever and severe pain in the thigh, and diffuse swelling thereof occurs within a few days, the diagnosis of acute osteomyelitis is clear. We shall refer to its various stages in connection with osteo- myelitis of the tibia. A com- parison of fig. 394 with fig. 395 shows how closely the position of the femur in osteomyelitis resembles the position in frac- ture. Swellings which come on gradually and without fever are not necessarily cold abscesses or new growths, but may be chronic forms of staphylo- or streptomycosis of the bone. In order to distinguish between the various possibilities, we must decide whether the swelling arises from the soft tissues or from the bone. This can only be determined by its degree of mobility in relation to the bone when the muscles are completely relaxed. As the swellings are not, as a rule, painful, this ex- amination can usually be made without an anaesthetic. If a sarcoma, originating in the soft tissues, has once become ad- herent to bone, differentiation is no longer possible. The his- tory may, however, indicate that Fjg. 396.— Acute osteo-myelitis of the right the swelling was movable at first. thigh. ^.—SWELLINGS OF THE SOFT TISSUES. (i) The skin and snbcntancons iissne may be the seat of soft fibroma — fibroma moUuscum— lipoma, especially in the upper part, lymphangioma, and occasionally sarcoma, originating in a nasvus. Their difierential diagnosis is too easy to require any consideration here. (2) Swellings of the deeper soft tissnes may arise in the lymphatic glands, blood-vessels, muscles, aponeurosis, nerves, and the loose connective tissue. (a) Swellings of the Lyniphalie Glands.— Tht crural glands, which 658 SURGICAL DISEASES OF THE EXTREMITIES alone concern us here, receive lymph from the whole of the lower limb, including the contiguous region of the perinaeum. Anv swelling in this region demands a search for some portal of entry of infection before we think of anything unusual. A young man came to the out-patient department with a small swelling in the crural region. The swelling pulsated, or at any rate appeared to do so. The recently qualified assistant, therefore, diagnosed an aneurism. It was, however, an inflamed gland over the femoral artery, and a small septic wound of the skin of a toe was found. We shall refer to sarcomata of the Ivmphatic glands later on. (b) Aneurisms. — The diagnosis of aneurism is easily made by its position in the course of a large vessel, almost always the femoral artery, and by its pulsation, as also bv the vascular conditions below the tumour, and, finally, by its frequent traumatic origin. Not every pulsating tumour is, however, an aneurism, for there are some very vascular sarcomata which pulsate, and over which a distinct murmur is heard on auscultation. It is therefore necessary to employ every expedient to verify the diagnosis of aneurism, especially the com- pression of the femoral artery just above the swelling. Arterio- venous anenrisuis may also occur in the thigh, but their diagnosis is facilitated by the fact that their origin is always traumatic. ic) Muscular SivelUugs — Angiomata, tubercular and gummatous nodules, herniae and osteomata of muscle behave as m the upper limb. It may be stated, however, that herni^e, as well as bony nodules, are mostlv found in the adductor muscles of riders, because they are subject to great strain ("rider's bone"). Such a bon}^ formation may also follow a single injury, for instance, a muscular contusion due to the kick of a horse. I have also seen it follow rupture of muscle through over-extension. There has been much ccjntroversy as to the possibility of ossifica- tion within a muscle, independently of injurv to the periosteum and misplacement thereof. In my opinion there is no doubt about this possibility, although it happens that in the thigh the periosteal origin of such traumatic muscular osteomata has been demonstrated in many cases. We will discuss sarcomata together with tumours of the connective tissue. id) Conucciive Tissue. — These tumours consist of fibromata and sarcomata. They may arise from the connective tissue between the muscles and nerves or within them. A firm tumour, which remains movable for years and causes no disturbance beyond its size, is a fibroma. The more rapid the growth of a tumour, the sooner it contracts adhesions and the more pain it excites, the richer it is in nucleated cells, and the more it approximates therefore to the SWELLINGS AND TUMOURS OF THE THIGH 659 type of sarcoma. As no sharp limitations can be drawn, even histo- logically, a positive diagnosis cannot be made clinically. It is better to eradicate the tumour before it becomes malignant than to wait until a positive diagnosis is possible. There are some fibromata, which at first recur as such, but in course of time their histological type approximates to that of sarcoma. It is therefore necessary to remove even the most innocent tumour while the patient is still in good health. The relations of the tumour to the muscles may be ascertained by examining it when the muscles are relaxed and when they are tense and comparing the results. A neurofibroma is diagnosed by its position along the course of a nerve, by its spindle or cylindrical shape, by the early onset of neuralgia and paraesthesia, and occasion- ally by its multiplicity or the existence of similar tumours in other portions of the body. The risk of secondary malignant degeneration is always present in these cases. 5._SWELLINGS OF THE BONE. (1) OSTEOMA AND CHONDROMA. If we find close to the lower epiphyseal line a nodular bony tumour which has existed for some time, and which is gradually growing away from the joint, we have before us the classical picture of a cartilaginous exostosis (figs. 397 and 398). These growths are congenital and arise from misplaced fragments of cartilage ; diey consist of bony tissue covered over by a thin layer of cartilage, and they continue to grow until the bone to which they belong has completed its growth. As they are usually situated on the diaphyseal side of the epiphysis, they become more and more distant from this line as the bone grows in length. Sometimes these exostoses occur in separate attacks, and we may therefore find several on the same bone, at various distances from the joint. Sometimes they drag with them an extremity of the joint capsule with which they have contracted adhesions in their original position ; in other cases they are covered by a mucous bursa, quite independent of the joint — exostosis bnrsata. If the diagnosis still remains uncertain despite the considera- tion of all these points, we should examine the other epiphyses of the body and probably find similar exostoses in other positions. Chiara found as many as a thousand in one person. Pure cartilaginous tumours, which may also exist at some distance from the epiphyseal line, form the transition between these innocent tumours and malignant growths of the femur. If they are accessible to palpation, they present the well-known nodulated surface and a consistence less hard than osteomata. Central chondromata, are not, as rule, diagnosed, until they lead to spontaneous fracture. 66o SURGICAL DISEASES OF THE EXTREMITIES (2) SARCOMATA AND ALLIED TUMOURS. We must never diagnose a prnnary malignant growth of the femur, before assuring ourselves that the case is not one of secondary growth. This is more especially necessary in connection with the upper half of the femur, because it is a favourite situation for such metastases. Cancer of the breast is the most likely original source,, but the primary disease may be cancer or sarcoma anywhere. I have seen fracture in the upper third of both femora occur in an aged female after cancer of the breast. The accident was merely a slight slip. In the absence of such an origin, we may assume that a new growth is present — probably some variety of sarcoma. The so-called blood-cysts of file long hones, some of which were formerly termed nnenrisnis of hone, are of a doubtful nature; at any rate they are not obviously sarco- mata. A spindle-shaped dis- tension of the diaphysis, looking like a large beetroot, takes place. The cortical portion of the bone is con- verted into a thin shell, and its interior is occupied by trabeculae. The structure contains pure blood. There are no tumour elements visible ; but it may be pos- sible to separate from the internal surface a thin layer of tissue, containing ele- ments similar to bone mar- row, especially giant cells. But whether the condition is a tumour, an inflammatory process (" ostitis fibrosa "), or the result of an injury (an abnormality of callus) is a subject of controversy (see also under "Leg")- Attention is usually first drawn to this condition in the femur by a spontaneous fracture. In other cases these growths are rather of connective tissue nature, and they cause bending, before spontaneous fracture occurs. Growths of this kind have been described as occurring in the subtrochanteric region. Fig. 397. — Cartilaginous exostosis of femur. SWELLINGS AND TUMOURS OF THE THIGH 66 1 Putting aside these conditions, which are rarities, sarcoma of the femur presents itself either as a diffuse thickening of the epiphyseal region or as a spindle-shaped distension of the diaphysis, which, later on, becomes nodular in character. For the purpose of discussing the differential diagnosis, we must separate these two forms, and we shall begin with the tumours of the epipJiysis. (a) Tumours of the Epiphysis. Sarcoma of the upper end of the epiphysis is usually treated as a form of hip disease, or as sciatica, or even as osteomyelitis, until the Fig. 398. — Cartilaginous exostosis of the left fetiiur. Fig. 399. — Sarcoma of the lower end of the femur. neck of the femur suddenly breaks, or the skiagram reveals the existence of something which is neither an ordinary inflammation of the hip-joint nor a simple neuralgia. I once saw a young man who was of an age when osteo- myelitis is frequent, with a high temperature and a rapid pulse. There was at the upper end of the thigh a soft elastic swelling which any clinical student would have considered fluctuating. I also thought that the swelling probably contained fluid, and I made an exploratory puncture in order to decide between tubercle and osteomyelitis. The examination of the tissue thus obtained, and the 662 SURGICAL DISEASES OF THE EXTREMITIES exploratory incision itself led to the conclusion that there was a small round-celled sarcoma of gelatinous appearance invading the pelvis. This was before the time of Rontgen rays and the young man rapidly succumbed. A vigorous man had kept his bed for several months because of " sciatica." On measuring, it was found that there was supra- trochanteric shortening, and the skiagram showed distension of the trochanter by a : the neck of the [ into it. ' Sarcoma at the lower end of the femur is easily mistaken, at first, for a tubercular joint. A middle-aged man noticed a growth, with femur wedged L. Fig. 400. — Osteomyelitis of the femur, of a few months' duration. Periosteal bone forma- tion beginning, s = sequestrum. Fig. 401. — Localized staphylomycosis of the medulla, a = healthy side ; d = diseased side. slight swelling about the knee, after a blow. A very experienced practitioner made the diagnosis of tubercular knee, and a surgeon who was called into consultation agreed. Five years went by, with iodoform injections and waiting. The knee continued to swell, but the movements of the joint remained free. Finally, the lower end of the femur assumed the appearance of a club-shaped structure, about as big as two fists. It was evidently a case of giant-celled sarcoma, covered by a thin shell of bone, similar to the case illustrated in fig- 399; ^vhich was also first diagnosed as tubercle. SWELLINGS AND TUMOURS OF THE THIGH 663 The main point in diagnosing these cases is to locaHze the swelhng accurately. In tubercle the capsule is thickened, but the underlying bone is of normal dimensions. The thickness of the capsule is easily detected by comparing both knees on palpation, especially at the borders. If the whole region of the knee appears to be swollen, -V .1 i^'* Fig. 402. — Osteomyelitis of femur, with bending of the lower end of the diaphysis. Fig. 403. — Skiagram of fig. 402. S = sequestrum. although the soft tissues and the capsule are free, we must assume the existence of a more deeply situated process — either a tumour of the bone or a chronic osteomyelitis. We may derive much assistance from the mobility of the joint. Movements persist for a long time in cases of tumour, but they are quickly interfered with by tubercle, although some tubercular knees retain their mobility for 5^ears. 664 SURGICAL DISEASES OF THE EXTREMITIES Thickening of the capsule which decides the diagnosis is, however, always present in these cases. Chronic osteomyelitis is more likely to be a source of error than tubercle. If the growth is characterized by sudden exacerbations, and especially if there are periods of deep and throbbing pain in the bone, accompanied by acute transitory effusion into the joint, the case is probably chronic osteomyelitis. If the disease has persisted for many years, we must assume that an inflammatory process exists. In the case just quoted there was a duration of live years j but this is the extreme limit which is consistent with the diagnosis of sarcoma. As a rule, the course of these tumours permits the diagnosis to be made verv much earlier than this. The appearance of a definite subcu- taneous venous nehvork is another sign which should be mentioned as an indica- tion that the deepiv situated large veins are compressed. This rareh' occurs in tubercle, but may take place in osteo- myelitis if thick periosteal indurations form. It occurs most frequently, however, in connection with malignant growths. Fig. 404. — Fracture of healthy shaft of femur. (b) Tumours of the Diaphysis. Ttimours of the diaphvsis are more difficult to diagnose than those of the epiphysis, because they are less accessible to palpation, and because the characteristic changes in the knee-joint are less in evidence. Otherwise the rules applicable to the epiphysis apply here also. It should be especially noted that osteomyelitis has a much greater tendency than sarcoma to travel along the whole extent of the shaft of the femur. Cases wherein the tumour is sharply delimited from the shaft of the femur are therefore easy to recognize; difficulty of diagnosis arises in con- nection wdth the more diffuse, spindle-shaped sarcomata. Tw^o examples will illustrate how errors of diagnosis may be caused by the unusual behaviour of the staphylococcus. A man, aged 32, otherwise in good health, had been suffering pain in his right thigh for a few weeks. The pain did not come on suddenly, and the patient was not conscious of any antecedent febrile disease, nor had there been any previous injury. For some time the patient thought he had rheumatism, but eventually consulted a doctor, who found a slight thickening in the middle of the femur, and thought of sarcoma. On palpation, however, the structure was somewhat SWELLINGS AND TUMOURS OF THE THIGH 66: more tender than one would expect in the case of a tumour. The X-rays revealed a slight thickening of the cortex, indicated by a sharply defined shadow (fig. 401). this pointed to an inflammatory condition. As tubercle practically never occurs in the shaft of the femur, the diagnosis was evidently a very mild form of "acute osteo- myelitis," or rather a chronic staphylomycosis, which better describes the actual condition present. But even this designation was ex- posed to the risk of error, because an identical clinical picture can be produced by the streptococcus and other pus organisms. The operation, however, showed that staphylomycosis was correct, because the small amount of pus which was found yielded the Staphylococcus aureus. Fig. 405. — Spontaneous fracture in myelogenous sarcoma. I saw the other case as a student in Kocher's clinic. It was subse- quently recorded by Kocher and Tavel in their work on staphylomy- coses. The tumour was situated in the lower portion of the femur, and completely simulated a sarcoma. It contained a brownish yellow granulation-like tissue, under a thick indurated sheath. A piece of the tissue was examined by a competent histologist during the operation, and declared to be sarcoma. Amputation would have been resorted to had not a small sequestrum which was found deep down, indicated another diagnosis. Inoculation on a nutrient medium yielded the Staphylococcus aureus, and the leg was saved. Spontaneous bending of the bone sometimes occurs as a result of osteomyelitis, and is due to the traction of the flexors of the knee on 666 SURGICAL DISEASES OF THE EXTREMITIES the partially destroyed diaphysis. Figs. 402 and 403 illustrate the consequent typical deformity. If there is a fistula, as there was in this case, the diagnosis cannot be missed. Sometimes — but not always — the skiagram differentiates between osteo-myelitis and sarcoma. The following applies both to the epiphysis and the diaphysis. The skiagram of osteomyelitis shows either (i) a normal edge to the bone; or (2) sharply defined, often clearly laminated deposits (figs. 400 and 401), gradually shelving away on both sides. The former appearance means that the process is comparatively recent, and that the palpable swelling depends upon peri- ostitis without new bone forma- tion. The latter appearance means that the process is some- what old, and has led to peri- osteal bone formation. The limits of the sequestrum (figs. 400 and 403) may often be recognized at this stage. The older the process, the less clear is the lamination, so that finally the appearance is that of a diffuse spindle - shaped or cylindrical thickening of the bone (partially in fig. 402), In myelogenous sarcoma the borders of the femur are equally enlarged, or on one side only. The cortex of the distended portion of the bone is greatly thinned — it may be as thin as paper. The osseous structure is obliterated, and light patches appear in the bone. " Spontaneous fractures caused by malignant growths are remarkable, as seen in the skiagram, by the rounded ends of the frag- ments or by the peculiar erosion of the cortex {cf. figs. 405 and 406). Periosteal sarcoma appears as a deposit, on the normal or more or less deeply eroded bone, and casts a light shadow. Sometimes pronounced deposits of periosteal bone appear, which make the picture very similar to that of osteomyelitis. Fig. 406. — Spontaneous fracture in a meta- stasis of cancer of breast. INJURIES IN THE VICINITY OF THE KNEE-JOINT 667 CHAPTER XCVII. INJURIES IN THE VICINITY OF THE KNEE-JOINT. In falling forward we instinctively bend the upper part of the body backwards, in order to protect it — and especially the face — from damage. The force of the fall is therefore borne by the knee, and by the hands which are extended at the same time. This explains the great frequency of injuries to the knee-joint. (i) If we find a swelling in front of the knee, after a fall directly upon the joint, and if on pal- pating the patellar region a cushion-like feeling is obtained, there is an efFusion into the prepatellar bursa. The more quickly the swelling develops after the fall, the more likely is it to contain blood ; the longer its development is de- layed, the more likely is it to be a serous effusion, i.e., prepatellar bursitis. (2) It is more frequent to find some intei'ference with movement — limitation of flexion — and a swelling not localized to the front of the patella, but around it, the groove on either side of it being obliterated (fig. 407). At the same time a transverse swell- ing appears above the patella, especially when the quadriceps tendon is relaxed. Sometimes the obliterated lateral grooves become •conveited into genuine swellings, and the superior transverse swelling increases in size. The patella is raised, and although it may be pressed back against the condyles of the femur, it instantaneously returns to its former level— so-called "riding" of the patella. The French term " ballottement " is, however, more accurate. Such a condition indicates an eftusion within the joint; whether it is more of a serous ■or of a haemorrhagic character, depends upon the rapidity of its development. If the skin presents abrasions, in evidence of the direct effect of the force, and if the parts upon which the force fell— the 43 Fig. 407. — Effusion into the joint in sprained knee. 668 SURGICAL DISEASES OF THE EXTREMITIES patella and tuberosities of the tibia — are tender, while the region of the lateral ligaments is free, the diagnosis is contusion of the knee-joint. If the injury was indirect, taking the form of excessive adduction or abduction or rotatory movement, we must assume the existence of a sprain, as long as the symptoms are limited to effusion and inter-, ference with movement. The manner in which the accident happened often makes it impossible for us to distinguish between contusion and sprain. The patient, for example, has fallen down, and lights upon his leg in a constrained attitude — more or less in the " tailor's attitude."' He may have sustained a contusion or a sprain. The absence of cutaneous abrasions does not necessarily exclude the latter. We therefore adopt another sign to differentiate between these two injuries : the localization of the tenderness to pressure. We have already seen where this is in cases of contusion. In sprains, however, it is found in the vicinity of the lateral ligaments, because the main force of the injury is situated there. Sometimes the ten- derness exists over both lateral ligaments, or over their attachments to the femur and tibia ; sometimes only over one ligament — generally the inner. It may be objected that these points are unnecessary refinements, seeing that the treatment is identical. It should, however, be remem- bered that contusions and sprains have their special complications, which will be indistinguishable clinically unless the nature of the original injury is recognized. In both cases, it sometimes happens that the trouble does not subside in the usual way. Creaking sounds,, which are often audible at a distance, may occur in the joint ; sudden severe pains interfering with movements, or a rapidly developing effusion may arise — conditions which were previously described by the term " derangennent interne." This vague diagnosis was rendered necessary by the vague knowledge of the actual conditions within the joint, in pre-antiseptic days, when operation was justifiably avoided. But to-day we possess data which enable a more accurate diagnosis to be made. If the original injury was a contusion, the Fig. 408. — Fracture of cartilage over median condyle of femur (x). INJURIES IN THE VICINITY OF THE KNEE-JOINT 669 internal lesion consists of the fracture of the cartilage of one of the condyles of the femur — generally the median. The detached piece has hyaline cartilage on the one side, and more or less altered bone on the other side. The depression, covered by a smooth cartilage-like scar, may be found, years afterwards, on the condyle. It is obvious that these fractures are more likely to happen if the cartilage or bone be diseased, i.e., in arthritis deformans. As the injury which causes these detachments may be very slight, even in young people, Konig assumes the existence of an ostco-chondritis dissecans as a predisposing cause — an assumption which has, however, met with considerable ob- jection. We cannot enter into the question here. The main thing is to recog- nize the injury, what- ever be its pathological antecedent. The principal evidence Fig. 409.- -Knee joint with two free foreign bodies {a and li). Patient aged 38. Fig. 410. — Sesanaoid {s) bone in popliteal space. of the presence of a foreign body in the joint is derived from actually feeling it, and from an accurate knowledge of the direction of the injury. Repeated examinations may be required in order to palpate the foreign body, and even then one may fail. X-ray examination is conclusive, if some bone is attached to the cartilage, as is usually the case. A sesamoid bone (fig. 410) m the flexor tendons of the knee must not be mistaken for a foreign body in the joint. There are some foreign bodies in joints which do not arise from injury. Cartilaginous proliferations in certain forms of arthritis may 670 SURGICAL DISEASES OF THE EXTREMITIES be broken off quite unknown to the patient. Cretinisiii, or at any rate hvpothyroidisiu, plays a definite role in this connection. If the injury was a sprain (generally an eversion of the femur on the fixed tibia), the "derangement interne" consists of the detach- ment and displacement and temporary "locking" of a semilunar cartilage, especially the internal. Besides the characteristic pain associated with this lesion, there are two other symptoms which lead to the diagnosis : (i) Pain on pressure over the attachment of the corresponding lateral ligament, or over the attachment of the semi- lunar cartilage to the tibia ; and (2) the extrusion of the cartilage from the joint cavity on extension of the limb — a somewhat rare symptom. Fig. 411. — Sprained knee with detachment of the insertion of crucial ligament into the libia (x). Fig. 412. — Fragment detached from internal condyle of femur. The former symptom is only found in comparatively recent cases, and the latter is frequently entirely absent, so that we often have to rely exclusively on the history. The differential diagnosis between fracture of the articular cartilage and laceration of the semilunar cartilage may also be suggested by the frequency of the attacks. If these are infrequent, but accompanied by very severe disturbances within the joint, the case is probably one of fracture of the cartilage over one of the condyles. If the attacks are frequently repeated, and if loud grating occurs on any extensive movement, the case is probably a laceration of the semilunar cartilage. . It should be mentioned that in Earth's opinion fractures of the LMIURIES IN THE VICINITY OF THE KNEE-JOINT 671 cartilage over the femoral condyles may also be caused by sprains. He assumes that a piece of cartilage may be torn off by means of one of the crucial ligaments. This, however, would be a rare contingency which does not invalidate what has already been said. Fig. 411 shows that the attachments of the crucial ligaments to the bone may be torn off in cases of severe sprain. Stieda has described a lamella of bone at the upper end of the internal lateral ligament as a late sequela of sprains. It is not clear whether this is due to a detachment of periosteum and bone at the moment of the injury, or whether it is due to secondary bone formation in the torn ligament. Both causes may possibly contribute. I have observed the entire disappearance of this lamella within a few months. Fig. 413. — Normal spine of tibia in a young person. Fig. 414. — Detachment of spine of tibia. To return to the recently inflicted injury. A patient suffering from a sprain or contusion can lift his leg in a position of extension, although it may cause pain. If this is impossible, we must conclude that there has been some injury either to the extensor apparatus or to the bone itself. (3) We can tell in a moment whether there is shortening, or pain on pressure on the axis of the limb, and thus decide as to fracture in the continuity of the bone. In the absence of this, the only other possible condition is laceration of the extensor apparatus. This may occur m one of three situations : (i) In the quadriceps tendon above the patella; (2) in the patella itself; and (3) below it, i.e., in the ligamentum patellae. Palpation of the region involved will at once give an approximate idea of the situation of the injury. Laceration 6/2 SURGICAL DISEASES OF THE EXTREMITIES Fig. 415.- -Transverse fracture of patella. Fig. 416. — Comminuted fracture of patella. Fig. 417. — Supracondylar fracture, seen from the FiG. 418. — Supracondylar fracture, seen from the fiont, with typical displacement. C.e. = external side. Typical displacement of lower fragment. condyle. C.i. = internal condyle. Upper fragment displaced forwards and outw-ards. IXJURIES IX THE VICIXITY OF THE KXEE-JOIXT 673 Fig. 419. — Supracondylar fracture. (From a case of cretinism.) Fig. 420. — Fracture of external tuberosity of the tibia. i^Fragments torn and broken off the femoral condyles. Fig. 421. — Condylar fracture. {Post-morlem preparation.) Y-shaped fracture. Fig. 422.— Fracture of the tibia, below tuberosities. 674 SURGICAL DISEASES OF THE EXTREMITIES of the quadriceps tendon, the rarest of these injuries, produces an easily palpable and even visible hollow above the patella. This is especially striking if the upper end of the tendon rolls up, and thus appears to be thickened. Detachment of the ligamentum patellae close to the knee-cap, with some bone substance adherent to it, is of more frequent occurrence. This injury is also easily detected by the finger. But fracture of the patella is still more frequent, and the results of palpation are so clear that a mistake is scarcely conceivable. The precise manner in which fracture of the patella occurs has been a subject of much contro- versy. It has been stated that the simple transverse fracture (fig. 415) is indirect, and caused by muscular contraction, and that the Y-shaped or radiate frac- FlG. 423. — Detachment of head of fibula. Fig. 424. — Dislocation of the knee. Promin- ence of the internal condyle. Ci., caught by the buttonhole mechanism ; P., patella. ture (fig. 416) is caused by direct force, i.e., by falling on the patella. Four-fifths of the cases of fracture of the patella were attributed to muscular action, whereas, as a matter of fact, recent careful observations show that the proportion is exactly the reverse. Schlatter describes cases wherein the spine of the tibia has been torn off or broken off at the epiphyseal line in young persons (fig. 414). INJURIES IX THE VICIXITY OF THE KXEE-JOIXT 67: One must, however, guard against mistaking the normal hne of the epiphysis, however unusual it may look, for the result of some trauma (fig. 413). In most cases the pains are due to tearing and not to gross anatomical changes. (4) If, on the contrary, there is pain on axial pressure with shorten- ing, however slight, combined with severe haemorrhagic effusion into the knee-joint, we conclude that the lesion is not in the extensor apparatus, but that it is located in the continuity of the limb, i.e., either a fracture of the lower end of the femur or the upper end of the tibia. Fig. 425. — Skiagram of same case. Attachments of crucial ligaments to tibia, torn off. These fractures are classified as supracondylar, diacondylar (in the epiphyseal line of the femur), fractures of the external and internal condyle, combined Y- and T-shaped fractures, and infracondylar (tibia). These various forms, however, are less subject to rule than the corresponding fractures at the elbow. Supracondylar fracture does not involve the joint directly, but it often happens that the upper fragment, which is usually displaced 676 SURGICAL DISEASES OF THE EXTREMITIES forwards and outwards, penetrates the joint between the lower fragment and the patella. The joint cavity is thus opened up and participates in the haematoma. The usual course of the lines of fracture is seen figs. 417-419. Fig. 419 represents the case of a dwarfed cretin, whose femora had, for a whole year, undergone subperiosteal bending at the same situations. Hypothyroidism is one of the chief causes of diminished bone stability. I was once consulted for a patient with thyroid inadequacy who had just sustained his twenty-second fracture. If the haemorrhagic effusion is considerable, an accurate diagnosis cannot be made without an X-ray examination, which should always be made in two directions at right angles to each other. Diacondylar fracture, occurring as a separation of the epiphysis, is a very rare event, and if the displacement is slight may be mistaken for a sprain. If the displacement is considerable, or if false mobility exists, the diagnosis is based upon the facts of lateral displaceability and the absence of any interruption of continuity above the joint line. Fracture of the condyles in their various combinations are recognized by the mobility of one or both detached condyles, on the shaft of the femur, and by the varus or valgus position assumed by the joint. Y- and T-shaped fractures arise from the shaft of the femur being driven in, like a wedge, between the condyles (fig. 421). Details are accurately obtained by a skiagram, which is preferable to the otherwise unavoidable examination under an anjesthetic. Similar fractures occur in the tibia (fig. 422); the infracondylar variety being the most frequent. Detachment of the head of the fibula, which is a very characteristic but rare fracture, should be mentioned here (fig. 423). Dislocations of the knee-joint and of the patella are still more rare. Dislocations of iJic knee — both congenital and traumatic — have been seen in all directions, forwards, backwards, downwards and outwards. Their appearances are so remarkable that it is unnecessary to discuss their differential diagnosis. But incomplete lateral dis- locations require very careful palpation. The button-hole mechanism, whereby one of the condyles becomes ''caught," as first described by Iselin, is worth noting. It is illustrated in fig. 424. I J Displacements of the patella, which are usually external, are diagnosed by careful palpation. This bone is quite superficial, and there is no difficulty in detecting whether it is displaced outwards or inwards, or perched on its edge. Two cases of vertical torsion through an angle of 180° have been described, but the diagnosis of this condition would be more difficult. ACUTE INFLAMMATORY DISEASES OF KXEE-JOIiNT 677 CHAPTER XCVIII. ACUTE INFLAMMATORY DISEASES OF KNEE- JOINT. Acute inflammation of the knee-jomt rarely presents any diagnostic difficulty. The first point to settle is, that the disease is really in the joint. Superficial examination may lead to a diagnosis of suppuration within the knee, when the condition is really one of prepatellar phlegmonous bursitis, if, as frequently happens, many ounces of pus are present and the whole knee appears to be swollen in an unshapely manner. But the distinction is easy if the examination is careful. The swelling is in front of the patella in bursitis ; in a suppurating knee, however, the prepatellar region is rather flattened out, and the patella itself can be felt just under the skin. In bursitis the popliteal space is free, whereas, in acute arthritis of the knee, it is painful on pressure. In considering the knee-joint itself, we must be quite clear as to the elements which such an inflammation may comprise, i.e., (i) effusion of fluid, (2) swelling of the capsule, (3) bony and cartilaginous changes. Often only one of these signs is present, but frequently there are two, and sometimes all three. Effusion into tlie joint is recognized by the filling out of the fossae on either side of the patella, and by the distension of the supra- patellar bursa. If the eftusion is considerable the phenomenon of '•'riding of the patella" appears. If the capsule becomes lax after the subsidence of the eftusion, the knee-cap can be displaced, to a remarkable extent, in all directions. In order to detect any slight degree of swelling of the capsule, it is necessary to compare its fold of reflection on both knees. Normally this can just be felt if the patient is not too fat. Involvement of tlie bone is often difficult to recognize, unless some striking change in shape is present, A tender area, which is sharply limited, and not at the situation where the capsule is reflected, indicates a lesion in the bone. Views differ as to the significance of the pain on axial pressure. This is usually held to be a sign of bone disease, but this cannot be correct if, as Lennander assumes, the bone itself is insensitive and only the periosteum possesses sensation. The etiology of acute inflammation of the knee is the same as that of acute arthritis elsewhere. We have already discussed this in full in connection with the shoulder-joint, and will only refer here to a few characteristic conditions. If we are consulted about a case of acute eft'usion in a joint, we 678 SURGICAL DISEASES OF THE EXTREMITIES must first inquire whether there has been any recent injury. In the absence of such a cause we must inquire about former injuries, and previous attacks of sudden joint swelhng. If we ascertain that such attacks have occurred and that they have been occasionally accompanied by severe pain which prevented any further movement,, we should think of a foreign body in the joint and locking of a semi- lunar cartilage. If necessary, the differential diagnosis must be made by means of X-rays (fig. 409). If the effusion occurs periodicallyr without the signs of a foreign body, we should think of the rare cases of intermittent hydrops of the knee, probably of nervous origin. In the absence of any injury or any previous attacks of a similar character, we should conclude that the case is of an infective nature^ if the effusion has come on within a few days with severe pain, tension and pyrexia. If the patient is a young man and the knee is the only joint affected, we should ask him sotto voce when he had gonovrliaa. He will rarely deny the impeachment, but may ask that it should be treated as rheumatism, out of regard "for the old- fashioned ideas of his parents." We should make the same diagnosis if a young woman has " caught cold" on her honeymoon. Secondary inflammation of the knee has been observed in infants with gonorrhoeal ophthalmia, as also in little girls with gonorrhoea. Insured persons will attribute it to an accident. In some cases this will be pure invention, but it is quite conceivable that a slight sprain may afford the gonococcus the opportunity of attacking a joint, if the organism already exists in the body. An acute inflammation of the knee-joint after a confinement or a septic abortion, presents difficulties of a therapeutic rather than of a diagnostic nature. Acute arthritis occurs more frequently in the knee than in other joints, as a result of direct iiijnry, varying from a needleprick — the needle remaining in the capsule — to the cut of a hatchet. This is not always followed by acute suppm-ative inflammation with great swelling and high fever. The knee more frequently swells up gradually in the course of a few days, the fever is slight and the periarticular changes are trivial. The shape of the distended articular space is very clearly discernible through the soft parts. As the symptoms are so mild, nothing but a purely serous exudation is expected ; but exploratory puncture shows that some turbidity already exists owing to fibrin and pus cells. If the case is treated without delay in an appropriate manner the knee will be saved, but if delay is incurred stift'ness will result. In growing children every case of acute inflammation of the knee should suggest the possibility of acute osteomyelitis of one of the adjacent bones. An articular eft'usion, sometimes purely serous, CHRONIC DISEASES OF THE KNEE 679 is often the only symptom of a localized diseased area in an epiphysis. Diagnostic interest may also attach to the late sequclce oj acute iiifiaininatory knee-joints. If, despite extensive incision, the tempera- ture remains high and the neighbourhood of the joint remains swollen, we must assume that periarticular abscesses have developed, which are most frequently found under the extensor muscles and the patella. Sometimes the joint continues to suppurate despite multiple mcisions, and the temperature persists at 100*5° although no periar- ticular abscesses can be demonstrated. X-rays will show that the interval between the femur and tibia is abnormally narrow, owing to more or less destruction of the cartilage. On exposing the joint the cartilage will be found to be eroded, the underlying bone more or less destroyed, and in young people the epiphysis may have formed a sequestrum. In other cases the joint itself may have undergone little change, but the adjacent metaphysis may be involved, and a sequestrum may even have formed. CHAPTER XCIX. CHRONIC DISEASES OF THE KNEE. There is no joint which varies so much as the knee in appearance as a result of chronic inflammation from one and the same cause. Great caution must be exercised in diagnosing the cause from the anatomical conditions present. Thus simple hydrops of the knee may exist in chronic traumatic inflammation, in tubercle, or in neuropathic disease of the joint; ankylosis may exist in chronic articular rheumatism, and in tubercle, &c. A chronically inflamed knee may present three essentially different conditions, each one of which possesses its own problems of differential diagnosis : — (i) Chronic articular eft'usion. (2) Thickening of the capsule, including the synovial membrane. (3) Rigidity of the joint. (1) CHRONIC ARTICULAR EFFUSION. We have already studied, in connection with acute traumatic effusions, how^ to recognize an articular effusion. Chronic effusions, however, last longer and attain a larger size, though their degree of tension is not so great. 680 SURGICAL DISEASES OF THE EXTREMITIES Certain articular effusions were previously termed idiopatliic. We now know, however, that, apart from very rare intermittent effusions due to nervous disturbances, that there is no such variety. The more careful the history is taken, and the more accurate the examination, the more certain is some cause to be discovered. {a) The diagnosis is usually chronic articular rheumatism, if several joints are affected simultaneously or in rapid sequence, and the remarks already made on this malady, when dealing with diseases of the shoulder, should be recalled. In the latter, the most frequent varieties are the adhesive and the destructive caries sicca, whereas in the knee exudative processes predominate. In the neuropathic forms there is a great tendency to proliferative processes. The diagnosis of rheumatism is often merely a refuge of ignorance. It should never be made until all other possibilities have been excluded. An example will illustrate this. A boy aged lo, suffering from articular effusion of both knees, was sent into the hospital as a suspected case of tubercle. But as the affection was on both sides, and as there were no other indications, we thought the case was one of chronic rheumatism. One morning, however, we noticed some injection of the eye and slight cloudiness of the cornea, which had supervened since the previous evening. This at once suggested "the sins of the fathers," and it was clear that the serous inflammation of the knees was due to congenital syphilis. The result of mercurial treatment confirmed this diagnosis. If there has been no attack of recent parenchymatous keratitis, hereditary syphilis may probably be indicated by old corneal opacities or by the shape of the teeth, in addition to the bilateral effusion. In other cases, we may ascertain that the patient bleeds easily, and that any pressure leaves a blue mark. This suggests that an early stage of so-called hsemorrhagic effusion is present — but this is a rare contingency. We have hitherto been assuming that all the articular diseases are of a serous nature. Although this is true for cases of congenital svphilis, it is not true for hjemorrhagic joints and for genuine chronic rheumatism, in both of which there may be effusion on one side and ankvlosis on the other. {b) The problem is quite different if only one joint is aff'ected. The most important question is whether fnbercle is present. In addition, one has to think of (i) chronic or recurrent traumatic effusions, (2) foreign bodies and dislocation of a semilunar cartilage, (3) gonorrhoea with an unusually protracted course, (4) the proximity of a focus of osteomyelitis, (5) tertiary syphilis, (6) rheumatism exception- ally remaining in one joint, (7) a neuropathic joint, and finally, (8) a mono-articular hsemorrhagic effusion. On the other hand, if the effusion is limited to one side, hereditary syphilis may be confidently excluded. We will deal bi'iefly with these possibilities, reserving tubercle till the end. CHRONIC DISEASES OF THE KNEE 68l Traumatic effusions come on in an acute manner. If the trauma is frequently repeated, or if the patient is rheumatic, the effusion may become chronic. There is no ev^ident thickening of the capsule, and this constitutes the distinction from tubercle supervening after an injury. The "locking" of foreign bodies and of the semilunar carti- lages, are distinguished by their intermittent character. A knee, the mechanics of which has been disturbed by a fracture — even extra-articular — may be subject to intermittent and remittent serous effusions, years after the accident. The diagnosis of chronic gonorrhceal effusion is made from the history and usually also from the condition of the urethra. Synovitis due to osteomyelitis is easy to recognize if the patient has the scars of that disease on the femur or on the tibia. There are, howevei", cases, which for years are called "rheumatism," when in reality an abscess exists in the bone, close to the epiphysis, and some- what acute attacks occur from time to time, accompanied by effusion into the joint. We must depend upon the history for the correct diagnosis, but examination will show that the main situation of the swelling and of the pain is not in the joint, but in the adjacent bone. The diagnosis of tertiary syphilitic synovitis is suggested by the history and the slightness of the pain ; but one cannot be certain of its accuracy until specific treatment has met with success: ' We may assume the presence of chronic mono-articular rheumatic synovitis if the capsule is not markedly thickened, the temperature over the joint is not definitely raised, and if the trouble has persisted for years without getting much worse. Mild forms of tubercle may drag on from infancy far into adult age without abscess formation and with a tolerable amount of move- ment, but with intermittent exacerbations. In these cases, however, the capsule is always definitely thickened. In the neuropathic forms the diagnosis is established by the absence of pain, despite advanced changes in the joint, and by the early onset of deformity, in addition to the pure synovitis. This variety of arthritis has been appropriately termed a " carica- ture of ordinary arthritis." If symptoms of tabes or syringomyelia co-exist, the diagnosis is naturally easier ; but sometimes it will be necessary to search for these diseases, because the joint trouble may be the first symptom of nervous disease to attract the attention of the patient. Haemorrhagic effusion has already been referred to. We have now arrived, by way of exclusion, to tubercle, which is by far the most common form of serous inflammation of the knee. The vast majority of these cases occur in infancy, but adults may become affected, and it is not rare even in old age. It is only distinguished from other forms of serous inflammation by the fact that the capsule SURGICAL DISEASES OF THE EXTREMITIES is somewhat thickened from the very beginning, and elevation of the temperature over the diseased joint, of the capsule must always be looked for at its /o/c/s, its superior border, and on both femoral condyles, knee is examined at the same time it will be easy to far the folds can be palpated in the normal condition. If the joint is full and tense, this sign cannot be de- monstrated. In such a case, the joint should be puncUired, and a positive diagnosis will be obtained by examining the fluid. Blood, pure or nearly so, indicates haemorrhage into tlie joint. Clear, serous, or mucous fluid may be found in by the persistent The thickening that is to say, at If the healthy appreciate how Fig. 426. — Slight tubercular hydroi.'^ of the right knee with almost completely free mobility. Very slight muscular atrophy, con- sidering that the disease has lasted nine years. Fig. 427. — Proliferating tubercular disease of knee, wiih moderate amount of serous effusion. Mobility still partially retained. every variety of inflamed knee, but if the fluid is purulent, turbid, or contains shreds of fibrin, the case is probably tubercular. In order to test the temperature, it suffices to lay both hands lightly upon the two equally long exposed knees. Effusions due to gonor- rhoea, osteomyelitis and recent injury, show some local elevation of temperature, but this vanishes much more rapidly than in tubercle, wherein the same amount of heat can be detected for many months at each examination. CHRONIC DISEASES OF THE KNEE 683 Fig. 428(2. — Normal knee. We might expect tliat tubercular disease of the knee-joint would lead to earlv liinifafioii of movements, as occurs with other joints. But, as a matter of fact, this is very often not the case. The excur- sions of the knee may remain perfectly free even in tubercular synovitis of many years' standing, as long as the joint is not over distended by the efifu- sion. In such cases the muscular atrophy does not supervene as soon as it does in tu- bercle with early anky- losis. IfV iiuiv bi'ic/lv sii Hi- ll uirizc ilie above, as folloics : Every iiwiio- artieiilar, eliroiiie, se- rous in/iaiiniiafion of flie knee, icJierein there is definite tJiickening oftJie reftected fotds of ttie cap- sule, and wJiereiu there is a persistent definite local elevation of tem- perature, must be re- garded as tubercular, even if mobility still remains free and pro- nounced nrusadar atro- phy is absent. Notliing but very clear evidence to the contrary ivar- rants us in departing from this rule of dia- gnosis. In rare cases, one or more movable foreign bodies may be felt in the swollen joint. They are not completely free and can only be moved in a small circle. These are examples of the polypoid form of tubercular knee (Plate lY, fig. b). The polypi consist of hard connective tissue, more or less abundantly permeated by tubercles. Fig. 428^. Tubercular knee. Secondary erosion of bone at X X. Cartilage somewhat narrowed. 44 684 SURGICAL DISEASES OF THE EXTREMITIES (2) FUNGATING INFLAMMATION OF THE KNEE-JOINT. If the capsule is greatly thickened in a dijfuse manner, the case is either tubercle, or tlie very rare condition of gummatous arthritis, whether there be effusion present or not. Localized fungating degeneration of the capsule might, apart from gumma, be confused with the rare condition of sarcoma of the articular capsule, if the joint is movable. But as we have already seen, free mobility does not by any means exclude tubercle. In other cases, however, movement is soon interfered with, and finally com- plete rigidity supervenes. Fig. 429. — Tubercular knee, with complete des- truction of articular surfaces, and with an area of disease in the internal condyle of the femur. Fig. 430. — Tubercular knee with area of disease, and a sequestrum in the patella (x). A momentary glance often suffices to distinguish these two forms, before we ask the patient to make any movements. If the mobility is preserved the muscles of the thigh and leg are not strikingly atrophied, and the thickened capsule resembles a moderate amount of effusion, more especially as some effusion usually exists. In cases of early rigidity, however, the diffusely swollen knee is slightly bent, the muscles of the thigh and knee are wasted, so that a spindle-shaped appearance results. The principal question from the diagnostic standpoint is whether Plate 4. Diagrammatic Representation of various forms of Tubercular disease of the Knee. Light pink = normal bone Blue = cartilage Red = Inliamed Synovial membrane Ulght yellow = serous effusion Green = pus Orange ^= Caseous thickening a. Serous inflammation of Knee. Synovial membrane slightly thick- ened, invaded by tubercles. Serous effusion. b. Polypoid Inflammation of Knee. On synovial membrane large fibrous polypi wHh tubercles. c. Fungating inflammation of Knee. Slight exudation. Much thickening of synovial membrane. d. Pungating & caseating inflammation of Knee. Caseous thickening of fungating masses. Purulent exudation. Abscess behind bend of Knee. e. The same, but cartilage of bone removed and destroyed by tubercular proliferation. /. Primary disease of bone, in the form of a wedge shaped area, with sequestrum. Quervain, IHagnostic Surgery. CHRONIC DISEASES OF THE KXEE 685 the condition is of :i purely fiiiigafiiig character, with or without serous effusion, or whether it has become pitnilciif. We may confidently assume that suppuration has occurred if there appear a circumscribed, elastic, or fluctuating bulging, which seems to be just under the skin. This appearance may present anywhere, but it is most frequent at the level of the joint cleft. It used to be the practice to incise such swellings early, in order to see their con- tents, or to remain loyal to the old maxim " iibi pus, ibi cvacua." As a rule the abscess re- fused to heal ; a fistula developed and secon- dary infection occurred. In this condition the case was turned over to the surgeon. We now know that such an incision into a tuber- cular abscess of a bone or a joint, however aseptically performed, almost unavoidably leads to secondary in- fection by pus organ- isms and does the patient considerable harm. It is only justi- fiable to open a tuber- cular abscess if one is prepared to proceed forthwith to a radical removal of the dis- eased area in the bone or of the capsule. Even if the tuber- cular nature of the malady is doubtful, in- cision is unjustifiable. An aseptic exploratory puncture suffices to obtain the requisite information, and does no liarm to the patient. If staphylococci or streptococci can be culti- vated from the unincised joint, the disease is osteomyelitis — or, more rarely, an acute suppurating arthritis. If the cultures remain sterile, Fig. 431. — Tubercular knee, slightly flexed and con- tracted, and in valgus position, with subluxation of the tibia backwards and outwards. 686 SURGICAL DISEASES OF THE EXTREMITIES and gonorrhoea can be excluded, the case is certainly tuberculosis. A decisive conclusion would be given by animal inoculation. We have already made several references to the starting-points of disease. The bone lesion is very often secondary, as shown by the existence of numerous smaller foci on the articular surface of the bone, especially where the capsule is reflected (fig. 428). We should only assume that the disease in the bone is primary, if an extra-articular lesion is clinically demonstrable in a case wherein the joint is but slightly aifected, or if the skiagram reveals a large localized lesion. Such lesions may be in the femur (fig. 429) or in the tibia, and excep- tionally in the patella (fig. 430). The latter is indicated by striking tenderness on pressure over the knee-cap. There are some rare cases, in which examination leaves one in doubt as between a serous effusion and a fungating thickening of the capsule, and on operation it is found that neither one nor the other exists, but that the condition is one of a lipoma-like proliferation of the articular tufts — so-called lipoma arborescens. As this change may occur in chronic arthritis of different origins, and exceptionally also in tubercle, it is not easy to make an accurate diagnosis. I have found this con- dition limited to the upper segment of the joint. (3j RIGIDITY. If contractures are present, the conditions which come into consideration for diagnosis are again abundant. One must first put aside those cases wherein the history points to some form of acute infective inflammation of the knee-joint, preceding the contracture or ankylosis. We have only to consider rigidity of gradual onset, and may even then be in doubt as to the (i) terminal stage of haemorrhage into- the joint, which is rare ; (2) chronic articular rheumatism^ forming adhesions ; and (3) tubercle causing early rigiditv. The previous history will indicate whether there has been haemorrhage into the joint. Articular rheumatism, producing ankylosis, is as rarely mono- articular as tubercle, producing ankylosis, is polyarticular. Further,, the ankylosing form of tubercle is always associated with some thicken- ing of the capsule, and with local elevation of temperature and often with fistulas, unless the process is completely at an end. Cases of tubercular polyarthritis, wherein the diagnosis remains uncertain for many years, exist, but they are very rare. The contracture does not alwa^'s develop into a simple flexion. We often find, especially in tubercle, that the posture is one of slight valgus, with subluxation of the tibia backwards and outwards, as illustrated in fig. 431. TUMOURS AXD ALLIED STRUCTURES ABOUT THE KX'EE-JOIXT 68/ CHAPTER C. TUMOURS AND ALLIED STRUCTURES ABOUT THE KNEE-JOINT. The knee-joint occasionally presents structures which do not fit in ^vith the previously described bone sarcomata, arising" from the femur or tibia, nor with chronic inflammatory processes, (a) Let us begin with the aitferior surface. Chronic prepatellar bursitis is at once evident, even to the beginner, owing to its superficial position, in front of the patella. The structure may vary in size from an almond to a fist, and accurate anatomical examination shows that it may be just under the skin, under the superficial fascia, or under the deep aponeurosis. Diverti- -cula extending laterally are of importance from the operative stand- point. If the wall of the structure is strikingly thick and persistently painful on pressure, one should think of tubercle of the bursa, which is, how- ever, rare. X-rays will show whether it originates in tubercle of the knee-cap. Occasionally, a change, corresponding to prepatellar bursitis, is found somewhat lower down, situated in front of the patellar ligament. {Bursitis prcvtibialis). Bursitis of the deep iufra-patcUar bursa bchiud the patellar ligament is still more rare. The swelling has a sub-divided appearance, and bulges on both sides of the ligament. The larger it is, the more it interferes with the movements of the joints. Among the rare tumours of the anterior surface of the joint should be noted, sarcoma of the patella; lipoma, fibroma and sarcoma of the synovial membrane or the sub-synovial connective tissue. Lipoma arborescens, i.e., lipomatous proHfera- tion of the articular fringes, has already been mentioned as occur- ring in various forms of chronic arthritis and in tubercle. It may be regarded as on the border line of tumour formation. Fibrous polypi which may attain the size of almonds and which feel very much like foreign bodies within the joint, are seen in rare cases of tubercle (Plate IV, fig. b). The freedom of the joint movements is characteristic of all these tumours. (6) With few exceptions, swellings in the popliteal space are either extensive bursae or aneurisms. The distinction is at once <;vident on palpation and inspection, from the absence or presence of pulsation. This, however, may occasionally be absent, even in the case of an aneurism, if its contents are coagulated. But no mistake ought to arise, as the consistence of the structure is 688 SURGICAL DISEASES OF THE EXTREMITIES comparatively firm, and the patient can always testify to the previous presence of pulsation. Soft or elastic non-pulsatile swellings are, as a rule, enlarged burs^e ; the bursa under the popliteus, if situated laterally, and the seiiiiuiembranoiis bursa, if situated towards the middle line. They may be confused with the very rare lipomata of this region, and also with a cold abscess. Differentiation is easy, if the contents of the swelling can be reduced into the knee-joint, as is often possible in enlarged bursae. Otherwise, if the swelling is very easily displaced, we should regard it as a lipoma ; if it has an atypical situa- tion, is painful on pressure, and if the movements of the joint are also in- terfered with, we should regard it as a cold abscess. If the abscess origin- ates in an extra-articular lesion, it may not be possible to diagnose it without a skiagram and an exploratory punc- ture. Effusion into a bursa may be due to chronic serous (rheumatic) inflam- mation of the knee-joint. The removal of the bursa is then occasionally fol- lowed by an unusually severe effusion into the joint. We need only add, in reference to the unmistakable; diagnosis of aneurism, that this soon causes neuralgic pains and paraesthesia in the leg, and that it may, after reaching a certain size, fix the joint in semi-flexion. It is due to the same causes as other aneurisms, i.e., trauma, arteriosclerosis and syphilis — especially the last, even if there is a history of injur}-. Fig. 432. — Prepatellar bursitis. SCIATICA AND OTHER PAINFUL DISEASES OF THE LOWER LIMBS 689 CHAPTER CI. SCIATICA AND OTHER PAINFUL DISEASES OF THE LOWER LIMBS. Medical nosology contains a number of vague terms whicli fortunately help to conceal the bitter truth from a patient, without prejudicing the diagnosis, but unfortunately these terms occasion- ally satisfy the doctor as well as the patient, to the latter's great detriment. Thus a multitude of ills mav be embraced under the designations of anaemia, liver trouble, intestinal colic, &c. The same is true of " sciatica." Neuralgic pains of the lower extremity are often summarilv diagnosed as sciatica, as if this condition were a clinical entity. Although references have already been made to this subject, we shall once more describe how a case of "sciatica" should be examined, not only by a surgeon, but by any practitioner. It is most important to examine the urine and the reflexes — patellar and pupillary — because the condition may be due to diabetes, tabes or paralysis. Then the surgical possibilities must be thought of. The gluteal region must be palpated, because an obstinate sciatica may be the first symptom of sarcoma, originating in the bone or muscle. The course of the nerve must be followed, because sciatica may be due to a malignant growth of the thigh or even lower down. A diffuse thickening of the shaft of the femur, indicating chronic osteomyelitis, may possibly be found. If an injury has preceded the sciatica the question of a foreign body may arise. A 3^oung man fell on a heap of wooden palings, while in an inebriated state. He was subsequently treated for many weeks for " sciatica," and a colleague of mme then succeeded in withdrawing a long piece of paling. The original wound had healed com- pletely over the piece of wood. If palpation elicits nothing, we must direc our examination towards the spine. Spinal caries, sarcoma of the lumbar vertebrae, or caries of the ileo-sacral joint may simulate a simple sciatica. If the patient is a young man, of an age when idiopathic sciatica is rare, we should inquire about gonorrhcea, and, if necessary, examine the urethra. I was once consulted by a young man for sciatica. My inquiry regarding gonorrhoea was answered by a decided and resentful negative in the presence of his father. But the youth reappeared on the following day, saying : " I have merely come to tell you that you were quite right." 690 SURGICAL DISEASES OF THE EXTREMITIES This cause should also be borne in mind, even in the case of patients of advanced age. A grey-haired grandmother consulted me for sciatica. She was also suffering from a profuse white discharge. Had her husband not consulted me a fortnight previously for gonorrhcea, I would hardly have diagnosed the cause of her sciatica correctly. We now proceed to rectal examination. This should never be neglected in a case of sciatica, however objectionable it may be to the patient and unpleasant for the practitioner. We examine in both sexes for cancer of the rectum and for new growth in the pelvis ; for malignant disease of the prostate in males and for some disease of the generative organs in the female. In the latter a vaginal examination should also be made. If this systematic examination were invariably practised, we should no longer come across cases wherein women, at the climacteric age, have been treated for weeks or months for sciatica, until at length, an offensive discharge or profuse haemorrhage has led to a gynjecological examination. The doctor is not always to blame. Female patients often refuse a vaginal or rectal examination because they cannot conceive what bearing it has on their sciatica. The young, inexperi- enced practitioner may yield to this refusal, but nevertheless he incurs the responsibility for his error of diagnosis. It may be said that such an error is of no consequence to the patient, because a malignant tumour, which has caused sciatica, is already beyond radical removal. Although this may be correct in the majority of instances, it is nevertheless true that an accurate diagnosis is better, not only for the reputation of the practitioner, but also for the interests of the patient and his friends, than futile spa and electric treatment and similar measures. But not all gynaecological diseases which cause sciatica are of malignant nature. Pelvic exudations and incarcerated myomata may irritate the sciatic nerve ; indeed rectal constipation may sometimes explain sciatic pains. Is it possible to distinguish clinically the sciatica which results from malignant growths from idiopathic sciatica ? The pain in the former is, on the whole, persistent, in the latter it is rather of a paroxysmal nature. In sciatica due to cancer the patients soon exhibit a peculiar restlessness. Even if the pain is not severe they are still restless, whatever posture they adopt. They cannot be persuaded to sit down, even in the doctor's consulting room; they often persist in walking up and down restlessly. In simple sciatica the disturbances aie limited to sensations of pain, there is not usually any loss of sensibility. If, however, it should be present, it does not usually reach any extreme degree. There are never any disturbances of motion. But both these conditions are as a rule present in advanced cases of sciatica, due to compression. Carcinoma may also produce nerve manifestations, owing to the SCIATICA AND OTHER PAIXP^UL DISEASES OF THE LOWER LIMBS 69I wandering and proliferation of cancer cells into the lymphatics of the nerve trunk. We must therefore regard " sciatica," which comes on after removal of rectal or uterine cancer, as a recurrence, although we may not be able to detect any cancerous mass com- pressing the nerve. If old people complain of severe "sciatica pains" in the leg extending to the toes — pains which often come on quite suddenly and cause limping, we should think of Charcot's ''intermittent limp," and should at once inquire whether attacks of pallor or bluish-red discoloration occur in tlie painful extremity. The occurrence of such attacks indicates the prospect of gangrene, especially if on exami- nation the foot is sometimes found to be pale and cold and at other times in a state of venous congestion. This diagnosis would be confirmed by the obliteration of the pulse in the dorsalis pedis artery and posterior tibial, and certainly by the absence of the popliteal pulse. This cause for pain is especially prevalent among old people, as the expression "senile gangrene" indicates. Younger people are, however, not immune from gangrene, but in their case some special cause is responsible, e.g., diabetes, early syphilitic arteriosclerosis, or acute infectious disease, typhoid fever being the most common. I have seen thrombosis of both femoral arteries and eventually of the abdominal aorta, follow a slightly septic finger in a girl aged 20. In some cases, however, no antecedent disease can be discovered. These cases are included under the comprehensive term of Raynaud's disease, the principal indication of which is its symmetry. This condition is attributed to a primary vasomotor disturbance, for want of a l^etter explanation. The following case belongs to this category, although the affection is unilateral : — A healthy man, aged 30, who had not suffered from syphilis, began to complain of severe neuralgia of his left foot. There was no obvious cause for this, except perhaps excessive gymnastics. The foot was sometimes pale and cold, at others, bluish-red. Eventually the cyanotic discoloration persisted and gangrene of the foot developed, requiring amputation. Pains and vasomotor disturbances supervened a few years later in the other foot, but gangrene did not follow. We should think of arteriosclerosis, in the absence of any other cause, if pain is present, even without severe vasomotor disturbances. Varicose veins should also be included among the causes of pain and "cramp" in the leg, especially in the calf. Deep varicose veins are conveniently blamed, when the diagnosis is obscure, because the}^ cannot be seen, and therefoi'e their presence cannot be denied. On the other hand, sciatica may be mistaken for some other condition — especially the form of sciatica termed scoliosis iscliiadica (Chapter LXXIX). Patients with sciatica often walk with an oblique 692 SURGICAL DISEASES OF^ THE EXTREMITIES gait, inclining the trunk, sometimes to the healthy side, at others to the affected side. A beginner, unaware of this habit, may easily devote his chief attention to the scoliosis, and look upon the sciatica as a secondary matter. This view would, however, only be justified in those rare cases wherein the sciatica results from disease of the lumbar spine, such as caries, and the scoliosis is a consequence of the lateral compression of the diseased vertebra. In such cases, all doubt is removed by the tenderness of the affected spinous process and the pain elicited by axial pressure. But in cases of true " scoliosis ischiadica " the condition is one of primary disease of the nerve. The patient endeavours to relax the sciatic nerve by abducting and slightly flexing his leg. Ehret has shown that this posture causes a remark- able approximation of the terminal points of the trunk of the sciatic nerve. The patient involuntarily compensates for the pelvic inclina- tion thus caused by assuming the posture of scoliosis and slight lumbar lordosis. Recent researches, however, appear to show that scoliosis is more frequently due to involvement of the lumbar nerves in the morbid process. The foregoing remarks regarding sciatica apply iiiiitntis uiittandis to neuralgia affecting the anterior crural nerve, the external cutaneous and the obturator nerves. But as neuralgia of these nerves rarely occurs as an idiopathic affection, it is more likely than sciatic neuralgia to suggest, even to the beginner, some special cause. Search should be made for pelvic tumours, spinal caries, burrowing abscesses, and also for malignant retroperitoneal and inguinal glands. The primary growth may be situated in any part of the area drained by these glands, so that the whole of it will require investigation. Obturator hernia may be the cause of an obturator neuralgia, but as advice is not usually sought for this hernia until strangulation takes place, it IS necessary to inquire for this neuralgia, in order to ascertain anything about it. If it is present, it enables us to exclude internal intestinal obstruction. Neuralgia of the external femoral cutaneous nerve has been described as a disease, sui generis, and provided with the designation of "meralgia paraesthetica." This term should, however, not induce us to abandon attempts to form a more accurate diagnosis. As the position of this nerve exposes it to external damage, we should always think of some isolated or repeated injurv {e.g. the friction of an abdominal belt) if there be no other cause of neuritis. It may be mentioned incidentally that this meralgia has been described as a consequence — very indirect — even of ffat foot. Many painful conditions of the foot have received special names^ e.g., talalgia, tarsalgia, Morton's nietatarsalgia, ptenialgia, &c. The practitioner is apt to believe that a diagnosis has thus been made, and that there is no further need to search for the cause of the pain. This cause may, however, reside in the most varied conditions of disease. Flat foot is the most frequent of these, but they include the sequelae of ULCERS OF THE LEG 693 injury, localized inflammatory changes in the burs^e, tendon sheaths, joints, ligaments, fascias, and also gout, neuritis (alcohol), and tabes, apart from various neurasthenic pains and the result of badly-fitting boots. Finall}^, it must not be forgotten that women often complain of severe pains and para^sthesia in the legs at the menopause. The correct diagnosis is frequently suggested by the fact that similar sensations, although of a less severe character, are experienced in the arms. CHAPTER CII. ULCERS OF THE LEG. " Ulcer of the leg " has become quite a standard type of lesion, so that the beginner is apt to imagine that there is only one variety of ulcer in this region. In addition to the ulcerative processes which occur around the orifices of fistulie, and which ma}^ themselves be of a tubercular nature if the fistulze are tubercular, there are three other forms of ulcer which affect the leg, Lc, (i) varicose ulcer. (2) syphilitic nicer, and (3) cancer of the skin. Varicose ulcers are usually already diagnosed bv the patient. As they preponderate enormously over the other two forms, we are justified in accepting the patient's diagnosis in most cases — not however, before seeing the ulcer. Varicose ulcers vary so much according to the stage in which we see them that we cannot speak of any characteristic appearance. Sometimes we see a brownish-red, hard infiltration of the skin with a circumscribed, superficial, and remarkably painful erosion in its centre. The beginner looks upon this as too trifling to deserve the name of ulcer, until he learns by experience that this erosion, unless it is treated, may develop into an ulcer lasting for weeks and even for months. Sometimes this will occur, even if the erosion does receive treatment. An ulcer of the leg may present itself as a deeplv penetrating loss of substance from the skin, with a necrotic base, and with edges which are serpiginous, steeply shelving, or even undermined. This may be a simple ulcer of the leg without any other supplementary element. The ofl'ensive discharge and the inflamed area around merely indicate neglect, either due to social causes or to laziness. At other tin.ies we find a flat ulcer with a granulating base and smooth edges, on which new epithelium is developing. Obviously this must ^94 SL'KGICAL DISEASES OF THE EXTREMITIES be an ulcer on the point of healing, and the duty both of the patient and practitioner is to do nothing to interfere with the heahng process, by unsuitable treatment or inappropriate conditions. Are varicose veins really indispensable for the diagnosis of a varicose ulcer ? As a rule they are present ; but sometimes it is necessary to search for them, and for this purpose the patient must stand up for a little while. If the patient has been confined to bed for any length of time, it may be impossible to see even very pro- nounced varicose veins. The absence of any abnormally dilated veins, does not, however, justify us in assuming a syphilitic basis for the ulcer. It is more likely to have resulted from some indefinite injury, from an abra- sion or contusion of the skin, which has developed into an ulcer owing to the unfavourable healing conditions of the leg, or through neglect. These ulcers heal rapidlv if the patient lies in bed, and if the necessarv cleanliness is adopted in the treatment of the wound. On the other hand, the presence of varicose veins is not in itself enough to justify the diagnosis of a varicose ulcer. Syphilitic patients may have varicose veins which probably encourage the development of gummatous processes. The appearance of the ulcer, as already indicated, shows us the stage of the ulcer, but does not of itself tell us anything definitely of its origin. Many errors will be made if all ulcers which are some- what polycircular in shape or have ser- piginous edges are put down to syphilis, or if all undermined ulcers are regarded as cancerous. There can, of course, be no doubt about syphilis, if the polycircular shape is very pronounced, probably in several ulcers, if there also co-exist round, kidney-shaped or horse-shoe-shaped erosions of the skin, looking as if they had been punched out with a perforating apparatus, and if they have been preceded by well-defined, painless, cutaneous gummata, instead of a diffuse, hard and painful infiltration of the skin. The localization of these morbid changes is very striking in less typical cases. Simple ulcers of the leg are situated in its lower half, extending as far as the malleoli. They may affect any part of this region, the front, back, the external or internal surface, and may even Fig. 433. — Varicose ulcers of ihe leg. ULCERS OF THE LEG 69: become rini^'-shaped. Ulcers situated higher up towards the knee, or lower down on the dorsum of the foot, may indeed be due to injury or to a ruptured varicose vein, but in the absence of such a cause, they are, so to say, always syphilitic. It occasionally happens that such a syphilide is found directly over the knee-joint, a position in which a varicose ulcer never occurs. r "^<.aW 1 \ Fig. 434. — Tertiary syphilitic ulcers on the right leg, which is also affected by severe varicose veins. Fig. 435. — Same case as fig. 434, one year later. Left leg. a, congested horse- shoe shaped ulcer ; />, an old puckered scar ^ c, cicatrizing ulcer. Fig. 434 illustrates the case of a vigorous peasant woman who came to the hospital for "an ulcer of the leg." The diagnosis seemed obvious, and there appeared to be no question of syphilis. She had numerous varicose veins, and had had thirteen confinements without any miscaiTiage. But the ulcers were on the upper half of the leg, partially in front of the knee, above which was an area of sharply defined red infiltration on the point of softening. There was a puckered scar on the front of the opposite patella,which the patient said was due to a similar ulcer, cured ten years previously by some domestic remedy. This of course settled the diagnosis, and iodide of 696 SURGICAL DISEASES OF THE EXTREMITIES potassium produced the anticipated result. I learnt subsequently that this patient had been treated twenty years previously for recent syphihs, contracted from her fiist husband. A year later, this patient Fig. 436. — Cancerous degeneration of ulcer of the foot. returned with an ulcer of the left thigh, which is illustrated in fig. 435 and seen to be perfectly characteristic. The puckered scar, just mentioned, isseen at b in the figure. The case illustrated in fig. 437, came as one of old- standing " caries " of the foot. There was nothing in the history nn which to base the diagnosis of syphilis, but it was suggested partially by the situ- ation and partially bv the shape of the nicer, and also by its yellow fatty -looking base. This diagnosis was confirmed by tlie result of treatment. It has been stated above that under- mined edges are not enough to arouse the suspicion of cancer. Indeed, an ulcer without undermined edges may be cancerous— although ordinarily this condition is an important sign. Fig. 437. — Tertiary syphilitic ulcer of the foot. SWELLINGS AND TUMOURS OF THE LEG 697 If an old scar breaks down and ulcerates — old scars have a decided tendency to become cancerous — and not only refuses to heal but actually increases in extent, this indicates a tendency to cancer. If the ulcer does not become covered with healthy red granulations, this constitutes a more important sign, and we must entertain some doubt. If the base constantly remains granular in appearance and if the well-known little whitish plugs can be squeezed out of the more recent portions, a histological examination of a piece of the margin is demanded forthwith. Sometimes the diagnosis of cancer is not made until the onset of enlarged glands in the popliteal space and groin. This occurred in the case of a young man, whom I saw while acting as an assistant. A very obstinate ulcer developed on an old scar due to a burn. The 3'outh of the patient disarmed any suspicion of cancer at first. But the onset of enlarged glands led to a histological examination and a diagnosis of cancer was made. CHAPTER cm. SWELLINGS AND TUMOURS OF THE LEG. (i) SwELLiXGS and tumours of the leg present similar conditions to those which we have considered in detail in connection with the thigh. But the proportion of affections of the soft tissues to tumours of the bone is less than obtains in the thigh — if we except ulceration and its associated changes. Otherwise they have no peculiarities specific to the leg. Perhaps the commonest of the tumours of the soft tissues are the small growths no larger than peas (tubercula dolorosa), or the larger fibromata or neuro-fibrouiata, which cause local and radiating pains (fig. 441). Sometimes large bunches of varicose veins look just like tumours. There can, however, be no difificulty in diagnosis if the serpentine course of the veins is visible, and if their lumen is clear, so that slight pressure or a change of posture suffices to empty them. Diagnostic interest centres around the questions whether the veins belong to the large or small saphenous group and whether the valves in the former have become incompetent. Trendelenburg's sign is useful in this connection. The patient lies down, to empty the veins of the limb. The root of the large saphenous vein is then compressed with the finger and the patient is instructed to stand up. If the veins remain empty but fill 698 SURGICAL DISEASES OF THE EXTREiMITIES up as soon as the pressure is relaxed, it is obvious that the large saphenous vein is affected {cf. figs, 438a and h). Even if the veins are thrombosed, the diagnosis is easy, as long as separate serpentine cords are recognizable. The beginner may be uncertain when confronted by an isolated thrombosed convolution of veins, looking like a tumour, but even then the history will give a clue, and the patient will probably have made the diagnosis already. Fig. 4380:. ■ — Varicose veins, after the limb has been emptied of blocd and the root of the large saphenous vein is being compressed. Fig. 438/'. — Same case, after relaxation of pressur from the vein (Trendelenburg's sign). (2) Cluiugcs in the bone are for anatomical reasons more accessible to examination than in the case of the thigh, and their diagnosis is therefore easier. We distinguish between tumours and inflammatory swellings. ^.—TUMOURS. Having considered the diagnosis of tumours in connection with the arm and thigh, it will be unnecessary to do more than briefly refer to a few forms which possess diagnostic interest. The most important SWELLINGS AND TUMOURS OF THE LEG 699 of these is, medullary sarcoma of the upper end of the tibia, which may easily be mistaken for a somewhat chronic osteomyelitis, more especially as it may, like all sarcomas, raise the temperature and may sometimes be very painful on pressure. A girl, aged 20, had been limping for some weeks, and complained of severe pains below the knee. The inner side of the head of the tibia was sliglitly swollen and very tender, but the skiagram revealed nothing characteristic. We thought of subacute osteomyelitis, particularly as the temperature rose in the evening to 101*5°. ^^ the Fig. 439. — So-called aneurism of the fibula. Skiagram of the specimen obtained by operation. (Cystic disease of bone.) Fig. 440. — Fibro-sarcoma of tibia origi- nating in the medulla. operation, the bone was found to be surrounded and partially penetrated by a soft granulation-like tissue, such as is sometimes seen in chronic osteomyelitis ; but there was neither pus nor sequestrum. The cultures which were prepared remained sterile, and microscopic examination of sections of the tissue showed the presence of sarcoma. This case occurred m the early days of skiagraphy. We should now conclude from the absence of any bony thickening or of an osteo- sclerotic zone around the diseased area, that the case was not one of chronic osteomyelitis or of tubercle, but rather one of new growth {cf. figs. 439 and 440 with figs. 446 and 447). 45 7CO SURGICAL DISEASES OF THE EXTREMITIES Cystic disease of bone (aneurism of bone) is indicated by disten- sion of the fibula or tibia to the sliape of a beetroot, by the sensation of parchment crackhng over the bone, and probably by hearing murmurs over it with a stethoscope (fig. 439). This condition is possibly allied to sarcomata. A medullary growth may in its early stages resemble an abscess of bone, both clinically and in a skiagram {cf. fig. 440 with fig. 447). If the spindle-shaped distension reaches a certain size, there can be no question of abscess, and the diagnosis of sarcoma becomes clear. A hard finely lobulated tum'mr, with sharply defined boundaries, projecting from the bone, is a chondroma. The X-rays will usually show that this structure is composed of cartilage and islands of bone. Cartilaginous exostoses, which onlv have an external covering of cartilage, are not of rare occurrence in the leg (see Chapter XCVI). Fig. 441. — Neurofibroma of the superficial peroneal nerve. Fig. 442. — Chondroma of the tibia. B.— INFLAMMATORY PROCESSES. Acute osteomyelitis only requires brief notice because its diagnosis presents no difficulty, as the position of the tibia is so super- ficial. It could only be missed in those rare cases wherein the patient is intensely septic and semi-conscious, so that he does not complain of the tibia, and a fatal result occurs before the pus has reached the surface. More interest attaches to the diagnosis of the stage of the disease, and of the anatomical changes which the operation may show. SWELLINGS AND TUMOURS OF THE LEG 70I Fig. 443, which represents acute osteomyehtis of the long hollow bones, renders it unnecessary to enter into any detailed discvission of these points. The principal exceptions to the usual course illustrated in this scheme depend upon the size and the number of the sequestra. They may be flat or circular, single or multiple. The medulla of the epiphysis may or may not be involved. If one has a clear conception of the pathological processes which may occur, there is no difficulty in correctly diagnosing the cases which run an irregular course. The diagnosis of chronic inflammation of the bone requires more detailed consideration, because it is frequently missed, or is the source of great difficulty. It is important to distinguish between the diffuse and circumscribed varieties of this inflammation. (1) DIFFUSE INFLAMMATORY PROCESSES. Diffuse swellings should suggest a mild form of osteomyelitis, which is usually due to syphilis, thus contrasting with what we have seen in regard to the femur. If the disease is acquired, the diagnosis of gumma is established by the presence of isolated, circumscribed, and scattered inflammatory areas on the anterior surface of the tibia quite apart from the history. In chronic osteomyelitis, the thickening of the bone is usually more diffuse, which is again a contrast to gumma (fig. 444). Localized abscesses, which heal up after the extrusion of a small sequestrum, often occur in this condition. The problem is, however, quite different in the case of children. Hereditary syphilis of the tibia is not usually of a gummatous nature, but is recognized by diffuse infiltration of the periosteum, and in its subse- quent course by diffuse thickening of the bone (fig. 445). If, therefore, palpation and X-rays demonstrate a circumscribed localization (fig. 446), it is an argument against syphilis and in favour of osteo- myelitis. Syphilis often proceeds just like osteomyelitis, by means of exacerbations, but it is differentiated from the latter by the absence of elevations in temperature and by its symmetry. Obviously the history is conclusive. It may be mentioned incidentally that the tibia and the bones of the forearm are the favourite sites for these lesions of congenital syphilis. A girl, aged 7, suffered from periodical attacks of painful swelling of both tibiae. A diffuse tender thickening of the bone could be demon- strated (see fig. 445). There was no pyrexia. The previous treatment had been directed against tubercular disease. The only indication of a syphilitic heredity was the mother's statement that the father occa- sionally suffered from an ulcerative skin lesion. Antisyphilitic treat- ment caused the symptoms to disappear in a very short time. 45^ >^c s ■« OJ 1 5 Zt o t •v3 j: ^ — c-1 C a re 1> o s o c o u d- <) c 5^ C O o 5 i c o rt >^ s m ■o ID ^) i- ^2- S p3 2 C C c S 2-a n! g^ m o = c a rt MojvS.':-- O = s^«^ .'ii o C JJ o-o IIS! V F Fo ■■erio leat /ith on i o -a '5 S " - = £ 2 S •? II " o O O 1) (1 if SWELLINGS AND TUMOURS OF THE LEG 703 (2) CIRCUMSCRIBED SWELLINGS. The distinction between diffuse and circumscribed swellings is obviously somewhat arbitrary. We include among the latter only tliose wherein the swelling and tenderness do not extend beyond one half of tibia, but which definitely originate within a much smaller compass. The principal diseases which enter into consideration are (i) the isolated ^umma, (2) the circumscribed chronic forms of osteomyelitis (usually staph3domycosis) and (3) tubercle, this again in contrast with the femur. We have already dealt with syphilis. In regard to the other two diseases, the most prominent objective signs are the swelling and new bone for- mation in the neighbourhood of the periosteum, so that the inexperienced observer is liable to be content with the diagnosis of periostitis. But the more carefully these cases are ex- amined and the more often the assistance of a skiagram is invoked, the more frequently will we find that this periostitis is due to changes in the bone marrow, either of the nature of an abscess or of an area of granulation, with or without sequestrum formation. Is it, however, possible to tell, by inspection whether the disease is tuberculosis or osteomyelitis ? It must be confessed that clinical exam- ination often leaves us completely in the lurch. We will consider separ- ately the diseases of the diaphysis and the epiphysis : — {(i) It was previously assumed that •disease in the diaphysis could only be tubercular if it occurred in children ; •disease in the diaphysis in adults was always considered to be osteo- myelitis. But as bacteriological examination became more frequent, it 45B Fig. 444. -Old diffuse osteomyelitis of the tibia. 704 SURGICAL DISEASES OF THE EXTREMITIES was seen that tubercular disease occurs in the medulla of the diaphysis of the tibia. To a considerable extent, we must depend upon the history for the distinction. An acute feverish onset with exacerbations of the same character denote osteomyelitis, but these symptoms are not always present. A gradual onset and a gradual increase of symptoms denote tubercle, but this may also take a sudden turn for the worse. The dia- gnosis is easier if the disease follows an acute infection such as typhoid fever, scarlet fever, &c. We shall probably be correct in attributing the cause to the organism of the primary disease (e.g., typhoid bacillus),, or to secondary infection by one of the ordinary pus organisms. The circumscribed osteomyelitis illustrated in fig. 446 followed a case of whooping-cough. If no conclusion can be arrived at, either from the his- tory or from the rest of the physical condition — other tu- bercular or other osteomyelitic foci — we must be content with the anatomical diagnosis, an abscess of the bone. If the abscess is situated immediately under the skin,, cultures should be made from the pus obtained from an ex- ploratory puncture, and within two days it can be ascertained whether organisms of acute suppuration are present or not. If they are not present the case is probably tubercular. If pus cannot be obtained without operation, the bacteriological examination may be supple- mented by annual inoculation, if necessary even after the opera- tion. It is our duty to the patient not only to open the abscess, but also to determine the nature of the disease, especially if tubercle is in question. We have already seen that tumours of the medullary cavity may resemble chronic abscess of bone, both clinically and in a skiagram. (b) It has long been recognized that disease in the epiyhysis is very significant of tubercle, and there is always the risk of regarding ag. tubercle what is really osteomyelitis of the epiphysis, in contrast to what we have already said in regard to the diaphysis. If the history and the rest of the physical condition are not conclusive, we may be guided by the extent of the periosteal thickening in the direction of the adjoining diaphysis. If the periosteal thickening is very circumscribed,, it suggests tubercle ; if it is extensive it suggests osteomyelitis. (a) Fig. 445. {d) Periostitis of the Normal tibia in tibia due to congeni- child of the same tal syphilis. age. SWELLINGS AND TUMOURS OF THE LEG 705 Finally, the existence of a sarcouiatoiis new growth is greater in this situation than in the diaphysis. We have, so far, been assuming that the practitioner has made the diagnosis of some bone disease. But this is not always so. These cases are often treated as rheumatism, and salicylates or ointments are given. Patients may thus wander for years from one doctor to another, and from one quack to another, until someone lakes the trouble to carefully compare one tibia with the other, in regard to palpation and tender- ness. If such an ex- amination reveals any thickening, however slight, associated with Fig. 446. — Localized subacute ostitis after whoopinf;-cough. A small sequestrum is seen in an abscess surrounded by a sclerosed area. Fig. 447. — Chronic abscess of bone in the lower end of the tibia. tenderness which has its maximum at this area, and which is the seat of periodical throbbing pains, severe enough to disturb the patient's sleep for weeks at a time, we are justified in diagnosing an abscess of bone, and we should resort to the aid of the X-rays. In the absence of a skiagram, the only condition which may lead to an error of diagnosis is the pain caused by syphilitic disease of bone. 706 SURGICAL DISEASES OF THE EXTREMITIES CHAPTER CIV. INJURIES ABOUT THE ANKLE-JOINT. In examining an ankle after an injury, the most important practical consideration is to ascertain whether there is any deformity or not. Indeed we shah adopt the absence or presence of deformity as a basis of classification, although at first sight it may not appear to be very scientific. (1) INJURIES WITHOUT DEFORMITY. If the shape of the foot remains normal after an injury, or at any rate is only slightly swollen, we may forthwith exclude dislocation and fracture with displacement. This at once limits the diagnosis to contusions, sprains, or fractures without displacement. The diagnosis of contusion requires no detailed consideration, because it is easily inferred from the nature of the injury and presents no difficulty whatsoever. The diagnosis of sprain is made by exclusion, just as in the wrist and elbow ; i.e., it can only be entertained if it is quite certain that there is no fracture present. The history is, however, often very suggestive. We may diagnose a sprain, if the patient, after sustaining an injury — not necessarily a severe one — to his ankle, complains of gradually increasing pain and tension, which do not entirely disappear,, even on complete rest. On the other hand, a severe pain at the moment of the injury, which subsides when the limb is kept at rest, and which returns when any movement is attempted, would a priori suggest a fracture. The explanation is quite simple. Pain which is not severe at the moment of the injury, but which gradually increases and does not disappear in spite of rest, indicates an effusion of blood within the joint — a circumstance which occurs in a sprain. A fracture may also lead to intra-articular effusion, but as the fracture opens up a path for the blood in the surrounding tissue, the effusion is under less tension. The general experience of fracture is, that the pain disappears when perfect rest is maintained once the fracture has occurred, and that it only returns as a result of movement. But it must not be assumed that all sprains present the same clinical features, for in some, laceration of the extra-capsular structures is the predominant lesion, and the pain therefore occurs mainly on movement, just as in fractures. Loss of power of inovenient is by no means decisive. The beginner is apt to diagnose a sprain if the patient is able to walk, and to diagnose a fracture if he is not able to do so. But, as a matter of fact, the position may be quite reversed. We often see that a patient who has a subperiosteal fracture of the malleolus — especially the fibula — is INJURIES ABOUT THE ANKLE-JOINT 707 able to walk, whereas a patient with a severe articular effusion will anxiously avoid the least step, even if the bone is not injured. The localization of the pain on pressure is of great importance for diagnosis. But before proceeding to palpation, we should test the pain produced by axial pressure. If this pain is pronounced, it indi- cates fracture of the tibia above the malleoli, or fracture of the tarsus. There is usually no pain on axial pressure in simple malleolar fractures without displacement. We now palpate the joint. A diffuse tender sw^elling over the entire anterior surface indicates an effusion of blood under tension — most probably a sprain. We next examine the ends of the bones of the leg. If the tibia presents a narrowly circumscribed J Fig. 448^. — Fractures of malleoli through adduction. Fracture lines 2 or 3 may occur alone ; fracture line i occurs in com- bination with 2 or 3. Fig. 4481^. — Fractures of malleoli through abduction. Frac'ure lines 2, 4 or 6 may occur alone. Fracture line 2 may occur in combination with 4 or 6 ; or 2 may occur with 4 and 5. area of tenderness above the joint line, traversing the entire thickness of the bone, it is quite certain that a supra-malleolar fracture exists, or, in a young person, a separation of the epiphysis (fig. 45i)- The same condition will usually be found in the fibula, either higher up or low^er down. If the continuity of the tibia is unbroken, we should palpate the internal malleolus. Circumscribed tenderness of itsextremity indicates that the internal lateral ligament is torn off or lacerated, thus constituting a sprain. If the tenderness runs transversely over the malleolus (fig. 452), or obliquely or even directly upwards (fig. 450), we must assume that a fracture exists, although it may be impossible to feel any fissure, sharp edges or false mobility. We examine the 7o8 SURGICAL DISEASES OF THE EXTREMITIES external malleolus in a similar manner. Tenderness at its extremity indicates laceration of a ligament; tenderness higher up points to a fracture. False mobility can be obtained much more frequently than on the inner side, but cannot always be elicited. Fig. 449. -Adduction fracture of left internal malleolus. (See fig. 450 for skiagram.) Fig. 450. — Adduction fracture of internal malleolus (see fig. 449). a — a, line of fracture. b — b, line of epiphysis. Fig. 451. — Slight cracking of Fig. 452. — Fracture of external fibula in classical position, with malleolus, situated low down, separation of the epiphysis of tibia (reduced). The easiest method of detecting this mobility is to place one finger on the tip of the malleolus and another on the most tender spot, and then to impart a see-saw movement to the lower end of the fibula. INJURIES ABOUT THE AXKLE-JOIXT 709 Indirect pain on pressure is another though less constant sign, which points to fracture of the fibula. This sign is obtained by pressing the fibula against the tibia in the middle of the leg. If the patient then feels a circumscribed pain lower down, there can be no doubt about the presence of a fracture, or at any rate of a fissure. If we are not in a position to confirm our diagnosis by means of a skiagram, confirmation will be derived from the angular shaped ecchymoses which form below and behind the broken malleolus, in the course of two to three days. Similar ecchymoses mav, however,, also appear after severe sprams. It is of some interest, from the points of view of treatment, to recognize the uiode of origin of tJic fracture and the position and Fig. 453. — Abduction fracture with cracking of fibula, in classical posi- tion. Fig. 454. — Torsion fracture (spiral frac- ture of fibula, with detachment of internal malleolus). direction of the line of fracture. Fractures of the malleolus are divided into those produced by violent adduction, by abduction and by eversion of the foot. In an adduction fracture the internal malleolus is always broken off^ either in the same plane as the joint line, or in an oblique or verticallv ascending direction. A fracture of the external malleolus is often associated with it at about the same level as the joint cleft (figs. 449, and 450). The fracture in the former instance is produced by bending^ and in the latter by tearing. In an abduction fracture the internal malleolus is torn off near its base ; skiagrams show that the fibula is broken at what is considered 'lO SURGICAL DISEASES OF THE EXTREMITIES to be its weakest spot, i.e., about 5 or 6 cm, above the tip of the malleolus. It is, however, frequently cracked much lower down. There is often, in addition, a detachment or a fracture of a wedge- shaped fragment of the outer margin of the tibia (fig. 448 and 456). In fracture produced by torsion the signs are similar to an abduction fracture, i.e., supramalleolar fracture of the fibula, sometimes a wedge- shaped detachment of the external margm of the tibia and generally a detachment of the internal malleolus. The fracture of the fibula does not, however, present the appearance of a fracture produced by cracking, but it is of a spiral shape (fig. 454). It is not safe to base the diagnosis exclusively on the position of the foot. The position of adduction (fig. 455) is fairly conclusive of an adduction fracture, but abduction may be the secondary result of Fig. 455. — Os trigonum (Tj. Fig. 456. — Bi-malleolar abduction fracture, with detHched fragment frnm the outer side of the tibia, and wiih subluxation of the foot backwards and outwards. attempts at walking, even if the original injury has been an adduction fracture. Over excessive dorsal or plantar flexion are rare causes of fracture ; the former leads to the detachment of a piece of the anterior surface of the tibia (Lauenstein) ; the latter leads to a detachment fiom the posterior edge of the tibia, or its posterior surface. This latter fracture was termed by French surgeons, long before the Rontgen period, "fracture marginale posterieure du tibia," and it has lately been described, with the aid of skiagrams, by Meissner of Von Brun's clinic. The fragments in both ca^es are usually trian- gular in form. The diagnosis is based upon the etiology, the results of palpation and ihe .skiagram (figs. 458 and 460). Corres- ponding fractures may also be produced by the laceration involved through reversed movements. Leuenbei'ger has proved from the INJURIES ABOUT THE ANKLE-JOINT 711 material in our clinic, that the detachment of a fragment from the posterior surface of the tibia is an injury which occurs at about the same age-period as the separation of the epiphyses, the epiphyseal line still partially persisting, i.e., from the thirteenth to the hfteenth year (fig. -457). If no lesion can be found in connection with the malleolus, but the patient nevertheless complains of sharp pain as soon as he puts his weight on the foot, so that walking is impossible, we must palpate the tarsal bones, especially the astragalus, as far as this is accessible. An effusion of blood on the anterior surface of the ankle, and great tenderness over the head of the astragalus with severe pain Fig. 457. — Separation of the epiphysis, with detached bone from the posterior surface in a lad aged 15. Fig. 458. — X, detachment of bone from anterior margin of tibia. Y-frac- ture of fibula. on dorsi-ffexion, render it very probable that a fracture of the astragalus has occurred. A positive diagnosis cannot be made without a skiagram. In interpreting it, however, it should be remembered that a small Wormian bone (os trigonum) is occasionally seen at the posterior end of the astragalus (fig. 455). This structure in the early da^^s of X-ray diagnosis was erroneously diagnosed as a fracture (Shepherd's fracture). I once had a case wherein this os trigonum led to a protracted action for damages. Fractures of the os calcis are much more frequent. The sym- ptoms are such as to differentiate this injury clearly from fracture of the malleolus or from a sprain. A special section will be devoted to this subject. '12 SURGICAL DISEASES OF THE EXTREMITIES We should not be content with the diagnosis of sprain until a careful examination of the bones has yielded a negative result. Many a case of traumatic flat foot and years of persistent pain have been the result of an inaccurate diagnosis and an untimely permission to walk. Laceration of ilie anterior tibio-fibular ligament ma\' be mentioned as a special form of sprain. It is recognized by localized pain and probably by an effusion of blood above the ankle-joint, between the tibia and fibula. Another injury is worthy of attention, despite its rarity. The patient himself probably hears a distinct crack at the moment of the accident and makes his own diagnosis of fracture. But neither palpation nor a skiagram reveal such a lesion. The tenderness is situ- ated at the poste- rior edge of the external condyle — a position which is not the seat of pain in a sprained foot. If the pero- neal tendons are, however, made tense, it will be seen that they move forwards, one after the other, over the malleo- lus, if indeed they are not already found there at the beginning of the examination. The case is thus a typical dislocation of the peroneal tendons (fig. 459), and the crack corresponded to the moment in which the wall of the tendon-sheath compartment yielded to the sudden and sharp contraction of the muscle. Fig. 459. — Dislocation of peroneal tendons, which project like cords over the external malleolus. (2) INJURIES WITH DEFORMITY. The diagnosis of sprain does not enter into consideration if, after an injury, the shape of the foot shows any deviation to one side or the other. The question then arises as to a fracture or a dislocation being the cause of the displacement, or as to the possibility of both being equally concerned in the injury. We must first recognize the nature of the deformity. For this INJURIES ABOUT THE ANKLE-JOINT 7T3 purpose both limbs are brought into the same position with the patella directed forwards. We then compare the direction of the axis of the leg and the instep on either side, as seen from the front, and the relations of the axis of the leg to the sole, as seen from the side. On inspection from the front we must note whether the long axis of the foot forms an abnormal angle with the axis of the leg, or whether it is displaced parallel to its normal position. On inspection from the side, we must test whether the axis of the leg strikes the foot too far forwards or too far backwards. If we are in doubt about any of these deviations, we should see whether we can cautiously rectify any indication thereof, or, on the other hand, whether we can increase it. The commonest displacement of the foot is posfero-extenial, wherein the axis of the foot usually makes with the axis of the leg an obtuse angle, open out- wards. The foot thus has slipped backwards and out- wards, and at the same time has become tilted somewhat outwards. The foot is usually in a condition of slight plan- tar flexion (tig. 460). We start by palpating the lower end of the shaft of the tibia, because the dis- placement just described is often caused by a supra- malleolar fracture. We then proceed to the malleoli. The most frequent condi- tion found consists of an abduction fracture thereof, i.e., a detached fragment from the internal malleolus, and a fracture of the fibula due to excessive bending. The as- tragalus is displaced outwards, and the upper fragment of the fibula rests directly upon it as shown in the skiagram (fig. 456). At the same time the foot is displaced backwards in relation to the leg, so that on a lateral view the tibia appears to project forwards, beyond the trochlear surface of the astragalus (fig. 460). Thus there is a bi-malleolar frac- ture v\/ith subluxation of the foot backwards and outwards, and displacement of the tibia forwards and inwards. The predominance of the one or other aspect of the deformity depends upon the nature of the injury. The more pronounced the displacement, and the less definite Fig. 460. — Bi-malleolar fracture with detachment from posterior edge of tibia (T), and backward dis- placement of foot (the tibia forwards). 714 SURGICAL DISEASES OF THE EXTREMITIES the fracture, the more justifiable is it to speak of a dislocation, without, however, being able to draw a hard-and-fast line between the two forms of injury. If we feel both malleoli intact, through the skin^ Fig. 461. — Dislocation of the foot backwards. and also see the outline of the bifurcation of the malleoli projecting forwards (fig. 461), we at once diagnose 2. pure dislocation. We may, liowever, still be in error, because a fracture of the fibula may exist much higher up. This occurred in the case illus- trated in fig. 462, in a manner which is by no means uncommon in the present age of athletics. The patient, who was devoted to sleigh- ing, knocked up against an obstacle with his heel, while the vis inertiae of his tibia continued forwards. Clin- ically, the case seemed to be one of pure dislocation, Fig. 462. — Incomplete posterior dislocation of the foot. but the skiagram showed that there was a fine subperiosteal fissure in the middle of the fibula. In other cases the skiagram shows (fig. 460) the previously mentioned detachment of a piece of the posterior surface of the tibia, INJURIES ABOUT THE AXKLE-JOINT 715 with or without separation of the epiphysis, according to the age of the patient. We diagnose, in a similar manner, the very much rarer disloca- tions and dislocation-fractures with displacement of the foot to the inner side and forwards. It is worth mentioning that the foot may be displaced forcvanls with the tibia resting on the posterior portion of the trochlear surface of the astragalus. This gives rise to a subsequent deformity which has been appropriately ^ ; termed " Assyrian foot," ' owing to its resemblance to Assyrian sculptures (fig- 463)- We now come to a very Fig. 463. — Bi-malleolar fracture, wiih displace- ment of the foot forwards (old case, so-called " Assyrian foot "). Fig. 464. — Dislocation of the astra- galus. (Skiagram of fig. 465.) different clinical picture of an injury, which may present itself in the same anatomical region. In this condition, which occurs after a severe injury to the foot, we find a round bony projection directly in front of the anterior edge of the tibia, or somewhat to its inner or outer side ; the skin is tightly stretched over this projection, accord- ing to the position in which the foot is displaced in relation to the tibia, either forwards, inwards or outwards. These signs point to one diagnosis only, viz., dislocation of the astragalus, i.e., the disconnec- tion of the astragalus from all its ligaments and its displacement 46 7i6 SURGICAL DISEASES OF THE EXTREMITIES under the skin. It does not matter, from the point of view of treat- ment, whether the bone is uninjured or actually broken — as sometimes happens. Fracture could only be detected clinically if crepitus is distinctly heard. It is very important to make the diagnosis of dislocated astragalus as soon as pos- sible, because the stretched skin over the displaced bone may become gangrenous within a few days, unless early treatment is applied. If we find a striking dis- placement of the foot in relation to tlie leg, al- though nothing wrong can be detected in the malleoli, whose relations with the astragalus seem to be nor- mal, the cause mav still be a dislocation be- low the astra- galus. Such dislocations are extremely rare, but they may occur in any direction. An intelligent inspection and palpation will easily decide whether the foot is displaced forwards, backwards or outwards. Fig. 465. — Dislocation of the astragalus forwards and outwards. X = pr jection of head of astragalus; necrosis of skin beginning (formation of vesicles). CHAPTER CV. FRACTURE OF THE OS CALCIS. A TYPICAL fracture of the os calcis cannot be mistaken for any- thing else, and yet it is an injury which is frequently overlooked. It occurs either through the pull of the tendo Achillis — a laceration fracture — or through its compression between the astragalus and underlying surface — a compression fracture. FRACTURE OF THE OS CALCIS 717 The term laceration fracture should be Hmited to the cases wherein the fracture involves the tuberosity of the os calcis, and then only if the line of fracture run parallel to the beam of the bone (fig. 466a) ; or if its course is more oblique towards the plantar surface, the term should be limited to the cases wherein the fracture does not reach as far as the under surface of the bone. All the other fractures are compression fractures, whether they involve the body of the bone or its anterior process. This does not, however, justify us in concluding that we can tell the form of the fracture from the nature of the injury. Both laceration fractures and compression fractures of the heel are usually due to falls on the sole from a height, and it occasionally happens that both forms of fracture occur in the same bone (fig. 466). Clinical ex- amination and a skiagram render the differentiation of the two varieties very easy. The clinical signs may be divided into four groups corre- sponding to four principal vari- eties of fractures of the os calcis. (i) In fractures of the first variety, occurring after a fall from a height, we find that the foot is not lower than normal, that is to say, that the extremities of the malleoli maintain their normal distance from the ground. On the other hand, however, we are struck by a localized thicken- ing at the lower end of the tendo Achillis, at the upper part of the tuberosity of the os calcis. On palpation the swollen area is found to be tender, but there is no tenderness on the under surface of the os calcis. We may possibly be able to obtain crepitus. Pressure in the axis of the leg is not painful. The patient is able to stand on his foot, and even to walk with a certain amount of pain. If ecchymosis occurs, it will be found on both sides of the tendo Achillis. In such a case the localized situation of the changes enables us to make the definite diagnosis of laceration fracture, which is very easily confirmed by a skiagram. (2) In other cases there is nothing abnormal to be felt at the tuberosity of the os calcis. The distance of the malleoli from the ground is normal, and the heel, as seen from behind, does not appear to be broadened. Nevertheless the patient avoids putting any weight on the injured foot. On palpation some slight thickening may be found, but there will be a special indication of pronounced tenderness Fig. 466.— Double fracture of the os calcis. a, Laceration fracture ; /■>, compres- sion fracture. 7i8 SURGICAL DISEASES OF THE EXTREMITIES Fig. 467. — Double fracture of the os calcis. a, Fracture of the tuberosity of the os calcis ; b, detachment of the anterior process. situated towards the tuberosity of the os calcis, or on the plantar surface, or towards the anterior process. Pressure on the sole of the foot in the axis of the leg is painful. The bruising usually occurs on the sole. In such a case we should think of a com- pression fracture iviiJiont marked dis- placenient of tlie frag- ments. I'he skiagram shows either a cer- tain amount of ob- literation of the bony structure,, from which we would conclude that a slight degree of crushing of the in- side of the OS calcis has occurred, or we may find distinct fissures running along the length of the bone (fig 4666) and transversely to it. Detach- ment of the anterior process is a special feature of this injury (fig. 467). These cases are usually diagnosed at first as sprains or contusions. It is only when the patient attempts to- put his foot to the ground in two or three weeks' time,, and the pain still persists, that a more severe form of injury is thought of. Palpation will now reveal a dis- tinct thickening of the OS calcis by callus, even in those cases wherein nothing abnormal could be found on the first examination. (3) The cases in the third group are much more easily recognized. The heel, as seen from behind, is evidently broadened from the Fig. 468.— Severe crushing of the os calcis. FRACTURE OF THE OS CALCIS 719 very beginning, and the malleoli are lower than on the uninjured side. The OS calcis is felt to be thickened, and is tender both on lateral pressure and on pressure in the axis of the leg. These are cases of comminution frac- tures, which are made up of fissures running lengthwise and also transverse- ly. Obviously the more accurate de- tails can only be made out from a ^l^: 469--01d compression fracture of the right os calci., treated as a sprain. The heel is broadened, the malleoh are low, skiagram, A trac- and the position is one of slight valgus. ing of the foot will show that it is widened about the heel. Patients are sometimes able to walkabout even after this injury, although the pain is considerable; pronation and supination are particularly deranged. Fig. 470. — Detached fragment from inner side of os calcis. (4) DetacJuncnt of the sustentaculnin tali — a very rare condition — should be thought of if we find that the foot is definitely in a valgus 720 SURGICAL DISEASES OF THE EXTREMITIES position, and the region below the internal malleolus tender, without the signs of fracture of the malleolus or of the astragalus, or those of an ordinary compression fracture. (5) Finally, there may exist lateral detachments of bone, which are only recognizable by the circumscribed pain on pressure and by X-ray examination from above, with the foot greatly dorsi-flexed (fig. 470). The following scheme briefly summarizes the foregoing remarks on injuries about the ankle-joint. No striking deformity, at most a little swelling Bone nowhere very tender, except at attachment of ligaments to one or other malleolus ; pain often per- sist?, even when at rest. No pain on axial pressure. Tenderness of bone trans- versely above joint (gener- ally on tibia and fibula) ; pronounced pain on axial pressure Great tenderness of or.e or both malleoli at a more or less considerable distance above their extremities ; false mobility not always demonstrable, but most likely in the fibula ; no pain on axial pressure. 'Malleoli at normal level ; pain over tuber cal- Tibia and fibula not tender I on pressure ; pain on axial | pressure (by pressing os I Ditto, but pain in body calcis on iinderlying sur-"( of os calcis face) usually present ; pain on lateral compression of the OS calcis Malleoli abnormally low; pain in body of os calcis Foot displaced in rela- tion to axis of leg Ditto, but pain on pressure in the astragalus and not , in OS calcis ; dorsi-flexion \ particularly painful /Hone not tender; bifurcation between malleoli can be felt under skin Both bones tender trans- versely above the malleoli Bone tender above tip of mal- leolus (tibia or fibula) or above the malleolus (fibula); sometimes accompanied by an actual dislocation Malleoli not tender ; bifurca- tion between malleoli ab- normally easily felt ; around body projects, usually for- wards, under the stretched skin Malleoli normal on palpation ; the bifurcation between them not very easily felt ; , considerable displacement \ of foot below astragalus ; head of latter to be felt Sprain of ankle. Supra-malleolar frac- ture without displace- ment. Malleolar fracture with- out displacement. Fracture of tuberosity of OS calcis. Fracture of body of OS calcis without dis- placement. Fracture of body of OS calcis ; bones com- pressed. Fracture of astragalus. Simple dislocation (foot usuallj' displaced back- wards and outwards). Supra-malleolar frac- ture with displace- ment, before the age of 14 usuallj' a separation of epiphysis (foot gene- rally displaced backwards and outwards as in dislo- cation). Fracture of malleolus with displacement (foot generally displaced as above, rarely for- wards). Dislocation of astraga- lus (often combined with fracture). Dislocation below tragalus (occurring various directions). INJURIES TO THE FOOT 721 Fig. 471. — Compression fracture of scaphoid. CHAPTER CVI. INJURIES TO THE FOOT, IN FRONT OF THE ANKLE-JOINT. We need not occupy any time over such rare injuries as disloca- tions of Choparfs or Lisfranc's joints. The displacement is so striking that the diagnosis can be made from anatomical considerations, unless the swelling is very great, in which circumstance a skiagram will be necessary. More interest attaches to certain trivial, but not in- frequent, injuries, which are quite characteristic, and which were previously over- looked or incor- rectly diagnosed. Owing to recently acquu'ed know- ledge, these injuries may now be recognized by their clinical signs, (i) Compression Fracture of Scaphoid. — If a person falls from a height on to his toes, the force is to a great extent gathered up by the scaphoid and transmitted to the astragalus. If the scaphoid is not sufficiently resistant, it becomes compressed, and, so to speak, is squeezed out of the skeleton of the foot. It then gains the dorsal surface, and can be distinctly felt through the soft parts (fig. 471). In the female sex a Wormian bone, described by Gruber as the OS tibiale externum, is often found on the tubercle of the scaphoid (fig. 472). Ignorance of this ab- normality has led to the erroneous diagnosis of detached fracture, Fig. 472. — Os tibiale externum (T). 722 SURGICAL DISEASES OF THE EXTREMITIES when in reality the pain complained of has been due to stretching of ligaments, which occurs in this situation through dancing. (2) Fracture of a metatarsal bone is much more frequent. If a heavily laden soldier, wearied by many hours' marching, begins to relax, and fails to impart the necessary elasticity to his steps by the proper use of the muscles of his foot, it is very easy for the metatarsus to become overweighted, and for one of the bones — usually the second — to crack. The symptoms thus caused : spontaneous pain, tenderness on pressure, and swelling, were previously attributed to inflammatory changes in the soft tissues, until it was shown that they were really caused by a subperiosteal metatarsal fracture, usually without any dislocation. Fig. 473.' — "Swollen foot." Old callus. Fig. 474. — " Swollen foot." Recent callus. Sometimes the skiagram which is taken forthwith reveals no change at all, because the fissure in the bone is purely subperiosteal. But in a few weeks' time slight callus is visible in the skiagram. The following is an illustrative case : — A slimly-built recruit showed the well-known signs of "swollen foot " in the neighbourhood of the second right metatarsal after a long march. The skiagram, which was taken immediately, revealed nothing ; but a diagnosis of fissure was nevertheless made. A subse- quent examination in a few weeks revealed definite callus. In a few months' time the young man had to resume his military duties, and the symptoms returned in his left foot after a long march with full INJURIES TO THE FOOT 723 equipment. On this occasion also the skiagram was negative, but examination a few weeks later showed the condition illustrated in figs, 473 and 474. The second metatarsal bone of the right foot, Fig. 475. — Fracture of tuberosity of fifth meta- tarsal. ' _ Fig. 476.— Epiphyseal line at base of fifth meta- tarsal (from lad aged 14). which was injured first, presented a spindle-shaped thickenmg which represented the remains of callus. The second metatarsal of the left foot presented well-developed recent callus. Before entering military service the patient had done much mountaineering without any result- ed) (^) Fig. 477. — Fracture of sesamoid l)one, seen from below and from the side. ing injury to the bones of his foot, thus sliowing that the military conditions are really responsible, i.e., the heavy equipment and the forced marching of the weary soldier when his muscles aie exhausted. 724 SURGICAL DISEASES OF THE EXTREMITIES (3) Fracture of the tuberosity of the fifth metatarsal bone is also a characteristic injury of the metatarsus. It can be diagnosed clinically, but is easily overlooked. It may be caused by direct violence, and probably also by the contraction of the peroneus brevis ; it has the appearance of a detached fracture (fig. 475). This fracture must not be confused with the separation of the epiphysis (fig. 476), which occurs in this situation between the ages of 12 and 14,^ as described by Kirchner and Iselin. (4) The possibility of fracture of a sesamoid bone (fig. 477) will be suggested by localized pain on pressure over the sole, and by painful- ness of the movements of the toes. We need not enter into details of the numerous and varied frac- tures and dislocations which may occur about the heads of the meta- tarsal bones and the toes. Pressure and traction on the separate toes will always show which of them is involved ; but a skiagram will be required for further details. CHAPTER CVII. INFLAMMATORY DISEASES OF THE FOOT. .4.— TARSUS. Inflammatory diseases of foot may be termed podartliriiis on the principle that inflammatory processes of the wrist are sometimes called cheir-aiiliritis. A general term of this nature may be justifiable in the case of the wrist, because of the small amount of bony structure which is involved, but in the case of the foot the diagnosis must be more definite. We differentiate : — (1) ACUTE DISEASES. It is usually easy to determine whether an acute inflammation involves the ankle-joint, or is situated more forwards in Ciiopart's or Lisfranc's joint. In the vast majority of cases the ankle-joint is alone involved, or at least is the principal seat of tfie affection. The nature of these acute inflammations is similar to those which occur in the shoulder and knee, and as also happens in these joints, the original site of the disease is frequently in the adjoining bone, and not in the joint itself. INFLAMMATORY DISEASES OF THE FOOT 725 (2) CHRONIC INFLAMMATIONS. Tubercle is, as always, the most important of the chronic inflam- mations. Adults are more frequently affected with tuberculosis of the ankle than any other joint. The patients usually complain of pain, of a few weeks' or months' duration, about the ankle. There is con- sequently some lameness. There is frequently no evident change at this stage ; the only sign of disease may be a certain amount of tender- ness in the region of the capsule of the upper part of the ankle-joint. A skiagram may reveal nothing but a striking transparency of the bone (fig. 478) — osteoporosis — due to the disappearance of lime salts. If the disease is somewhat more advanced, there may be swelling of those portions of the capsule accessible to palpation, or there may possibly be a para-articular abscess. The grooves on either side of the tendo Achillis are very frequently obliterated at this stage, and the tendon itself may appear to lie in a depression (tig. 480). The skia- gram will show that the articular surfaces are partially eaten away. The mutual approximation of the bones indicates that the cartilage has already to some extent disappeared. It may be possible to detect individual areas of disease in the bone. We have seen, in connection with the knee-joint, how to distinguish between primary and secondary lesions. When the capsule is swollen the condition may be mistaken for gummatous disease or chronic gonorrhcEal effusion. 1 was inclined to diagnose syphilis in the case of a young healthy man, because the swelling was so remarkably painless. The history was definitely against this view, and I, therefore, decided to operate. I immediately alighted on gummatous tissue, and, therefore, desisted from further interference. The patient made a rapid recovery under iodide of potassium. If the disease process has broken through externally, it supports the diagnosis of tubercle, as against rheumatism or gonorrhoeal arthritis. It is not, however, any contra-indication of syphilis ; on the contrary, it suggests tertiary disease if the appearance on the skin is not that of a fistulous orifice, but that of a sharply marginated ulcer. In the Tropics we may be confronted with " madura foot," a disease allied to actinomycosis which may give rise to a clinical picture similar to tubercle or syphilis. In the cases hitherto discussed the principal feature has been involvement of the ankle or its neighbouring joints. But we frequently find that lameness and pain in the foot may arise, although the movements of tlie Joints are perfectly free. Accurate examination will show that the tenderness is not in the capsule of the ankle-joint, or of Chopart's joint, but that it is in the lower end of the tibia, or the OS calcis, or in rarer cases in the scaphoid or cuboid. 726 SURGICAL DISEASES OF THE EXTREMITIES Tubercle of the lower end of the tibia may occur in one of three forms: (i) A simple central abscess of the bone, with diffuse thickening of the cortex ; (2) a lesion with a spongy sequestrum situated quite close to the joint ; (3) small areas of granulation. The last applies to tubercle of the os calcis, which is rather frequent, and which is usually situated in its posterior half. We generally find one or more abscesses surrounded bv sclerosed bone, which often contains large spongy sequesti\a. The disease sometimes remains within the OS calcis for vears, and only becomes manifest from time to time by fresh inflammatory exacerbations. This intermittent course and the Left (diseased) side. Right side. Fig. 478. — Early stage of tubercular synovitis ot the left ankle-joint. The skiagram only shows great osteoporosis. skiagram render it easy to differentiate tubercle from sarcoma, which has occasionally been observed in the os calcis. It is very important not to confuse early tubercle with the so-called Achillodynia. This term indicates a painful inflammation of the mucous bursa between the tendo Achillis and the os calcis — due either to rheumatism, gout, or gonorrhoea. It may also come on, after fatiguing marches, and is thus particularly liable to occur in soldiers, or in mountaineers, who have no kind of predisposition thereto. INFLAMMATORY DISEASES OF THE FOOT 727 Affections of the bursa snhcalcanca, and of the bursa Achillea posterior, which hes on the tendo Achihis, may occur under similar v.. J J^^m^-\ A M Mt Fig. 479. — Tubercle of ankle. Narrowing of cartilage. Bone eaten away. Lesion in external malleolus. New bone formation at X. Fig. 480. — Tubercle of right ankle. Tendo Achillis looks like a furrow between the two lateral swellings of capsule. circumstances. Traumatic or painful inflammatory swellings are sometimes found in the iendo Acliillis itself, after long marches. I'lG. 481. — Tubercle of left ankle (both feet are flat). The grooves on either side of tendo Achillis are obliterated on the left. The pain produced by the sub-calcaneal bursa has been incorrectly termed '•' talalgia." " Calcanalgia " is a more correct designation, but ^' pternalgia" is quite superfluous. 728 SURGICAL DISEASES OF THE EXTREMITIES i?.— METATARSUS AND TOES. If the metatarso-phalangeal joint of the great toe becomes tender oii pressure, inflamed and spontaneously painful, a typical attack of gout is obvious. It is of some diagnostic interest to recognize that a typical attack may occasionally be followed by signs of visceral gout. In rare cases the attack starts with visceral manifestations, to be followed by a typical seizure m the great toe. I have, for instance, seen a gouty subject, who had been free from attacks for ten years, suffer successively from angina, trigeminal neuralgia, gouty seizure in the foot, non-purulent urethritis, proctitis, sciatica, pneumonia and nephritis. Acute phlegmonous processes in the neighbourhood of a hallux valgus are generally due to suppuration in the bursa over the head of Fig. 482. — Tubercle of os calcis (superficial lesion in bone, with sequestrum). Fig. 483. — Tubercle of os calcis (deep abscess in bone). the metatarsal bone. These abscesses in the foot, which are situated under callosities, often assume the shape of a stud, just as they do in the hand. They really consist of two abscess cavities, the one being under the epiderinis, the other more deeply situated under the skin, the two intercommunicating by a narrow opening. If a toe exhibits signs of intermittent bluish-red congestion, with pains not limited to the discoloured area, but which may even extend to the leg, we should think of commencing grangrene in elderly or diabetic patients. The considerations which apply to dactylitis of the hand and fingers are also applicable to chronic inflammatory processes of the metatarsus and toes. The first metatarsal bone suffers most frequently. DEFORMITIES OF THE FOOT 729 CHAPTER CVIII. DEFORMITIES OF THE FOOT. jMost deformities of the foot are so easily recognized that difftcuhies in diagnosis hardly ever arise. We shall therefore only refer to a few points which occasionally perplex beginners. (1) FLAT FOOT. The frequency with which a valgus foot and a flat foot are combined has given rise to the impression that both deformities are of the same significance — an error which has led to much bad treatment. I once saw a patient who had a pes valgus calcaneus (figs. 492 and 493) provided by the bootmaker with a flat foot pad, although an abnormally well-developed arch was present, because the practitioner had not given any accurate instructions. Pes valgus, or everted foot, is characterized by the inclination of the OS calcis outwards, i.e., it is not directly in the line of the axis of the leg, but forms an obtuse angle with it, as seen from the outer side. This angle disappears as soon as the foot is placed upon a corre- spondingly inclined plane (fig. 484). The foot becomes flat — pes planus — when the arch sinks, and the anterior part of the foot at Chopart's joint becomes abducted, so that its axis deviates externally from the perpendicular to the line connecting the malleoli (fig. 485). A flat foot in the valgus position, with these signs, is obvious even to a lay observer. In such cases, the impressions made by the sole of the foot will be of the character illustrated in figs. 490 and 491. These severe cases do not, however, possess as much diagnostic interest as those wherein the patient complains of pain in various places on his foot, without the presence of any definite flattening of the arch. But careful inspection will often show that the heel is turned somewhat outwards and that the anterior part of the foot has undergone some lateral deviation. The impression of the sole may nevertheless be almost normal, or at most show a somewhat wide connection between the heel and the balls of the toes (fig. 489). The pam is sometimes localized to definite spots, i.e., astragalo- scaphoid joint, the head of the astragalus, the internal side of the scaphoid and the area in front of and below the external malleolus. In other cases the pain is more diffuse, extending over the whole tarsus, or radiating forwards between the metatarsal bones. The pain is very sharp on standing, it is less severe on walking, and it disappears rapidly on resting. Well-fitting boots relieve it ; low soft shoes 730 SURGICAL DISEASES OF THE EXTREMITIES Fig. 484. — Bilateral pes valgo-planus. On ihe right side Fig. 485. — Same case from the front. Externa the valgus position has disappeared, because foot is resting deviation of the anterior part of foot ; the arrow; on an inclined plane. indicate the normal positions of the inner margin: of foot. Fig. 486. — Pes valgo-planus on right side after traumatic division of the tibialis pos- ticus tendon. Fig. 487. — Same case from behind. increase it. Occasionally the pains are felt as much in the calf as in the foot, or even more so. They may even be felt in the thigh. If one neglects to make an examination in this stage, or does so only cursorily, such an unsatisfactory diagnosis as talalgia or meta- tarsalgia, &c., is apt to be given. DEFORMITIES OF THE FOOT 731 Fig. 488. — Normal foot. Fig. ■ Commencing flat FiG. 490.— Moderate fiat foot, foot. Fig. 491. — Severe flat foot. Fig. 492. — Pes calcaneus 47 Fig. 493. — Pes excavatus. 732 SURGICAL DISEASES OF THE EXTREMITIES If the pains become so severe that the patient contracts all the muscles in order to fix the joints of the foot, the term spastic flat joot is employed — or incorrectly, inflaniuiatoyy flat foot. It may resemble a commencing tuberculosis in this stage. Flat foot may accidentally coincide with tubercle. If the first examination is not decisive, the patient must be instructed to rest for two or three weeks. The pain of fiat foot will then disappear, but that of tubercle will either persist or only abate in a slight degree. Fig. 494. -Congenital absence of fibula, with pes valgus, in girl aged 8 years. Fig. 495. — Congenital absence of fibula ; skia- gram of fig. 494. Errors of diagnosis, such as rheumatism, neuralgia, &c., are not likely to be committed even by the inexperienced, if the patient is a young person whose occupation demands constant standing. On the other hand flat foot is frequently overlooked in corpulent women at the climacteric period. • The increased body weight which often sets in at this age puts loo great a strain on the slender bony structure of a woman's foot. It therefore sinks dow-nwards and inclines outw-ards. The pains of flat foot supervene, and they are attributed to rheumatism, neuritis, to DEFORMITIES OF THE FOOT 733 varicose veins, which are usually evident, and if they are not, to " deep varicose veins " which are usually discovered ad hoc. The fact that the pain is felt in the calf muscles is the basis of this last assumption. A valgus foot or a flat foot, re- sulting from an injury (fracture of the malleolus, os calcis, or a meta- tarsal bone) often remains misunder- stood for a con- siderable time, be- cause the foot does not assume the classical picture of flat foot from the beginning. On the other hand, pes valgus may arise as " habitual contracture " after an injury, without any deformity of bone (fig. 496). Fig. 496. — Habitual contracture of left foot in valgus position, after a healed fracture of fibula without dislocation. Fig. 497. — Congenital clubfoot (simple form). Fig. 498. — Habitual contracture of left foot, assuming a club foot posture, after a sprain and completely healed fracture of posterior process of astragalus. 734 SURGICAL DISEASES OF THE EXTREMITIES Patalxtic flat foot as a symptom of paralysis, especially of infantile paralysis, is easily recognized. It resembles the flat foot which results from division of tendons (tibialis posticus, figs. 486 and 487). Congenital absence of the fibula is suggested by a striking valgus posture with shortening of the limb and curving of the tibia forwards and inwards. Palpation will show that the external malleolus is absent. The tibia usuall}^ presents a scar-like stripe, running length- wise (figs. 494 and 495). This mal-development is frequently bilateral and the fibula is absent, either completely or partially. The toes are sometimes quite perfect, at others they are imperfectly developed towards the little toe. The so-called Volkiuaiin's subluxation of tlic foot outwards constitutes a slight degree of this deformity. (2) TALIPES, PES EQUINUS, PES CAVUS, PES CALCANEUS. These deformities are so distinctive where their characters are once known, that we may be content with a few typical illustrations. The cause of these deformities is, howevei", of importance, from the therapeutic standpoint. Whereas in flat foot the mechanical and rachitic changes pre- dominate over those of paralytic or congenital origin, the deformities at the head of this section are mainly due to congenital or paralytic causes, rarely to injuries and never to rickets. The first question in regard to equinus must be in regard to its congenital or acquired \ ^ ^ origin. The history usually supplies the answer. If not, we may assuine a para- lytic or acquired origin if there is coldness or blueness of the foot, and obviously also if definite paralysis exists. Atrophy of the calf muscles is of itself not conclusive evidence, because this may also arise in course of time from want of activity of certain muscle groups as a result of congenital club foot, and may indeed reach a very considerable degree. Neither does the unilateral or bilateral existence of the deformity give any information on this point, because the congenital and the acquired forms may both affect either one or two sides. But if it once be ascertained that the talipes is of the paralytic variety, certain important conclusions as to the cause of the paralysis follow therefrom. Fig. 499. — Paralytic pes equinu? DEFORMITIES OF THE FOOT 73; Unilateral talipes with flaccid paralysis is usually due to acute an- terior poliomyelitis, but may exceptionally be the result of spina bifida. The latter cause is suggested by the simultaneous existence of Fig. 500. — Paralytic pes cavus in a case of spina bifida. disturbances of sensation and incontinence of urine. If no swelling is evident on the back, a spina bifida occulta should be looked for. Similarly, bilateral talipes with flaccid paralysis should suggest some congenital defect in the lumbar cord. ^ Unilateral talipes com- bined with spastic paralysis is due to infantile cerebral paralysis, but is in excep- tional cases the result of an injuiy to the brain (see false meningocele). If both feet are aft'ected with talipes and spastic paralysis, we may as- sume that the cause is Little's disease, the pathology of which we cannot here dis- cuss. The spastic forms of club foot are classified as acquired, although their ultimate cause is congenital. The development of the deformity does not, however, occur until post-foetal life. One form (jf talipes deserves special mention because it plays an imp(jrlant part in the considerati(jn of accidents, i.e., the so-called Fig. 501. -Pes calcaneus of slight degree, con- genital origin. 736 SURGICAL DISEASES OF THE EXTREMITIES hahit contracture. If for some reason or other, generally an injury, the movements of the ankle and Chopart's joint become painful, these joints are held rigid by muscular fixation so that the foot does not yield at all on walking, but is planted down stiffly on its outer edge, as in talipes. If the patient is very sensitive to pain, or has neuro- pathic tendencies, or if there be a question of compensation involved, this posture may persist after the disappearance of the pain or after the recovery from the injury ; it becomes a habit contracture. I have seen a habit contracture of this kind come on after a con- tusion of the foot. Although there was not the slightest anatomical change, the foot was always held in the talipes position on walking. The muscles of the whole limb were somewhat atrophic, and there was some cyanosis due to the deficient muscular activity. The condition had been present for three years owing to the protracted legal proceedings. The preceding remarks on ordinary Fig. 502. — Hallux valgus of various degrees. Fig. 503. — Hammer-toe (second). talipes apply also to pes equinus, pes calcaneus and pes cavus. These varieties may be either congenital or acquired, and in the latter case are usually of paralytic origin. Bilateral pes cavus and some- times also pes calcaneus may gradually develop in advanced infancy or at puberty, without any definite ascertainable cause. It is probably due to some congenital disturbance of the co- ordinating power of the various muscle groups, and may be a very slight sign of some hereditary mal-development of the spinal cord, such as defective development of certain anterior horn cells. DEFORMITIES OF THE FOOT 737 Fig. 499 shows that pes equinus may be mistaken at first sight for hip disease. (3) DEFORMITIES OF THE TOES. Many an elegant shoe conceals deformities which not only offend the aesthetic taste, but which also make the life of the wearer a torture, until the patient decides to part with the toe or to permit a resection of the deformed joint. Fig. 504.— Hallux valgus. Skiagram of fig. 502. Fig. 505. — Hallux valgus. Skiagram of fig. 502. This is especially true of the deformity, which is a product of civilization, known as hallux valgus. A glance at the two degrees of tlie deformity, as depicted in figs. 502, 504 and 505, suffices for the purposes of diagnosis. We have already referred to the secondary inflammation of tlie bursa which may ensue. Hammer toe (fig. 503) is another frequent deformity. It may be due to hereditary disposition, as well as to badly htting boots. When this condition gives rise to pain, it is mainly the result of inflammation of the bursa. 738 SURGICAL DISEASES OF THE EXTREMITIES CHAPTER CIX. TUMOURS AND ULCERS OF THE FOOT. AlAXY different forms of tumours and of ulcers have been observed on the foot, as on the hand, but there are very few characteristic enough to deserve mention. Fig. 506. — Multiple chondromata of the toes (from the surgical clinic, Berne). Fig. 507. — Cutaneous horn on heel. Fig. 508. — Cavernous angioma of foot. (1) TUMOURS. Chondroma of the toes is the most important of the innocent new groivilis, and its character is similar to that of chondroma of the fingers (fig. 506). TUMOURS AND ULCERS OK THE FOOT 739 If a toe-nail is gradLially raised by a tLunoiii"-like structure beneath it, a sub-ungual exostosis is suggested, as already described by Dupuytren. Fibromata originating in the nail-bed, and growing under or close to the nail, are rare. Cutaneous horns (fig. 507) are also unusual. Lipomata have been seen on the metatarsus and they are liable to spread between the bones and plantai- aponeurosis. Cavernous angiomata of congenital origin also occur on the foot. Although these are histologically innocent, they invade various tissufs such as skin, muscle and tendons, and the}' may lead to profound disturbances therem. Their granular surface, and their translucent bluish-red colour, and their emptying on piessure are signs which render them immediately recognizable. Fig. 508 is a tvpical illustration of the appearance of a cavernous angioma in general. Sarcoma of the os caicis is the only mallgnani iuiuour which is at all characteristic in this region. Its diagnosis from tubercle has already been discussed. (2) ULCERS. In addition to the well-known tiiad of ulcers — tubercular, syphilitic and malignant — the foot presents frequent examples of "perforating ulcer" and of circumscribed gangiene of the skin. The nature of the ulcer can generally be diagnosed from its situation. In the dorsum they are usually tubercular or syphilitic (fig. 437), rarely lualignant. The recognition of syfthilis and of tubercle has been dealt with in Chapter CII. A malignant ulcer is ditferentiated from both of these by its papillomatous appearance, or by its hard edge and base. If we find a discoloration of the skin, either circular or map-hke in shape,, towards the toes, associated with loss of sensation in the ailected area and with neuralgic pains, we must diagnose commencing gangrene and should examine for arterio-sclerosis, diabetes, or nephritis. Alcohol and syphilis may be indirect causes, if the patient is young. The gangrene becomes quite definite in the course of two or three weeks, the area involved becomes black and sloughs away from the healthy skin. The condition of the arteries and of the general 48 Fig. 509. — Fcif raim^ ulcer due to alcoholic neuiiii.s. 740 SURGICAL DISEASES OF THE EXTREMITIES circulation determines whether the process ceases with this circum- scribed destruction, or whether it is merely the prelude to an ascending gangrene. An ulcer on the sole is either malignant or of a neuro-paralytic nature. The latter (perforating ulcer) is diagnosed from its situation on parts especially subjected to pressure, such as the heel, the ball of the great or little toe, by its slight local painfulness and its associated disturbed sensation and anaesthesia, often combined with radiating pains. These pains are not accidental accompaniments, but are indicative of the cause of the malady, i.e., of a neuritis. The margin of the ulcer is formed of thickened epithelium, and the central necrosis may extend to the tendons and bones. Attacks of phleg- monous inflammation around the ulcer are very characteristic of the condition. Sometimes an injury to a peripheral nerve accounts for the perforating ulcer, but it is more frequently the result of the nerve disturbances which follow on spina bifida, or of some disease of the spinal cord or cerebral system, such as syringo-myelia, tabes dorsalis or general paralysis. Alcoholic neuritis is, however, the most frequent cause. Ulcers due to circumscribed gangrene in arterio-sclerotic and diabetic subjects, as noted above, must not be confused with per- forating ulcer. The former occur usually on the dorsum of the foot and toes, and are attended by severe neuralgic pains. Of course, it is quite possible that a genuine perforating ulcer may also develop in these patients. If an ulcer forms on a part of the sole not subject to pressure it may be an epithelionna, which is rare, or a sarcoma of the skin, which is still rarer. Finally, reference must be made to the ulcerative processes in the vicinity of the toe-nails. Ingrowing toe-nail is so familiar that it hardly requires mention from the diagnostic aspect, were it not that syphilitic and tubercular ulcers also occur at the same spot. The latter is sometimes termed onychia maligna. Syphilis is diagnosed from the history, Wassermann reaction, and the results of specific treatment. Tubercle is diagnosed if the treatment for ingrowing toe-nail and for syphilis fail to cure the ulcer; but it is a better plan to remove a small piece of the margin for the purpose of histological examination. INDEX. Abdomen, surgical diseases of, 235 — , injuries of, 244 — ■ - -, Avith external wound. 251 — ■ — , without external wound, 244 Abdominal cavity, acute inflammation in, 254-276 — — , effusion of bile into, in injuries of liver, 247 , entrance of gas into, in rup- tured intestine, 245 , m perforation of stomach, 298 , tumours in, demonstration of, 287-290 , by exploratory puncture, 291 -- hernia, epigastric, 369, 370 -- injuries, gunshot, 252 — integument, abscess of, 272, 369 — — , actinomycosis of, 377 , fibroma of, 374, 375, 376, 2,17 , tenderness of, in peritonitis, 258, 259 , tumours of, 287, 368-376 , atypical positions, 376 — in inguinal region, 374 lumbar region, 375 — umbilical region, 371 _ . upper abdomen, 368 — lipoma, subcutaneous, 369, 376 — • muscle, tuberculosis of, 376, 2>n — nsevi, sarcomatosis, 214, 376 — rigidit}-, reflex after intestinal injuries, 246 , in peritonitis, 258, 275 — sinuses, jin — — in groin, 379 — — at umbilicus, zil — tumours caused by inflammatory changes, 287 ■ — — ■ causing intestinal obstruction, 287 Abdominal tumours, consistence of, 289 , determination of origin of those which fill up entire abdomen, 289 — • — , innocence and malignancy of, 290 , movable, 288 , phantom, 287 — • — , slightly movable and not very extensive, 289 , type of displacement of un- paired organs, 236 — viscera, diagram of parts felt on palpation, 240 displacements, 235; congenital, 235 ; acquired, 237 — wounds, perforating and incised, 253 Abducens nerve (6th), focal symptoms in lesion of, 40 , paralysis of, in fractures of base of skull, 5 Abrasion fracture of eminentia capitata humeri, 565, 567 Abscess, ai:)pendicular, 335, 336; position of, 334 — — , diagnosis from hip disease, 652 • — — , peritonitis, 262, 272, 273 — , Bezold's, ZZ^ 133 — , cerebellar, 32 — , epidural, 30 — , epigastric, 368, 369 — , gluteal, 519 - -, inguinal, 517, 518 , meso-coeliac, diagnosis from peri- tonitis, 264 — - of abdominal wall, 274 — ■ axilla, 211 — brain, 18 ■ — ■ — , diagnosis, 17, 18 , etiology, 19, 20 , symptoms, 17, 18, 19 — breast, 220, 221 742 INDEX Abscess, breast, superficial, 221 — kidney, 447, 452 — liver, 265, 326, 327 — lumbar region, 375, 517 -- lung, 195, ig6 , diagnosis from bronchiectasis, 198 — neck, 134, 135, 517 — ■ — , chronic, 134, 135 , due to caries, 518 , tubercular (cold), 134, 135, 138 — palate, 95 — pelvic bones, 517 — ■ seminal vesicles, 431 — spleen, 266, 330 — supra-clavicular fossa, 133 — • supra-symphysis pubis, 272 — temporal lobe, 30, 31 — tibia, lower end, 705 — , peri-articular, of foot, 725 knee, 679 — , perineal, 519 — , peri-nephritic, tubercular, 375, 442 — , peri-proctal, 410 — , pharyngeal, 96 — , posterior cervical, 133 — , prostatic, 431, 471 — , residual, in peritonitis, 256, 268, 336 — , retrobulbar, 50, 61 — , retromammarj-, 219 — , retroperitoneal, 266, 335 — , retropharyngeal, gi, 114 — , retrotonsillar, 91 — , submental, 131 — , subphrenic, iqs, 276 , in appendicitis, J,2>^ — — , with pleural exudation, 279 , without pleural exudation, 277 — , sub-umbilical, 272, 378 — , tubercular (cold), of skull, 56 of spine, 135, 215, 515, 516 Accessory goitre, 96 , true and false, 150 — thyroids, malignant growths of, 171 Acetablum, fractures of, 617 — , displacement of, in hip disease, 649, 650, 653 Achillodynia, 726 Acne pustules of axilla, 211 Acromegaly in tumours of pituitary body, 24 Acromio-clavicular joint, injuries of, 535, 536 Actinomycosis of ileo-csecal region, 288,"377 — jaw, 78, 79 — limbs, 571 — lungs, 198, 210 — mamma, 222 — neck, 13s, 140 — • — , with sinus formation, 136 — tongue, 107 Adamantinoma, 87 Adenoids of roof of pharynx, gi Adenoma of liver, 326 — , testicle, 422 -Adiposis dolorosa, 24, 175 Air-goitre, nature of, 141 Air passages, diseases of, chronic, 118 ■ — , surgical, no , foreign bodies in, 116, 117 — • — , injuries of, 116, 189 x\lbuminuria in diphtheria, 113 Alveolar process, haemorrhage in frac- ture of upper jaw, tj, — tumours, 85 Anaesthesia dolorosa in tumours of jaw, 84 — paralysis, of upper limb, 594 x\nal region, iistulse, 410, 424, 425 , complete and incomplete, 426 ■ , nature of, 426 , injuries of, 412, 413 , prolapse of, 411, 412 , tumours of, 409-412 Anarthria, diagnosis and surgical significance of, 46 Aneurism, cirsoidal, of face, 64 — of aorta, 201, 205 — ■ — , penetrating through thoracic wall, 213 — carotid, 163 — fibula, 690 — innominate artery, 203 — • neck, 127, 162 , arterio-venous, 164 , diagnosis from other tumours of neck, 140, 163 — thigh, 658 — , femoral, 658 — , ophthalmic, 50 — , popliteal, 687 — , subclavian, 163 Angina, diffuse and unilateral, 90, 91 INDEX 743 Angina, dysphagia in, 123 — , Ludovici, 132 — , Ludwig's, 90 Angioma of arm, 572 — face, 63, 64, 66 — foot, 738, 73Q — hand, 600 — longitudinal sinus, 53 — mouth cavity, g4 — , mulberry-like, of infant, 54 — orbit, 56 — sacral region, 485 — scalp, 51, 52, S3, 54 — thigh, 657, 658 — thoracic wall, 216 — tongue, 105 Ankle, contusions of, 706 — , dislocations of, 714, 715 — , fractures of, 706, 709, 710 — , gonorrhoeal effusion of, 725 — , injuries of, with deformity, 712 , without deformity, 706 , summary of, 720 — , sprain of, 706, 710 — , tuberculosis of, 726, 727, 728 Ankylosis of hip-joint, 655 — jaw, causes, 76, 77 — - knee-joint, 686 — vertebral joints, 521 Anuria, 427, 443 Aorta, aneurismi of, 201, 202, 203, 205 , skiagraphy in, 203 , diagnosis from tumour, 201, 287 Aphasia, focal diagnosis of, 46, 47 — in cerebral abscess, 30 ■ cerebral pressure, 14 Appendicitis, 266, 272, 332 — , chronic, 262, 339, 345, 346 — , complications, 336, :i37 — , condition of vermiform appendix and its surroundings in early stages of, 332 — , diagnosis of, 332 in the intervals, 338 , from abdominal tumour, 288 cholecystitis, 317 — - — hip disease, 652 peritonitis, 267 ruptured tubal pregnancy, 273 . urinary tuberculosis, 460 — , diagram of its most important forms, and some diseases con- cerned in differential diagnosis, 268-271 Appendicitis, exploratory puncture in, 336 — , history of, 272, 338 — , ileus in, 337, 354 — in hernial sac, 401 — , pregnancy and puerperal period, 276 — , larval (Ewald), 338 — , physical signs, 338, 33Q — , position and extent of appendix abscess, 334, 335 — , residual abscesses and their sig- nificance, 334, 2,3^ — , symptoms in localized peritonitis, 333 ^ — in early stage, 332 — — when accompanied by general peritonitis, 333, 334 — with peritoneal symptoms, 264, 333 Appendix vermiformis, abscess of, 272, 333 , displacement of, 237, 317, 318 — — , its condition and surroundings in early stage of appendicitis, 33^ , palpation of, 239 — • — , position of, 334 Arm, chondroma of, 576 — , fibroma of, 576 — , gumma of, 574, 575, 576 — , mobility in injuries of spinal column, 490 — , muscular angioma of, 572 — , muscular tuberculosis of, 573 — , myositis ossificans of, 574 — , neuroma of, 572 — , osteoma, traumatic, of, 574 — , osteomyelitis of, 575, 576 — , posture of, in transverse lesion of spinal cord, 491 — , sarcoma of, 576 — , tuberculosis of, 573, 575, 576 Artery, femoral, aneurism of, 658 — , mesenteric, embolism of, 264 — , ophthalmic, aneurism of, 50 Arthritis, acute, of elbow, 569 — , deformans 589, 590, 591 — of foot, 724 — hip, 643, 644, 646 — jaw, 76 — — , ankylosing, 77 — shoulder, 550 — vertebral joints, causing chronic deformity, 521 — wrist, 588 , tubercular, 589, 590, 591 744 INDEX Articulation, sacro-iliac, sprain of, 630 — . , fissure in neighbourhood of, 630 Ascites, chylous, in old umbilical hernise, Z12, , diagnosis from exu- dative tubercular peritonitis, 283 Assyrian foot, 715 Astragalus, dislocation of, 715 — , fracture of, 711 — , injuries of, 715 Auditory nerve injuries through frac- tured base, 5 , focal symptoms in, 44, 45 Axial rotation of intestine, 364, 365 Axilla, abscess of, due to acne pus- tules or furuncles, 211 — , enlargement of glands, 210, 211 , in cancer of breast, 22g, 230 — , hydro-adenitis of, 211 — , lymphadenitis of, 550 -— , pendulous lipoma of, 572, 573 — , phlegmon of, 210, 211 B BACILLURIA, 434 — — - in cystitis, 465 — Back, fiat, 525 — — -, mobility of, after vertebral in- — juries, 4Q0 — — , muscles of, fibro-lipoma of, 216 — , fibroma, lipoma, and sarcoma — ■ of, 218 — — , round, 525 — , skin of, tumours of, and their differentiation, 214, 215, 216, 217 — : Balanitis, 475 — Balanoposthitis, 475 — Banti's disease, 314, 331 — Barlow's disease, signs of diagnostic importance, 100, 511, 656 Base of skull, fractured, symptoms of, 3, S, 6 Bayonet fracture, supra-condylar, in elbow-joint, 558 Bennet's fracture, 586 Biceps muscle, hernia of, 574 Biliary passages, catarrh of, 313 , injuries of, 247, 248 — - — , obstruction of, 321-323, 324 Biliary passages, surgical diseases of, 313 , with peritoneal sym- ptoms, 265, 273 Bites of mucous membrane of cheeks, ulcers due to, qq Bladder, calculi, 461 , aseptic, 461 — . — , cystoscopy in, 462 , diagnosis from tumours of, 462 , from stone in kidney, 462 , in diverticula, 463 , infected, 463 , in skiagram, 463 , obstructing urethra, 430 , primarj- and secondary, 463 , symptoms of, 461 — , catarrh of, 464, 465 — , colic of, 436 — disturbances in spinal injuries, 492 — , ectopia of (vesical), 370- — , examination of, 438 — ■ — , with cystoscope, 440 — , fibroma of, 467 — , fistulse of, 427 — , foreign bodies in, 465 — , gunshot wound of, 252 — , haemorrhage from., 436, 467 — , hernia of, 391 — , inflammation of, 429, 464 injuries of, 250, 465 — , papilloma of, 467 — , rupture, extra-peritoneal, 250 — ■ — , intra-peritoneal, 251 , difference between extra- peritoneal and intra-peritoneal, 251 — , sarcoma of, 467 — , tenesmus of, 432, 458, 462 — , tuberculosis of, 459, 460, 465 — , tumours in muscle of, 467 — ■ — , mucous membrane of, 466 Blindness, unilateral and bilateral, focal diagnosis, 38, 39 Blood, condition of, in Graves's disease, 145 — • cysts, in long bones, 660 — , effusion of, diagnostic importance in fractured ribs, 189 skull, 3, 4 — , freezing point in kidney disease, 441 INDEX 745 Blood in joints, 680, 681, 686 — tumours at side of neck, 162 — , vomiting of, hysterical, 2q6 , in cancer of stomach, 310 Bone, abscess of, chronic, at lower end of tibia, 704, 705 , with sequestrum, in humerus, 575 — , aneurism of, in femur, 660 — , cysts of, in leg, 6gQ, 700 — , perineal fistulse, in connection with, 424 — , tumours of, in ileo-sacral region, 480 — • — , in thorax, 218 Botriomycosis of hand, 600 Brain, abscess of, 17, 18, ig , diagnosis, 17, 18 — ■ — , etiology, ig, 20 ■ in temporal lobe after aural suppuration, 30, 31 , symptoms, ig, 20 — , angioma of, 50 — , base of, nerves of, 44 — , concussion of, 8, g , course, g , diagnosis, 8, g , symptoms, g, 10 — • — • — , local, 14 — , contusion of, 7, 10, 11 — - — , diagnosis, 10, 11 , symptoms, 10, 11 — , cortical areas of, 42, 43 — , cysts of, ig, 21, 22 — , focal diagnosis, 38 — ■ , in tumours, 23, 24 — , gumma of, 18, 22 — , hernia of, 51, 52 — • — , differential diagnosis, 53 , position of, 51, 52 , symptoms of, 52 — , injuries of, 17 — , tubercle of, 18, 22 — -, tumours of, 17 , diagnosis, 18 , localization, 23, 24 , new growths and granulation tumours, 22 , diagnosis from abscess of brain, 17, 18 — pressure, 7, 8, 12 , general and local, 12 , commencing and complete, 13 Brain pressure, commencing, dia- gnosis, 14 — ■ — , symptoms, classical, 13, 14 — ■ — ■ — , local, 14 Branchial cleft cancer, 171 — • — • fistula, 138, i3g — — cysts, 15s, 164 — ■ — • — , diagnosis of, 165 Breast, see also Mamma — , bleeding, 233 — , cancer of, diagnosis, 228 , adhesioiis to pectoral muscles- in, 22g , contracting, 227, 22g, 232 , diminution of the areola in 22g — ■ — , elevation of nijDple in, 22g — • — , enlargement of axillary glands- in, 22g , medullary, 231 — — ) prognosis, 231, 232 — — , retraction of nipples in, 22g , scirrhus, 225, 226 — - — , secondary growths, 231 , ulcerating, 228, 230 Bronchial glands, enlargement of, 200, 201 Bronchiectasis, diagnosis, ig8 — — , from abscess of lung and tuber- cular cavity, ig6 — diffuse, of right upper lobe of lung, 206 Bronchocele, 141 Bronchoscopy, diagnostic importance of, 1 10, 118 . . ' Brown-Sequard's lesion, 4g4, 508 Bryant's triangle, determination of, in injuries of hip, 612, 632 Bulbar palsy, dysphagia in, 122 Buphthalmos diagnosis from exoph- thalmos, 4g Burrowing abscess, due to spinal caries, 383, 386, 3g3, 515, 518,. 519, 651 — • — ) gluteal, 5ig , inguinal, 374, 384, 386, 3g2,. 516, 5t7 — - — , perineal, 5ig ^ in iliac fossa, 518 loin, 375, 517 — neck, diagnosis from aneur- ism, 163 — ■ — • — • true pelvis, 47g Bursa, iliac, effusion into, 652 746 INDEX Bursa, mucous, of hand, inflammation of, 605 — ■ — • foot, inflammation of, 727 • knee, inflammation of, 677, 687, 688 — — shoulder, inflammation of, 550 — pre-patellar, tuberculosis of, 687 Bursitis, infra-patellar, 687 — • over olecranon, 570, 572 tendo Achillis, 726 — , pre-patellar, 687, 688 , phlegmonous, 677 — , pre-tibial, 687 — , sub-calcaneal, 727 — , traumatic and tubercular of shoulder-joint, 547, 550 — under callosities of palm, 605 Cadre colique, 358 Csecal region, herniae in, as causes of intestinal obstruction, 366 Csecum, movable, 344, 345 Calcanalgia, 727 Calcaneus, compression fractures, 718, 719 — , crush fractures, 71Q — , fractures, 716, 717, 718, 719, 720 — , laceration fractures, 717 — , sarcoma of, 726, 739 — , tubercle of, 726, 728 Cancerous cachexia, diagnostic sig- nificance of, 306 Cancroid of back of hand, 601 — concha of ear, 72 — lips, 65 — nose, 70 Caput obstipum, 185 , congenital, 184 Carbuncle of back of neck, 133 Carcinoma, branchiogenous, 171 — of bladder, 467 — breast, 225, 227, 228 , contracting, 227, 229 , ulcerating, 228, 230 cervical glands, secondary, 159 — cheek, 67, 68, 69 — clavicle, 212 — concha of ear, 72 — floor of mouth, 99 — , perforation of, 139 — hand, 601 Carcinoma of intestine, 351, 352 — kidneys, causing intestinal ob- struction, 353 — larj-nx, iiy , histology, 120 , perforation, 139 — — , position, 120 — lips, 64, 67, 68 — liver, 325, 326 , secondary', 207 — Inng, 207 — nose, 67, 6q, 70 — ■ oesophagus, 127, 130 — ovary, 232 — pancreas, 329 — parotid gland, 169 — penis, 477 — pharyngeal wall, 103 ■ — , perforation of, 139 — prostate, 470 — puncta of eye. 69 — pylorus, 311 — rectum, 275, 352, 407, 408, 411 — ■ scalp, seborrhoeic, 58 — scrotum, 415 — sigmoid flexure, 352 — ' soft palate, 103 — stomach, 305 , cardiac end of, 306 — • — , body of, 310 — submaxillary gland, 169 — testicle, 422 — thyroid gland, 153 • — , secondary deposits, 155 — tongue, 108, 109 — tonsillar region, loi, 161 — umbilicus, 374 — upper jaw, 82, 83, 84 — uterus, 353 Caries of spine. See Spinal caries Carotid gland, new growth of, 172 Carjoo - metacarpo - phalangeal joint, dislocation, 585 Cartilage, detachment of, in knee- joint, 670 Cartilaginous tumours in pelvic joints, 480 Catheterization of urinary passages, 438, 439 in ruptured bladder, sym- ptoms, 250 • — , injuries through, 472 INDEX 747 Cauda equina, compression of, irrita tive symptoms, 508 Cavernitis, chronic, of penis, 475 — Cellular tissue, subcutaneous, of — • finger, inflammation of, 603 — Cephalhaematoma, 3 Cephalo-hydrocele, traumatic, 22 — Cerebellar abscess after chronic otitis, diagnosis of, 32 — — tumours, 24 — Cerebello-pontine angle, tumours of, 24 — Cerebral injuries, i, 7 — ■ — , pressure symptoms, 12, 13 — , symptoms, 8, 9 • — — localization, 38 — , auditory nerve disturbances, 45, 46 — , disturbances of peripheral — ocular muscles, 39 — , facial nerve lesions, 41, 42, 43 — , methods of marking most im- portant motor centres on surface of skull, 43, 47, 48 — , new growths in brain, 22, 23 — , paralysis of limbs, 44 — , speech disturbances, 46, 47 -— , visual disturbances, 38 — - pressure, 9 — puncture, diagnostic value in brain tumours, 25 — ■ swelling, traumatic, 14 Cerebro-spinal fluid, discharge of, from ear and nose in fractures of base of skull, 4 Cervical cord, injuries of, diagnosis of segment, 497 — fistulae, 136 — • — , arising from a goitre, 139 , cancer, 139 — — , branchial-cleft sinuses, 138 , complete and incomplete, 138, 139 , congenital, 138 — • — , median, 138 — — , mouth, larynx, and pharynx, 139 , origin, course, and external appearance, 136 3 position, 138 , secretion, 137 — ribs, 140, 163, 172 , symptoms of, 172, 173 Cervical spine, injuries of, disturb- ances of motion in, 495 , sensation, 497 , irritative symptoms, 497 — veins, dilatation in mediastinal tumours, 200 — vertebrae, caries of, 184, 514, 515, 516 , contusions, 177 , dislocation fracture (complete dislocation), 176, 177, 178, 183 , unilateral (rotation-dislocation), 180, 182, 183 , fracture of axis, 179 , injuries, 176 , normal position of atlas and axis, 179 , osteo-myelitis of, 180 , sprains, 177 , tubercle of, 134, 136, 515, 516 — — , tumours of, 181 Cervico-dorsal scoliosis, with eleva- tion of shoulder, 525 Chancre, hard and soft, 476 — , on the fingers, 60& — , primary, on face, 72 , fingers, 606 , gums, 100 , lip, 64, 98 , tongue, 107 tonsillar region, 102 Cheeks, bites of, 99 — , gangrene of, 91 — , lupus of, 71, 72 — , molluscum contagiosum of, 71 — , rodent ulcer of, 68, 69, 70 — , tumours of, 71 , mucous membrane of, 92, 99 Cheyne-Stokes's respiration, in brain- pressure, 12, 13 Chimney sweep's cancer of scrotum, 41S Cholangitis, acute, 324 Cholecystitis, acute, 316 , differential diagnosis, 299, 316, 317 — , gangrenous, 318 Cholesteatoma of temporal bone, diagnosis, 26, 31 Chondritis of ribs, 213 Chondroma of arm, 576 — • cervical rib, 173 — hand, 600 748 INDEX Chondroma of lower jaw, 87 — • mamma, 234 — parotid gland, 169 — spine, 517 — thigh, 659 — thorax, 207, 218 — tibia, 700 — toes, 738 Chopart's joint, dislocation of, 721 , inflammation of, 724 Cicatricial stenosis of bowel, 352 — -^ pharynx, 123 — • — ■ stomach, 299 Circumflex nerve, paralysis of, raising of arm in, 594 , through dislocation of shoulder, 549 Cirrhosis of liver, hypertrophic, 314 — ■ stomach, 311 Clavicle, carcinoma of, 212 — , dislocation of, 534, 535, 537 — , fracture of, 534, 535, 536 — , osteo-myelitis of, 210 — , sarcoma of, 212 Club foot, 734, 735 , bilateral, with flaccid paralysis, 735 ■ — / spastic, 735 — hand, 595, 597 Cochlear nerve, focal symptoms in injury of, 45 Colic, intestinal, 347 , in obstruction, 360 Colitis, 339 — -, chronic ulcerative, 341 — , muco-membranous (symptoms and diagnosis), 342, 343 Colloid goitre, diffuse, 142, 148 , unilateral, 145 Colon, see Large intestine Comminution fracture of head of humerus, 542 lower end of ulna, 581 'OS calcis, 719 patella, 672 Common bile-duct, closure of, 321, 324 — ' by stones, 321, 322 tumour, 321, 322 metastases in, 322 Compression fractures, cause of curva- ture, 523 , diagnosis from lumbago, 488 Compression fractures of os calcis, 717, 719 scaphoid, 721 spinal column, 502, 503, 505 — ■ brain, 9 Concretions in stomach, 293 — umbilicus, 378 — urine, 436 Concussion of brain, 7, 8, 9 Condyles of femur, fractures of, 673, 676 — humerus, fractures of, 559, 560, 561, 562, 563, 556-565 Condylomata, tip of penis, 477 Conglomerate goitre, 145 Conjunctiva, chancre of, 72 Constipation, causes of, 343, 345 —, ascending type, 343 — , painful, 343, 409 Contracture, Dupuytren's, 597, 598 , of foot, TZ^) -— in ulnar paralysis, 598 — , posture of spinal column, 531 Contrecoup contusion of brain, 15 — fractures of skull, 6, 15 Contusion, axial, of spinal column, 506 — -, fracture of sernilunar bone, 585, 586 — , intramuscular osteoma after, 574 — of ankle, 706 — brain, 7, 10, 11 — — , diagnosis, 11 -— cervical vertebrae, 177, 178 — gastro-intestinal canal, 245 — • • — , symptoms, 246 — hip-joint, 621 — knee-joint, 668 — ■ scrotum, 414 — shoulder-joint, 535, 546 — thorax, 189, 190 -- urethra, Avithout external wound, 472 Coronoid process of ulna, fracture of, 556, 561, 566, 567 Coxa vara, 631, 639-643 , diagnosis between spontaneous and traumatic forms, 627 , diagnosis from hip disease, 642 , from congenital dislocation of hip, 631, 642 — — , due to rickets, 636, 638, 640, 641 INDEX 749 Coxa vara, due to injury, 621, 627 , false, 640 — ■ — , important diagnostic signs, 642 of adolescence, 640, 642, 643 , unilateral, limping in, 641 Cranial nerves, injury of, 4, 5 — — • — , focal symptoms, 38-47 Craniometry, after Kocher and Kron- lein, 47, 48, 49 , diagrams of, 47, 48 Cretinism, fractures in, 670, 673 Crutch-palsy, 594 Cubitus valgus, 561 Curvature of spine, 522-533 Cyroscopy, 441 Cystadenoma phyllodes of the breast^ 232 Cystic goitre, 146, 148 Cystitis, 433, 465 — , causes of, 464 — , composition of urine in, 434, 465 — , primary, diagnosis of, 464 — , tubercular, 465 Cystoma of jav\-, multilocular, 87 — ■ testicle, 422 Cysto-sarcoma phyllodes of the breast, 232 Cystoscopy, 427, 440, 441, 456, 459, 462, 464 Cysts between testicle and epididymis, 420 --, blood, 162 — in true pelvis, 407 — , lymph, 161 — of abdominal cavity, diagnosis from sacculated tubercular effu- sions, 285, 290 — bones of leg, 699, 700 — brain, traumatic, 17, 20 — branchial clefts, 155 — breast, 223, 224, 225 — - hand, traumatic, 599 — jaw, 84, 87 — kidneys, congenital, 458 — liver, 326 , parasitic, 327 — mouth cavity, 92, 93 — • neck, congenital, 155, 164 — pancreas, 329 — prostate and retro-prostatic tissue, 481 — spleen, 331 Cysts of thyreo-glossal duct, 155 — thyroid, 148 — umbilicus, 373 — urachus, 372, — ■ vitelline duct, 2>73 D Dacrocystitis, phlegmonous, 61 Dactylitis, syphilitic, 608, 609 Defense musculaire in abdominal injuries, 246, 258 Degeneration, fibro - epithelial, of mamma, 223 Dental cysts, 83, 84, 87 — periostitis, 60 — sinus, inflammation of jaw in, 78 Derangement, internal, of knee-joint, 670 Dercum's disease, 175 Dermatitis of hand, 602 , through drugs, 602 Dermoid fistulse around coccyx, 423, 486 — • of back of neck, 174 — face, 63 - floor of mouth, 89, 93 — - lung, 207 — mediastinum, 207 — - neck, 165 -- pelvic cellular tissue, 481 — penis, 475 — - sacral region, 486 — scrotum, 415 — skull, 51, 53 — testicle, 422 — umbilicus, 378 — , sublingual, 93 — , suppurating, 89, 131 — , supra-orbital, 63 Detached fracture of coronoid process of ulna, 561, 566 — • — head of fibula, 674, 676 internal condyle of femur, 670 epicondyle of humerus, 563 OS calcis, 718, 719 rim of acetabulum, 617 spine of tibia, 671, 674 styloid process of ulna, 518, 577, 580 trochanter of femur, 622 tuberosity of humerus, 542, 544 750 INDEX Dextroposition of stomach, 236 Diaphragmatic hernia, after injuries to lung, igi , diagnosis of, 367 Diaphyseal tuberculosis of humerus, 576 — ■ — tibia, 703 — • tumours of femur, 664 Diphtheria, bacteriology of, 112 — • of larj-nx, 112, 113 — throat, 112 — , paralj'sis of palate in, 122 — , secondary symptoms, 113, 114 Diplegia, from spinal cord haemor- rhage, 495 Diploe, sarcoma of, 57 Dislocation, acromio-clavicular, 539, 5 40 — , axillary, 542 — , central, of femur, 620, 630 — , compression-fracture of spine, 505, S07 — — -of cervical vertebrae, 176, 505 — , congenital, of hip, 631, 634, 635 — fracture, complete, 503 in ankle, 715 of cervical vertebrae, 177 — • — spinal column, 503 , typical, inter-carpal, 585, 587 — , iliac, 615, 616 — , ileo-pectineal of pubic, 617, 618 — , infra-cotj'loid, 620 — , obturator, 6ig, 620 — of ankle, 712, 714, 716 — astralagus, 715, 716 — carpo-metacarpo-phalangeal ioint, 58s — Chopart's and Lisfranc"s joint, 721 — clavicle, 534, 536 — elbow, 555 , backwards, 554, 561-568 , forwards, 568 — ■ — , lateral, 562 , outwards, 561 -~ femur, 615 — , central, 620 — hip, 610, 615, 616, 617, 618, 6ig, 620 , backwards, 615, 616 — — , complicated, 616, 617 . congenital, 631, 634, 635, 637 , forwards, 617 Dislocation of hip, inflammatory, 645 — humerus, 538, 539, 540 — - inter-carpal phalangeal joints, 584 — knee-joint, 676 — lower jaw, 74 — lumbar vertebrae, 500 — neck, unilateral, 182, 183 , complete, 176, 178, 182 — patella, 676 — peroneal tendons, 712 — shoulder-joint, 538, 539 — tibia, 676 — ulna, 561 — vertebral column, 502, 503 , complete, 506 — wrist, 578, 579, 583, 584, 585 — , perineal, 619 — , radius, 563, 566 — , sciatic, 615, 616, 617 — , semilunar bone, 579, 583 ■ — , sub-astragaloid, 716 — , sub-coracoid, 539, 542 — , supra-cotyloid, 620 — • — , congenital, 637 Diverticula in lower portion of large intestine, inflammation, 276 — , Meckel's, invagination of intes- tine, caused by, 364 — of bladder, stones- therein, 467 — oesophagus, 128, 135, 140, 162 — , perforation of, 267 Dorsal scoliosis, 527, 528, 529, 530, 531 — spinal cord, local diagnosis, 500, 501 — vertebrae, compression fracture, 503 , i^rimary scoliosis of, 532 , segmental diagnosis of, 500 — - — , suppuration, 516 — , with burrowing abscess, 517 Duodenal ulcer, diagnosis from chole- cystitis, 316 ■ gastric ulcer, 297 ■ intestinal obstruction, 358 — — , perforated, 299 — ■ — , peritonitis in, 265 Dupuytren's contraction, 597, 598 Dura mater, haematoma of (local pressure symptoms), 12, 13, 14 , pedunculated fibroma of, 175 INDEX 751 Dysentery, diagnosis from intestinal obstruction, 347 , ulcerative colitis in its later stages, 341 Dyspnoea in cerebral pressure, 13 — diphtheria, 113, 114 — • mediastinal tumour, igg — perforated gastric ulcer, 2q8 Dysuria, 429 Ear, cancroid of, 72 — , concha of, prominence of, in mas- toid otitis, 27, 28 — , haemorrhage from, diagnostic significance in fractured base, 3 — , lupus of, 72 Echinococcus of kidnej-, 465 — liver, 326 , multilocular, 326 — lur-g, 207 — mediastinum, 207 — spleen, 331 — vertebral column, 509, 510 Elbow glands, inflammation of, 568 — • joint, dislocation, 554, 555 , backwards, 554, 555, 556, 557 ■ — , complete and incomplete, S6i , forwards, 556, 557, 567 — , lateral, 555, 562 — , outwards, 555 — - — fractures, at lower end of humerus, 555, 556, 557, 558, 559, 560, 561, 562-565 — • — • — , coronoid process, 566 head of radius, 565, 566, 567 olecranon, 556, 557 ulna, ^56, 561 , inflammation, 569, 571 — — , injuries of, 553 , examination for, 554 ■ by inspection, 554 — palpation, 560 testing movements, 555 • — X-ray examination, 567 — — , normal, 557 — — , position of three lines of frac- ture of, 563 , sprain of, 566, 567 Elbow joint, syphilis of, 571 , tuberculosis of, 569, 571, 572 Elephantiasis of penis, 475 — scrotum, 415 Embolism of mesenteric artery, 264 — lung, 107 Embryoma of testicle, 422 , diagnosis from embryoid tumour, 422 Eminentia capitata humeri, abrasion fracture, 565 Emissary inastoid vein, thrombo- phlebitis of, 2>3 Emphysema in injuries of thorax, 190 Empyema necessitatis, 209 — • of antrum of jaw, 83 — gall-bladder, 323 — lung, 195, 196 — - — , scoliosis after, 522 Encephalocele, 52 Encephalomeningocele, 52 Enchondroina, see Chondroma Endothelioma, relation to cutaneous cancer, 70 Enteroptosis, 235, 236, 242, 243 — , confirmation by palpation, 240 — • — by skiagram, 241 Epicondyle of humerus, internal, fracture of, 558, 559 Epicondylitis of humerus, 572 Epididymitis, gonorrhoeal, 415, 416, 417, 419 — , syphilitic, 419 — , traumatic, 416 , sinuses in, 420 — , tubercular, 420 Epigastrium, acute inflammation, 265 — , chronic abscess of, 368, 369 — , hernia of, 369, 371 — , subcutaneous lipoma of, 369 Epilepsy, diagnosis from hysteria, 34, 35 — , diagnostic significance of course of attacks, 36 , the history, 35, 36 , physical condition in inter- vals, 36, 2,7 — , epileptiform attacks in brain tumours, 18 — , Jacksonian, attacks of, in cerebral pressure, 17 cerebral tumours, 18, 2>7 , typical form of, 36 752 INDEX Epilepsy, surgical significance of the various forms, 34 Epinephritis, 442 Epiphyseal swellings of femur, 661 Epiphysis of tibia, tuberculosis of, 704 —5 separation of, at head of femur, 627, 64s in the new-born, and in infants with hereditary syphilis, 545 radius, 579, 580 Epispadias, 47s Epithelial cysts of neck, congenital, 164 , traumatic, of hand, 599 Epithelioma of face, calcified, 64 Epulis, Q4 Erb's paralysis, posture of hand and fingers in, 594 Erysipelas of face, 59 — scalp, 51 Erysipeloid of finger, 603 Esmarch's paralysis in the upper ex- tremity, 594 Eye muscles, nerves of, injuries to, 5 , peripheral derangements of, focal diagnosis, 39-41 , in Graves's disease, 143 Eyelids, cancer of, at puncta, 69 — , ulcers on, 70 — , xanthelasma of, 64 Eyes, conjugate deviation of, in cere- bral pressure, 13, 14 , diagnosis from peri- pheral derangements of ocular muscles, 39 Exophthalmos, diagnostic significance of unilateral and bilateral, 49, 50 — • in Graves's disease, 49, 143 — ■ pulsating exophthalmos, 50 — , surgical, 49 — — , mode of origin, 50 Exostosis of femur, cartilaginous, 659, 660, 661 — , subungual, of foot, 730 — ■ tibia, 700 Expansile pulsation in aneurism, 163 Extension apparatus of knee-joint, laceration of, 671 — fracture of lower end of humerus, 5S8, 561 Extra-uterine pregnancy, peritoneal symptoms, 273 Extremities, measurement of the lower, after injuries, 612, 613, 626 Extremities, mobility of, after cerebral injuries, 44 vertebral injuries, 489, 490 — , rigidity of the lower, causing limp, 611 — , sciatica and other painful diseases of the lower, 689-693 — , surgical diseases of, 536 Face, angioma of, 64, 66 cirsoid aneurism, 64 cutaneous warts of, 64 dermoid of, 63 — , supra-orbital, 63 epithelioma of, 64 erysipelas of, 59 inflammatory processes of, 59 lipoma of, 64 lupus of, 66, 68, 71 primary chancre of, 72 sebaceous cyst of, 63, 64 syphilide of, 71 tumours of, 62 — , closed, 63, 64 ulcerative processes of, 62, 64 xanthelasma of, 64 Facial nerve injuries, focal diagnosis of, 41-43 , diagram of, 41 — paralysis in fracture of skull, 5, 41, 42 , tetanus, 75, "]"] False croup, symptoms of, 112 — ■ tail in sacral region, 486 Fat necrosis in pancreatitis, 264 Fatty neck, Madelung's, 174 — tissue, retrobulbar, venous throm- bosis of, 61 Femoral hernia, 392, 393-394 , abnormalities in, 395 , diagnosis of, 394, 395 , from burrowing abscess, 392 distension of saphenous vein, 392 , glandular enlargement, 392 pedunculated subserous lipoma, 393 — ■ — , external, 395 in women, 393 , with divided sac, 30S , pro-peritoneal, 396 , strangulated, 396, 403 INDEX 753 Femur, Barlow's disease, 657 — , chondroma of, 659 — ■ dislocation, 615 — — , anterior, 617, 618, 6iq , central, 620, 630 — — , complicated, 617 , congenital, 631 , posterior, 616, 617 — , exostosis, 659, 660, 661 — , fracture of cartilage of, 668, 669 , diaphysis, 628 — • -at upper end, 622-630 at lower end, 672, 673, 675, 676 , spontaneous, 665, 666 — , osteomyelitis of, 643, 656, 657, 659, 662, 663, 664, 665 — , sarcoma of, 657, 658, 661 — , tuberculosis of, 658, 661, 663 Fibro-adenoma of mamma, 224, 226, 232, 233 , phyllodes, 223, 233 Fibro-lipoma of muscles of back, 216 Fibroma of abdominal wall, 374, 375 -- arm, 572 — back of neck, 175 -' - bladder, 467 --- hand, 600 — knee-joint, 687 — ■ larynx, 121 -- leg, 87 — - lower jaw, 697 — - mouth cavity, 92, 94 -— nail-bed of toes, 739 - naso-pharynx, 84, 85, 96, 121 — neck, 166, 169, 170 -- pelvis, 480 — sacral region, 486 -- scalp, 55 — ■ scrotum, 415 ^^ thigh, 657, 658 -— thorax, 216, 217, 218 — tongue, 105 — - umbilicus, 374 Fibro-myoma of ligaraentum teres, 37- — • of the uterus, 289 Fibro-sarcoma of neck, 170 — skin of back, 214 — small intestine, 348 — tibia, 699 Fibula, aneurism of, 699 — , bending of, 708, 709 Fibula, congenital defect of, 732, 734 — , fracture of, 707, 708, 709, 710 head of, detachment, 674 Finger, anomalies of posture in nerve lesions, 593, 594, 595 — , bent little, 597 — , derangement of movement in tendon-sheath inflammation, 588 — , dermatitis of, 602 — , destruction of, by leprosy,' Ray- naud's disease and syringomyelia, 607 — , Dupuytren's contraction, 597, 598 — , erysipeloid, 603 — , inflammation of, 601 — — , chronic, 605 — — , subcutaneous cellular tissue of, 603 — , injuries of, 586, 587 — joint, inflammation of, 604 , gonorrhoeal, 603 , purulent inflammation of bone, 605 — , syphilis of, 603, 608, 610 — , teno-synovitis of, 588, 590, 603 ■ — , crepitating, 604 , gonorrhoeal, 603 — , trigger, 598 — , tuberculosis of, 599, 606 — , tumours of, 599 — — , innocent, 599 , malignant, 600, 601 Fissures of fibula, 714 — pelvic bones, 630 — • rectum, 409 — skull, 6, 7 , course of, 6, 7 — upper jaw, 73, 74 Fistula in ano, 424, 425 , acquired, inflammatory, 424 ; congenital, 424 — in connection with goitre, 139 Flat-foot, 729, 730, 731 — , contracture in, 7:^3 — , paralytic, 734 Flexion fracture of lower end of humerus, 562 Flexor tendons of fingers, teno-syno- vitis of, 590 Focal diagnosis in cerebral diseases, 38 Foot angioma of, 738, 739 754 INDEX Foot, bursa of, inflammation, 726 — , carcinoma of, 739 — , chondroma of, 738 — , deformities of, 729 — , dislocation of, 712, 713, 714, 715 — • — , at Chopart's and Lisfranc's joint, 721 , Volkmann's, 734 — , fibroma of, 739 — , gout of great toe, 728 — , gumma of, 725 — , habit contracture of, 732, y2>3i 73^ — , inflammation of, 724 metatarsus and toes, 728 tarsus, 724 — , injuries of, 721-724 — , lipoma of, 739 — , normal, 731 — , perforating ulcer of, 739 — , peri-articular abscess of, 724 — , sarcoma of, 726, 739, 740 — , syphilis of, 725, 740 — , tuberculosis of, 725, 726, 740 — , tumour of, 722 — , ulcers of, 738, 739 Foreign bodies in bladder, 438 knee-joint, 669, 678 — ■ — • larynx, 114, 116, 117, 118 ■ — , dyspnoea in, 118 oesophagus, 123, 126 — - — • pharynx, 123, 124 — ■ — • rectum, 411, 412 — ■ — ■ stomach, 293 trachea and lungs, 116, 117, 196 urethra, 430 Fork-like posture of hand in fracture of radius, 577 Foveola coccygea, 423 Fracture at ankle-joint, 706, 710 — ■ knee-joint, 672-676 — , Bennet's, 586 - -, bi-malleolar, 710, 713, 715 — , diacondylar at knee-joint, 675 — , greenstick, 534, 577 — of anatomical neck of humerus, 541, 544 — astragalus, 711 — axis, 179 — capitulum radii, 565, 567 — clavicle, 534, 535 — condyles of femur, 673, 676 Fracture at coronoid process of ulna^ 556, 561, 566, 567 — • epi-condyles of humerus, 556, 559, 562, 563, 568 — femur, at lower end, 672, 673, 675, 676 — ■ femur, at upper end, 610, 614, 618, 621, 623, 624, 627, 628, 631 , shaft of, 628 , spontaneous, 665, 666 — fibula, 674, 708, 709, 711 — humerus at lower end, 562-568 at upper end, 540, 541, 543, 54S, 546 below tuberosities, 541, 543, 544 , condyles of, 556, 559, 560, 561, 562, 563, 564 , diacondylar, 556, 560, 561, 567, 569 through tuberosities, 540, 541, 542, 543, 544, 545 — laryngeal cartilage, 116 — leg, 672, 673, 676, 707 — lower jaw, 72> — malleoli, 706, 707, 708, 709, 710, 713, 715 — metacarpal bones, 586 — metatarsal bones, 722, 723 — neck of femur, 625 , inter-trochanteric, 623, 624,. 625, 628, 631 , per-trochanteric, 623, 625,. 629, 631 , subcapital, 622, 623, 625,. 628 , subtrochanteric, 623, 624^ 625, 629, 630 — - neck of scapula, 545, 546 — olecranon, 556, 557 — OS calcis, 716, 717, 718, 719 — patella, 672, 674 — • pelvic fossa, 628, 62Q — pelvic ring, 628, 629 — ■ pelvis, 474, 629 — radius, 565, 566, 577, 578, 579^ 580, 581, 582 — ■ ribs, 187 — rotula, 556, 559 — scaphoid of wrist, 584, 587 of foot, 721 — scapula, 545, 546 — semilunar bone, 585, 586 INDEX 755 Fracture of sesamoid bone of foot, 723, 724 — - skull, I — ■ — , course of, 6 , secondary injuries, 5 — sternum, 188 — sustentaculum tali, 719 — tibia, 673, 676 , at lower end, 706, 707, 708, 709, 710, 711, 714 , infracondylar, 673, 676 — tuberosity of fifth metatarsal, 723, 724 — upper jaw, jz, 74 — vertebral column, 176, 177, 488, 502, 503, 504, 50s — , Shepherd's, 711 — , supracondylar, at lower end of humerus, 556, 557, 558, 559, 561, 568 , knee-joint, 672, 673, 676 — , supramalleolar, 713 Furuncle in axilla, 211 — ■ of back of neck, 133 — lips, 59, 89 Gall-BLAUDER, abnormalities of posi- tion, 316, 317 — ■ — , empyema of, 323 ■ — ■ — . — , source of infection for cere- bral abscess, 20 — - — • fistulae, 378 — — , gangrene of, 318 , hydrops of, 323 • — , diagnosis from floating kidney, 323 — • — , rupture of, 248 Gall-stone colic, 314 • — , anatomical basis of, 315 , diagnosis from epigastric hernia, 315 — from peritonitis, 262 — ■ -■ renal colic, 315 — - stones causing intestinal obstruc- tion, 321, 362 , diagnosis of, 314, 318, 319 , in small intestine, 275 Ganglion of wrist, 600 Gangrene of foot, diagnosis from sciatica, 691 — lung, 195, 196 — , senile, 691 49 Gangrene of toes, 728 Gastro-intestinal canal, contusion of. 245 • , diagnosis, 246 , gunshot wounds of, 252, 253 • — , rupture and its symptoms, 245, 246 Gastroptosis, 238, 241, 242 Genitalia, diseases of, in women, examination for, 439 — of hermaphrodite with vagina and testicles in hernial sac, 383 Glanders, ulcers of nose in, 103 Glandular abscesses in neck, 132, 134, 135 , chronic, 135 — ■ swelling in cancer of breast, 229 — • — ■ inguinal region, 657 • , diagnosis from hernia, 392 in leukaemia and pseudo- leukaemia, 157 supra-clavicular fossa in cancer of stomach, 309 syphilis, 156 tonsillar ulceration, loi, 102 tuberculosis, 156, 157 ■ of neck, 155, 156 — • — • — , malignant, 159 Glossitis, symptoms of, 90 Glottis, oedema of, 114 Goitre, aberrant, 96 — , abnormalities in position of, 149 — , circumscribed nodular, 146, 148 — , complication of, 150 — , cystic, 146, 147, 148 — , deep, 149 — • — , diagnosis from mediastinal tumour, 201 — , diagnosis from aneurism, 163 - — , diffuse colloid, 142 — , external appearances of, 142 — , haemorrhage in, 148, 150 — , heart, thyreotoxic, 144 — , inflamed, 151, 152 ■, oesophageal stenosis in, 127 — in Graves's disease, 143, 144 — , intra-thoracic, 149, 200, 202, 205 — , malignant, 153, 154 , diagnostic signs of, 153 — , pendulous, 145, 148 — , plongeant, 147, 148 — , proliferating (Langhans'), 154 756 INDEX Goitre, retro-sternal, 149 -— , retro-tracheal, 149, 150 --, retro-visceral, 149 --, secondary growths, 57, 155 — , skiagram of, 148, 149 — , vascular, 142 Gonorrhoea, diagnosis from sciatica, 689 --, examination of urine in, 433 — of ankle, 725 — • epididymis, 416 — finger-joints, 605, 606 — hip- joint, 644 — knee-joint, 678 — pelvis of kidney, 451 — penis, 477 — prostate, 471 — rectum, 408, 411 — shoulder-joint, 551 — tendon sheaths of hand, 603 — urinary passages, 433, 434 — wrist, 589 Gout, 728 — of foot, 728 — hand, 605 ■Granulation of dorsal spinal cord, 508 — , tubercular, of hand, 599 'Granulomata, inflammatory of brain, diagnosis, 22 — , local, 23, 24 ■Graves's disease, blood condition in, 145, 146 , changes of thymus in, 146 — — , commencing, 143 , diagnostic signs of, 49, 143-146 , forme fruste, 144 , pronounced, 144 Groin, bilocular or communicating hydrocele in, 374, 387 - — , burrowing abscess, 374, 375 — , glandular enlargement in, 382 — , lymphadenoma, 375 — , sarcoma of, 375 — , sinuses in, 378 — , strangulation of testicles in, 399 — , testicles in, 374, 383 — , tubercular, 375 — , tumours of, ^-/z, 375 •Gumma of arm, 571, 574, 575 — brain, 18, 22 -— foot, 725 — knee-joint, 691 - — larynx, 120 Gumma of leg, 701 — liver, 326 — mamma, 222 — mouth cavity, 100, loi. 102 — neck, 136, 140 — palate, 95, 103, 105 — penis, 477 — pharyngeal wall, 103 causing paralysis, 123 — ■ ribs, 213 — shoulder, 553 — skull, 56, 58 — - spinal cord, 510 — • sternum, 213 — testicle, 419 — thigh, 658 — thoracic wall, 211 — tongue, 106, 107 — tonsillar region, loi — - vertebrae, 521 Gums, acute circumscribed, and wide- spread swelling of, 89 — , growths of, 94 — , haemorrhage from, 100 — , lead line on, 100, 262 — , pus from, 100 — , tubercular, 79 — , ulcers of, 100, 108 H Habit contracture of foot, '/■Z2>, 73^ Haematocele of testis, 416, 420 — , retro-uterine, 274 Haematoma, extradural, 12, 16 — , intradural, 12, 16 — in vicinity of Broca's convolution, 14 — of ear, 64, 65 — • spinal cord, 494 — , peri-tubal, 271, 274 — , peri-urethral, 474 Haematomyelia, symptoms of paralysis in, 494 Haematuria in renal calculi, 454 — — • tumours, 456 — urinary tuberculosis, 460 Haemophilia, effusion in knee-joint in, 682, 686 — , haemorrhages of gums in, 100 — , renal haemorrhages in, 436 Haemorrhoids, 409, 410 Hair tumour in stomach, 293 INDEX 757 Hairy margin of head and face, tumours of, 71 Hallux valgus, 728, 736, -/Zl Hammer-toe, 736, 737 Hand, abnormal postures of, 592 in fracture of radius, 577, 578 nerve paralj'sis, 592-595 , position of damage, 593 — , angioma, 600 — , botriomycosis of, 600 — , carcinoma of, 601 — , chondroma of, 600 — , deformity of Madelung"s, 596, 597 — , dermatitis of, 601 — , epithelial cysts of, traumatic, 599 — , fibroma of, 600 — J ganglion of, 599 — , gout of, 605 — , inflammation of, acute, 601, 605 bursae under callosities, 605 bone, 608 , chronic, 605 skin, 605 tendon sheaths, 607 — , injuries of, 576, 605 — , leprosy of, 606 — , lipoma of, 599, 608 — , lupus of, 606 — , cedema of dorsum of, 586, 588, 605 — , osteomyelitis of, 605 — , -post-morte^n tubercle of, 606 — , sarcoma of, 600 — , sebaceous cyst of, 599 — , syphilis of, 608 — , tendon sheath, inflammation of, 588, 602 — • — , gonorrhoeal, 608 ■ — J tubercular, 589, 607 — , tubercle of, 599 ■ bone, 608 — , tumours of, 599 — ■ — , innocent, 599 — ■ — , malignant, 600 Head, abnormal posture of, 175 , asymmetrical, 181 , symmetrical, 176, 184 — , rigidity of, painful, 175 of gradual onset, 181 — • — -of sudden onset, 176 — , surgical diseases of, i — tetanus, 75 Head, tetanus, with facial paralysis, 111 76, TJ — • tumours acquired, 55 , innocent, 55 ■ — , malignant, 56-58 , congenital, 51 Heart, compression of, by effused blood, 193 — , injuries of, 191 5 avoidance of probing in, 191 , cardiac dulness in, 192 , diagnosis, 194 , pure, 192 — — , subjective sensations in, 192 — ■ — , with injury to pleura, 193 • — 3 position and nature of, 191 , reflex symptoms in, 192 Hemianopia, diagnostic significance of, in cortical tumours, 23 Hemianopsia, diagnostic significance in brain jjressure, 14 — , focal diagnosis of, 38, 39, 40 Hernia, abdominal, 376 — , crural, 392, 393, 394, 395 — , duodeno-jejunal, 366 — , epigastric, 370, 371 , diagnosis from biliary colic, 314 — , Hesselbach's, 396 — in csecal region, 366 — , incarcerated, 365, 398, 400 — , inguinal, 374 , external, 379, 386 , internal (direct), 390 — in linea semicircularis Spigelii, 376 — , intermuscular, 380, 381, 385, 386 — , internal, in csecal region, 366 — ■ in Winslow's foramen, 366 — , irreducible, 398 — , labial, 382, 387, 388 — , Littre's, 401 — , lumbar, 375 — , multilocular, 372 — , obturator, 365 — of diaphragm, igi, 367 — umbilical cord, ziZ — , pro-peritoneal, 381, 384, 396 — , scrotal, 387, 388 — , strangulated, irreducibility of, 398 758 INDEX Hernia, strangulated, condition found at operation, 403, 404 — , strangulated, 398-406 — — , after reduction, 353, 366, 405, 406 — . — . — . — , diagnosis from a stran- gulated inguinal testicle, 400 — . ■ — hydrocele, 3q8 — ■ peritonitis, 263 diagnosis of, 310, 3Q8, 399 — . — , fistulse subsequent to, 370 _ — , its position in femoral lierniEe, 396, 403 — -^ — ■ — in inguinal hernise, 403 in umbilical herniae, 403 , intestinal obstruction with, 366, 402 — - — , reduction en masse, 402, 406 , stages of, 404 — , subcutaneous, 381, 384, 386 — , tendency to, 379, 381 — , traumatic, 396, 397 — , umbilical, 371, 372 Hernial sac, appendicitis in, 401 — • — , contents of, 402 in male hermaphrodite, 383 — — , peritonitis of, 401 , sub-divided, 384 — — , tuberculosis of, 401 with peri-hernial fat, 389 Hip, adducted (coxa adducta), 639, 640 , important diagnostic symptoms, 641 — ■ disease, 643 — - — , acute infective, 643, 644, 646 — • , consequences of, 645 , chronic, non-tubercular, 654, 655 , diagnosis of, differential, 650, 6si — — • — ■ by gait, 646 painfulness, 650 • — palpation of joint, 650 posture of leg, 649 skiagram, 653 — ■ testing movements of joint, 647, 648 , secondary changes in, 653 , tubercular, 646, 647, 648, 649, 650, 653 , variety and degree of, 652 — joint, acute inflammation of, 643 Hip-joint, acute inflammation of, re- sults, 645 , arthritis deformans of, 639, 64'^, 6SS — — , chronic inflammation of, 646 — ■ — , contusion of, 621 — ■ — ■ — , diagnosis, 614 , deformities of, congenital, 631- 639 , non-traumatic, 631 — - — , dislocation of, 615-620 , anterior, 617, 618, 619 — , complications, 616, 617 , congenital, 631, 634, 635, 637, 639, 651 , inflammatory, 649 — , irregular, 616 , posterior, 615, 616, 617 , examination of, 611 by inspection, 611 palpation, 614 testing mobility, 614 fracture of, 610, 621-627 gonorrhoea of, 644 injuries, table of, 630, 631 osteomyelitis, 643 rheumatism of, 651 sarcoma in vicinity of, 480 senile disease of, 655 skiagraphy of, 653 sprain of, 621 tuberculosis of, 646 Hirschsprung's disease, 356, y:,-] , diagnosis from abdominal tumour, 287 Hodgkin's disease, see also Pseudo- leuka;mia , signs of, 157, 158 Horns, cutaneous, 71 — — , on heel, 739 Hour-glass stomach, 302, 303, 304 — ■ — ■ — , causes of, 305 Humerus, dislocations of 539, 540 , varieties, 538, S39, 542, 546 — , fractures at lower end of, 555-568 upper end of, 540-546 — , muscular hernia over, 574 — , myositis ossificans over, 574 — , osteomyelitis of, 576 — , sprain of, 546 — , tumours of, 572 — ■ — , bone, 576 , muscles and nerves, 572 INDEX 759 Humerus, tumours of, skin and sub- cutaneous tissue, 572 Hydatids, see Echinococcus Hydro-adenitis of axilla, 211 Hydrocele, bilocular in inguinal canal, 374, 387, 388 — , communicating, 374, 387 — , diagnosis from strangulated hernia, 398 — of spermatic cord, 385, 387, 415 — • women, 374 — testis, 387, 388 — , relation of vaginal process of peritoneum, 387 Hydrocephalus in meningocele, 53 Hydro-myelomeningocele, 483 Hydronephrosis, closed, 454 , diagnosis from ovarian tumour, 28g — , intermittent, 448, 460 — , open, 448 — , remittent, 448 Hydrops of bursa iliaca, 652 • — gall-bladder, 323 , diagnosis from movable kidney, 323 — knee-joint, 679 , intermittent, 678 , traumatic, 681 , tubercular, 680 — prepatellar bursa, 667 -— subdeltoid, diagnosis from effusion into shoulder-joint, 547, 548 Hygroma of neck, congenital, 161 Hyperextension fracture, 558, 561 Hyperkeratosis of hand, 601 Hypernephroma, 458 — , secondary, 204 Hyperthyroidism in Graves's disease, 143, 144 Hypochondrium, inflammatory foci in, 265 Hypospadias, 426, 475 Hypothyroidism, predisposition to fracture of cartilage of femoral condyles in, 670 Hypertrophy of bronchial glands diagnosis from mediastinal tumours, 200, 201 — of prostate, 468, 469, 470 — spleen, 330, 331 — thymus, 200 — • — , diagnosis, 201 — thyroid, 142 Hysteria, abdominal pain in, 259 — , diagnosis, from epilepsy, 34 hip disease, 652 — • — intestinal obstruction, 367 — — paralysis, 548, 549 iLEO-CiECAL region, tumours of, 2>n Heo-sacral tuberculosis, 517 , burrowing abscess, 516, 518 Incised wounds of abdomen, 253 — • — ■ thorax, 189 Incontinence of faeces, 493 — ■ urine, 431 — , paradoxical, 431, 492 Infantile paralysis, club-foot following on, 735 — ■ — , spinal, diagnosis from con- genital dislocation of hip, 637 , unusual localization of, 375 Infarct of bowel, 364 — kidneys, 453 — • testicle, 418 Infiltration, diffuse gummatous of tongue, 107 Inguinal abscesses, 516, 517 — hernise, 37Q-39I , bladder in, 391 — ■ — , diagnosis of external, in absence of swelling, 380 , in the presence of a swell- ing, 382 — • , labial and scrotal herniae, 387, 388 — • — , differential diagnosis from femoral hernia, 385-394 • — burrowing abscess, 386 — ■ varicocele, 388 -of external and internal, 390, 391 , external, 379, 381, 382, 383, 386, 387, 388, 389 — ■ — -in women 381 , intermuscular, 383, 384, 385 , internal, 390, 391 , preperitoneal, 381, 384 , relations of, to abdominal wall, 381 — • — - — , to vaginal process and hydroceles, 387, 388 , scrotal, 387, 388 ■, site of strangulated, 403 , subcutaneous, 381, 385, 386 Intercarpal joints, dislocation of, 584 76o INDEX Intestinal crises, tabetic, diagnosis from obstruction, 358 — distension, abnormal, with visible and palpable contractions of bowel above, 347 , murmurs, at seat of, 347 — murmur in stenosis, 347 — obstruction, 346 -, acute, 357 - — ■ — • — , causes, 361 (axial rotation), 364 (bands and kinks), 361, 362 (gall-stones), 362, 363 — • — (intussusception), 363 — , position of obstruction, 358, 359 -- — ■ ■ (strangulation of an in- ternal hernia), 365, 366 symptoms, 357, 358 ■ — , varieties, 360, 361 — ■ — , arterio-mesenteric, 362 — ■ — , chronic, 347 , appearance of bowel in, 347, 348 , condition of stools in, 34S, 349 — , through external compres- sion, 353 , position of stenosis in, 350 — • , variety and cause of stenosis in, 351 , combined with external hernia, 409 , diagnosis from cholecystitis, 318 ■ — perforative peritonitis, 358 peritonitis, 255, 262 , effect on general condition, 350 , hysterical, 367 in appendicitis, 337 , intermittent, 354, 361 -in tubercular peritonitis, 285 of sudden onset, 361 , spastic, 367 , transition of incomplete to com- plete, 360 — rigidity, 348 — stenosis, cicatricial, 352 , concentric, in cancer and tubercle of bowel, after reduction of a strangulated hernia, 353, 406 , condition found on palpation, 351 Intestinal stenosis, condition of stools in, 348, 340 , general condition in, 350 of gradual development, 347 large intestine, 345, 406 small intestine, 348 , skiagraphy in, 354, 355, 356 — ■ — through tumours in bowel, 353 Intestine, abnormalities of position, 236 , decussation of large and small intestine in, 237 , position of appendix in, 237 — • — • — , principal varieties, 236, 237 — , appearance of, in strangulated herniae, 403, 404 — , axial rotation of, 364, 365 — , carcinoma of, 351, 352 — , fibroma of, 353 — , fistulse of, 378 — , haemorrhage of, 244 — , herniae of intestinal wall, 401 — , infarction of, 364 — injuries, 245, 246, 247, 353 , clinical picture of, 245 — , intussusception of, 275, 364 — , lipoma of, 353 — , myoma of, 353 — , obstruction of, 358 — paralysis in injuries to spinal column, 492 — , sarcoma of, 353 — , syphilitic stricture of, 353 — , tuberculosis of, 286 — ■ — , diagnosis from cancer, 351, 352 — , ulcers of, 351, 358 Intussusception of bowel, 363, 364 — — , diagnosis from tumour, 287 Iodoform dermatitis, 602 Isthmus faucium, inflammation of, yo JACKSONIAN epilepsy, 15, 36, 37 Jaundice, catarrhal, 313 — • — in cholecystitis, 316 , infective, 317 — ■ — through obstruction of common bile duct, 321 Jaw, actinomycosis, 76, 78, 80 — , ankylosing, Ty — , antrum of, empyema of, 83 , inflammation, 59 — , arthritis, 76 INDEX 761 Jaw, cancer of, 82, 83, 85 — , cysts of, 83, 84 — , dislocation of, 74 — , fractures of, TZ-, 74 — , inflammation, acute, 78 , chronic, 78, 79 — , lower, chondroma of, 87 , dislocation of, 74 -, fibroma of, 87 , fractures of, T}> , multilocular cyst, 87 — - — , osteoma of, 87 ,. sarcoma of, 87, 88 , tumours of, diagnostic signs, 85-88 — , multilocular cystoma of, 87 — , osteoma of, 87 — , osteomyelitis, 76, 78, 131 — , periostitis, 59, 60, 75, 78, 83, 84, 131 • — , phosphorus necrosis of, 81 — , sarcoma of, 86, 87 - — , tuberculosis of, 60, 76, 79, 80, 81, 83 — , upper, carcinoma of, 83 , empyema of, 83 , fractures of, T2>, 74 , periostitis of, 59, 83, 84 — ■ — , sarcoma of, 82, 83 , tuberculosis of, 83, 84 , tumours of, 82 , innocent, 85 , malignant, 83 K Kidney, abnormal mobility of, 444 — ■ abscess, 452 — calculi, 453, 454 , composition, 451 in renal tuberculosis, 460 , primary, 453 , secondary, 455 , X-ray diagnosis, 454 — , carcinomata, 456 — , colic of, 436, 453, 460 , diagnosis from biliary colic, 315 peritonitis, 262 — , cysts of, 458 — , displacements of, 238 , acquired, 444 , congenital, 235 Kidney, displacements of, diagnosis from distended gall-bladder, 323 — , examination of functions of, 441 — haemorrhage, 249, 436 — • — • in hsemophilia, 436 tuberculosis of, 460 tumours, 455, 456 — , hydatid of, 457 — infarcts, 453 — , inflammation around, 249, 266, 442 — , injuries of, 248 ■ , extra-peritoneal, 249 , intra-peritoneal, 249 — , pelvis of, inflammation of, 452 — • — , new growths of, 456 , suppuration of, 450 — , sarcoma of, 456, 457 — , spontaneous suppuration of, 450 — , bacteriology of, 451 — — — , diagnosis, 452 — , tuberculosis of, 443, 450, 458 — tumours mixed, 289 ■ of, 455 3 diagnosis, 456, 457 , displaced, 458 Klumpke's paralysis, posture of hand and fingers in, 594 Knee-joint, abscess, peri-articular, 679 — • — , aneurism, 687 — — , bursal inflammation, 667, 687, 688 — • — , chronic rheumatism of, 679, 680, 688 — - — , contracture of, 686 — • — , contusion of, 668 , detachment of internal semi- lunar cartilage, 670 ■ , its incarceration, 670, 678 — - — • — ■ cartilage of femur in, 669 , dislocation of, 674, 676 , effusion, acute, 667, 679 — , chronic, 679 — • — • — , idiopathic, 680 • — ■, traumatic, 681 — • — , fibroma of synovial membrane, 687 , foreign body in, 669, 678 , fractures of, 670, 672, 673, 676 , fungating, 685 — ■ — , gonorrhoea of, 678, 681 762 INDEX Knee-joint, gumma of, 684 in haemophilia, 680, 681, 686 , injuries of, 667, 676 , intermittent hydrops of, 678 , tubercular, 679, 682 ■ — • — , lipoma arborescens of, 686, 687 , normal, 683 , osteomyelitis of, 678, 681 , rigidity of, 684, 686 ■ — ■ — , sarcoma of, 684, 687 , sesamoid bone, 66g , sprain, 668, 669, 670 , results of, 671 , syphilis of, 680, 681 , tuberculosis of, 680, 681, 682, 683, 684, 685 • — , ankylosing, 686 , tumours and allied structures in neighbourhood of, 687, 688 Labyrinth, injuries of, s Large intestine, displacements, chief varieties, 236 in skiagram, 240, 241, 242, 243 — ■ — , disturbances of function, with anatomical changes, 339 • , without typical anatomi- cal changes, 342 , diverticula of (inflammation), 276 , stenosis of, 350, 351, 352, 355 — • — • — , diagnosis from stenosis of small intestine, 358 — • — , syphilis of, 341 , tubercle of, 341 Laryngoscopy in laryngeal diseases, no Larynx, carcinoma of, 119, 139 — 3 circulatory disturbances of, 115 — , diphtheria of, in — - — , diagnosis from lacunar tonsil- litis, III, 112 — ■ • — — pneumonia, 113 , secondary symptoms, 113 --, false croup, 112 — , fibroma of, 121 — , foreign bodies in, 116, 117 — , fracture of cartilage of, 116 - — , inflammation of, in Larynx, injuries of, 116 --, oedema of, 114, 115 , angioneurotic, 115 — , papilloma of, 121 — , stenosis of, 115 — , surgical diseases of, no — — ■ — , acute, 1 1 1 — ■ — • — , chronic, 118 — , syphilis of, 118, 119, 120 -~, tubercle of, 119, 120 — , tumours of, 121 — , ulcers of, 115 — • — , differential diagnosis, 120 — • — , position, 120 Leg, abscess of bone of, 704 — , bony cysts of, 699, 700 — , carcinoma of, 696 — , chondroma of, 700 — , diffuse inflammation, 701 — , dislocations of, 712-716 — , exostosis of, 700 — , fibroma and fibro-neurorha of, 697, 700 — , fractures of, 706-712 — , gumma of, 703 — , localized inflammation, 703 — , osteomyelitis of, 700, 701, 702, 703 — , sarcoma of, 699, 705 — , swellings and tumours of, 697, 698, 703 — , syphilis of, 695, 6g6, 701 — , tuberculosis of, 703, 704 , — , ulcers of, 693 , malignant, 696 , syphilitic, 695, 6g6 , varicose, 693, 694, 695 — , varicose veins of, 691 Length measurements of lower limbs after injuries, 612, 613 Leprosy of hand, 606 — - of nose, 103 Leukaemia, glandular swelling in, 157 — , haemorrhage from gums in, 100 — , pharyngeal swelling in, 95 — , splenic enlargement in, 331 Leukoplakia of tongue, 104 Ligamentum patellae, detachment of, 674 — teres, fibromyoma of, 375 — tibio-fibulare anticum, laceration, of, 712 Limping, 610 — J intermittent, 691 INDEX 7t>3 Limping, painful, 6ii — , paralytic, 6io, 637 — • through rigidity of limbs, 611 — ■ — shortening, 610 — , unilateral, 640, 642 — , voluntary, 646 Lipoma in femoral canal, 394 , diagnosis from hernia, 393 — • of abdominal wall, 369 — axilla, 572, 573 — back, 216, 217 — neck, 134, 173, 174 , periglandular, 174 — ■ breast, 211, 234 — epigastrium, 369, 370 , subserous, 370, 371 — face, 63 — floor of mouth, 92, 93 — foot, 739 — hand, 509, 608 — knee-joint, 686, 687 — lumbar region, 376 — ■ neck, 166 — pharynx, 97 — sacral region, 486 — shoulder, 572 — spermatic cord, 389, 391, 416 — thigh, 657 — tongue, 105 — upper arm, 573 - — ■, perihernial, 393 Lips, cancer of, 64, 67, 68, 99 — , furuncle of, 59, 89 — , gangrene of, 91 — , primary chancre of, 64 — , tumours of mucous membrane of, 92, 93, 99 Lisfranc's joint, dislocation of, 721 , inflammation of, 724 Little's disease, spastic club-foot after, 735 Littre's hernia, intestinal obstruction in, 401 Liver, abscess of, 265, 326, 327 — , acute yellow atrophy, 313 — , adenoma of, 326 — , carcinoma of, 326 — , cirrhosis of, 314 — , constricted lobe of, 325 — , cysts of, 326 , parasitic, 326 — , diagnosis from tubercular peri- tonitis with effusion, 283 Liver, displacements of, 236, 238 — , floating, 238, 325 — , gumma of, 326 — , hydatid cyst of, 326 , multilocular, 326 — , injuries of, 247, 253 — , tumours of, 325 — — , primary, 325 , secondary malignant, 325 Lordosis of spine, 524, 525 Lumbago, 486 — , course of symptoms, 487 — , diagnosis from renal tumour, 456 — , rheumatic and traumatic, 487, 488 Lumbar kyphosis, 525 — • lordosis, 525 in congenital dislocation of hip, 634, 635 — pains in renal disease, 456, 460 — puncture in cerebral pressure, 16 — — meningitis, 33 — region, abscess, perinephritic, 375 — ■ — , areas of inflammation in, retro- peritoneal, 266 , burrowing abscess of, 375 , false hernia, 375 — ■ — , hernia of, 375 — • — , lipoma of, 376 , pigmented nsevus of, 214 , reflex muscular rigidity in unilateral renal injury, 249 — scoliosis, 523, 527, 528, 532 — - vertebra, caries of, 516, 517 — — , compression fracture of, 501 , determination of injured, 500 , dislocation of, 500 Lumbo-dorsal scoliosis, 529, 532 Lumbo-sacral cord, segmental diagno- sis of lesions, 405 , symptoms of injury of, 498 ■ — , types of paralysis, 499 Lung, abscess of, 195 -in skiagram, 196 — , actinomycosis of, 198, 210 — , bronchiectasis of, 198 — , cancer of, 207 , metastatic, 207 — , chondroma of, 207 — , dermoid of, 207 — , embolism of, 197 — , empyema, 195 — , foreign bodies in, 117, 196 — , gangrene of, 196, 197 764 INDEX I,ung, hydatid of, 207 — , injuries of, i8q , diagnostic signs of, 190 , secondary injuries, iqo — , sarcoma of, 207 — , surgical diseases of, 195 -— , tubercular cavities in, 198, 209 -—, tumours of, 199, 207 , differential diagnosis, 208 Lupus of cheek, 71 — of face, hypertrophic, 67, 72 — hand, 606 — nose, 65, 72 Lymphadenitis, acute submaxillary, 90, 132 — in neck, 155, 182 , malignant, 159 -— of axilla, 550 — , phlegmonous submental, 89, 131 Lymphangioma of ear, 64 floor of mouth neck, 160 sacral region, / scrotum, 415 thigh, 657 thorax, cystic. 89, 93 217 — tongue, 105, 106 Lymphangitis of arm, tubercular, 569 Lymphatic cysts of neck, 161, 162 — gland, enlargement in axilla, 211, 212 — cancer of breast, 229 — inguinal region, 375, 392 neclv, diagnostic significance, 155 , sarcoma in neck, 170 ■ — thigh, 657 ulcers of tonsil, loi, 102 , causes of, 155, 156 Lymphoma, malignant, 158, 159, 160 , diagnosis from lymphosarcoma, 170 — of neck, tubercular, 156 Lymphosarcoma of neck, 170 — lung, 207 M Macroglossia, 104 Madura foot, 725 Malarial spleen, 331 , rupture of, 247 Malleoli, fractures, 706, 707, 710, 711 708, 709, Malleoli, fractures, position and direc- tion of lines of fracture, 710 Mamma, abscess of, 211, 219 , retro-mammary, 221 — , actinomycosis of, 222 — , carcinoma of, 226, 227, 228, 232 — ■ — , important diagnostic signs, 229-232 , scirrhus, 229, 231 — — , secondary, 231 — • — , ulcerating, 230 — , chondroma of, 234 — , cysto-adenoma phyllodes of, 232 — , cysto-sarcoma phyllodes of, 232 — , cysts of, 223, 224, 225 — - — , solitary, 226 — , fibro-adenoma of, 223, 224, 226, 232, 233 — , giant growth of, 232 — , gumma of, 222 — , inflammation of, 219 , acute, 21Q — — , chronic, 221 — , lipoma of, 211, 234 — , sarcoma of, 232 — • — , secondary, 233 — , tuberculosis of, 221, 222 — , tumours of, 223 — ■ — , isolated, 224 — ■ — -of the male breast, 234 , multiple, 224 , types of, 223 Manubrium sterni, osteomyelitis of. 133 , see also Sternum Manus valga, 596, 597 — vara, 595 Mastitis, acute, 221 — , chronic cystic, 223 — neonatorum, 219 — , puerjDeral, 220 Mastoiditis, brain symptoms of, 25,. 29, 30 Mastoid process, inflammation of, 28 Median nerve paralysis, posture of hand in, 593 Mediastinum, dermoid of, 207 — , hydatid of, 207 — , injuries of, 191 — , phlegmon of, 127, 133 — , sarcoma of, 207 — , tumours of, 199, 204 — — , malignant, 207, 208 INDEX /"O Mediastinum, tumours of, malignant, diagnosis from deep and intra- thoracic goitre, 205 • enlargement of bronchial glands, 201 ■ — ■ of thymus, 201, 202 innominate and aortic aneurisms, 201, 202 Medullary cancer of breast, 231 — — penis, 477 — sarcoma of upper end of tibia, 6Qg Meningitis, diagnosis of, 3^ — , purulent, resulting from otitis media, 29, 30, 31 — , serosa circumscripta spinalis, 510 Meningocele, 52, 174, 482, 484, 485 — , spurious, 53 Meningoencephalocele, 174 Menstruation, intra-abdominal, 263 — , painful, diagnosis from peritonitis, 263 Meralgia paraesthetica, 692 Mercurial stomatitis, 76, qi Mesenteric cysts, 285, 287 — ■ vessels, thrombosis of, 353 ■ — , diagnosis from ileus, 358 ■ peritonitis, 264 Mesentery, common, 236 — , detachment of, 353 — , ileo-caecal, 237 Metacarpus, fracture of, 586 — , osteomyelitis and periostitis of, 60s Metatarsus, fracture of, 722, 723, 724 — , inflammatory processes of, 728 — , tumours of, 738 Middle ear, inflammation, purulent, brain complications of, 20, 21, 25, 26, 27 Mikulicz's disease, 167 Mind blindness, 39 Mixed tumours of kidneys, 289, 457 palate, 95 parotid, 168 • submaxiliary region, 167 Molluscum contagiosum of face, dia- gnosis from cutaneous cancer, 70, 71 Motion, power of, after cerebral in- juries, 44, 45 vertebral injuries, 493, 495 Mouth cavity, acute swelling in floor of, 89, 90 Mouth cavity, angina of, 90, gi — • — , angioma of, 93 , cancer of, gg ■ — , perforating, 139 — — , cysts of, 92, 93 — ■ — , dermoid of, 89 ■ — , sublingual, 93 — ■ — , examination of, in dysphagia, 124 — — , fibroma of, 92, 94 , gangrenous stomatitis of, 91 , gumma of, 95, 98, 100 , haemorrhage from, due to frac- tured base of skull, 3 , inflammatory processes in, 88- 91 — - — , lipoma of, g2, g3 , lymphadenitis of, 8g, go — ■ — , lymphangioma of, 8g, 93 — — , noma, 91 — • — , primary chancre of, 100, loi , salivary glands inflammation, 89 , tubercle of, 98, 100 — • — , ulcers of, 98, 99 Mucous colic, diagnosis from peri- tonitis, 262 — ■ cysts of mouth cavity, 92 — polypus of nose, 08 pharynx, 97 rectum, 407 Muscle of thigh, osteoma of, 658 Muscles of neck, gumma in, 140 — thigh, gumma in, 658 — thorax, gumma in, 212 Muscular angioma of arm, 572 thigh, 658 — atrophy, progressive, with lordo- sis, 522, 524, 63s, 639 — • hernia of thigh, 658 upper arm, 574 — paralysis of abdomen, localized, 375 — tuberculosis of abdominal wall, 375 — — arm, 573 — — ■ neck, 140 thigh, 658 — ■ — • thorax, 212 Myelitis, chronic, 509 — , traumatic, 4g7 Myelo-cystocele, 483 Myelo-meningocele, 483, 484, 485 766 INDEX Myoma of bladder, 467 — • intestine, 353 — • uterus, 289, 468 — ■ — , constipation in, 407 Myositis in wry neck, 181, 185 — of sterno-mastoid, 133 — ossificans of arm, 574 N N^vus of abdominal wall, becoming sarcomatous, 376 — , pigmented, 214 — , vascular, 54 Nail-bed, inflammation of, 602 — ■ — , syphilitic, 603 — , tumours of, 139 — •, ulcers of, 740 Naso-pharyngeal fibroma, 84, 97, 123 — — polypi, 96, 97, 123 Neck, abscesses of, 130, 133, 516 • after aural suppuration, 2>2> — — , chronic, 134, 135 due to spinal caries, 514 — • — , tubercular, 134, 140 — , actinomycosis of, 80, 135 — — with sinus formation, 137 — , aneurism of, 140, 162, 163 — , back of, abscesses in, 133, — ■ — , carbuncle of, 136 — — , cerebral hernia in, 52, — ■ — , dermoids in, 134, 174 — - — , fibroma of, 175 , lipoma of, 134, 173, 174 • , rigidity of, with gradual onset, 181 — • — ■ — , with sudden onset, 176 -^ — , sarcoma of, 175 , sebaceous cysts in, 174 — , blood cysts of, 161 — , branchiogenous carcinoma of, 171 — 5 cavernous angioma of, 162 — , congenital hygroma of, 161 — , cysts of, 155, 160, 161, 163, 164, 165 — , dermoid of, 165 — , diffuse carcinomatosis of the lymphatic glands, 160 — , enlarged glands of, 113, 131, 132 - — , fibroma of, 166, 169, 170 — , fibroma-sarcoma of, 170 — , gumma of, 136, 140 — — -in muscle of, 140 134 174 Neck, gumma of, inflammatory pro- cesses of, 127, 131, 135, 166 — , lipoma of, 166 — , lymphangioma of, 161 — , lymphatic cysts of, 161, 162 — • — ■ glands of, swelling, 102, 155, 156, 157, 158 — - — — , malignant, 159 — , lymphosarcoma of, 170 — , neuro-fibroma of, i6q, 170 — , phlegmon of, 127, 130, 133 — , pseudo-tumours of, 139 — , sarcoma of, 169, 170 — — , deep, 163 — • — , vascular, 163 — , sebaceous cyst of, 165 — , surgical diseases of, no — , syphilis of, 136, 156 - — , tubercle in muscle of, 140 — — of, 136, 141, 156 — , tumours of, 139 — ■ — ■ back of, 174 — • — side of, 155, 169 , in anterior triangle, 140, 155 , solid, 166 , with liquid contents, 159 Nephritis, chronic haemorrhagic, 436 Nerves of base of skull, 46 Neuralgia of anterior crural nerve, 692 — - external femoral cutaneous, 692 — ■ inferior dental nerve, 73, 86 — infra-orbital nerve in malignant growths of upper jaw, 82 — ■ obturator nerve, 692 — - sciatic nerve, 68g — , peri-articular of hip, diagnosis from dip disease, 652 Neuro-fibroma of arm, 572 — back, 217 — leg, 697, 700 — neck, 169 — thigh, 659 Neuroma of arm, 572 Nipple, retraction of, 229 Noma of lips and cheeks, 91 Nose, cancer of, 67, 68, 69, 70, 160 — , glanders of, 103 — , haemorrhage from, in fractured base of skull, diagnostic sig- nificance of, 3 — , leprosy of, 103 — , lupus of, 65, 72 INDEX 767 Nose, lupus of, hypertrophic forms, 67 — , mucous polypi of, 97, 98 — , rhino-scleroma of, 103 — , sarcoma of, 97, 98 — , sebaceous cyst at root, 64 — , syphilis of, 65, 66 — , tubercle of, 103 Nystagmus, local diagnostic sig- nificance of, in brain lesions, 40, 41 o Occipital bone, cerebral hernia at, 52 , osteo-myelitis of, 134 — lobe, tumours of, 24 Oculo-motor nerve, injuries of, s Odontomata, 86, 87 CEdema of back of hand, 586, 605 — ■ glottis, 114 — ■ larynx, angioneurotic, 115 CEsophagus, carcinoma, 129, 130 — , compression, 128, 129 — , difficulties in swallowing in neighbourhood of, 124-130 — , diverticula of, 128, 135, 140, 162 — , foreign bodies in, 124, 126 — — ■ — , diagnosis of, 124, 125 ■, removal of, 127 — , injuries of, 191 — , spindle-shaped dilatation of, 128 — , stenosis of, 127 — , stricture of, syphilitic, 130 — — , corrosive, 127, 130 Olecranon, fracture of, 556, 557 — , tubercle of, 572 Oliguria, 432 Omental cysts, 287 — • hernia, 389 , strangulated, 402, 403, 421 — • tumours, 287 — ■ — , torsion of, and its symptoms, 358, 402 Onychia maligna, 740 Optic nerve, injuries of, 5 — • — ■ — , localization, 38, 39 — ■ neuritis, diagnostic significance in cerebral abscess, 18 ■ tumours, 18, 19 Orbit, angioma of, 50 — , injuries of, 4 — , osteoma of, 50 Orchitis, 417 — , metastatic, 417 Os calcis, see Calcaneus Osteo-chondritis dissecans of knee- joint, 669 Osteoma of arm, traumatic, 574 -~ cervical rib, 173 — • lower jaw, 87 — ■ orbit, so — skull, 55 — thigh, 658, 659 — ■ thorax, 218 — ■ vertebra, 511 Osteomyelitis of arm, 576 — • clavicle, 133, 210 — femur, 656, 657 — finger, 604, 605, 609 — ■ hand, 605 — hip-joint, 643, 644 — humerus, 553, 575, 576 — jaw, 78, 131 — - knee-joint, 665, 666, 680 — ■ occipital bone, 134 — ■ ribs, 210 — scapula, 210 — ■ shoulder-joint, 553 — • skull, 51 — spine, 180, 521 — sternum, 133 — thigh, 643, 644 — ■ — , chronic, 662, 663, 664 — tibia, 700, 701, 702, 703 Osteoporosis in fracture of elbow, 591 — of bones of foot, 725, 726 -- carpus, 592 Ostitis fibrosa of femur, 660 — - — finger, purulent, 604 humerus, 575 — of mastoid, prominence of concha in, 27, 28 — • ribs, chronic, 213 Os trigonum, 710, 711 Othaematoma, 64, 65 Otitis media, chronic, cerebral com- plications of, 19, 25, 26-33 — , symptoms of, 27, 28, 29 Ovarian cysts, 289 — — , diagnosis from hydronephrosis, 289 — — , torsion of, 267, 299, 358 -^ hernia, diagnosis of, 383 Ovary, cancer of, causing intestinal obstruction, 353 768 INDEX Ovary, fibro-sarcoma of, 289 — , strangulated, 403 P Pachymeningitis, hsemorrhagic, dia- gnostic signs of, 17, 2O3 21 — , hypertrophic, 508, 509 Palate, abscess of, originating in root of tooth, 95 — , acute inflammation of, 123 — , carcinoma of, 103 — , defects in, 123 — , paralysis of, 122 — , polypi of, 06 — , scar development in, 123 — , syphilis of, 103 — , tubercle of, 103 — , tumours of and their diagnosis, 95, 96 Palati, velum, ulcerative processes on, 103 Palm, callosities of, with dilatation of mucous bursse beneath, 605 — , lipoma of, 608 Palmar aponeurosis, Dupuytren's con- traction of, 597 Panaritium (Whitlow), 602, 603, 604 Pancreas, cancer of head of, 329 — , cysts of, 329 — , diagnosis from cholecystitis, 316 — , haemorrhage of, 264, 265, 328 — • — , intestinal paralysis in, 358 — , stones in, 329 • — , surgical diseases of, 327 — , tumours of, 329 Pancreatitis, acute, 328 — , chronic, 329 , fat necrosis in, 264 — , diagnosis from cholecystitis, 316 • ileus, 358 ■ perforated gastric ulcer, 299 ■ — • — • peritonitis, 264 — , urinary reaction in, 329 Papilloma of bladder, 467 — larynx, 121 — palate, 96 Para-goitres, 171 Paralysis in cerebral pressure, 12, 14, IS — congenital dislocation of hip, 637, 638 — , complete injuries of spine, 493 Paralysis, ischaemic, 595 — , partial injuries of spinal cord, 494 — of arm, diagnosis from traumatic neurosis, 549 — hand and fingers after nerve lesion, 592-595 — palate, 122 — , types of, 499 Parametritis, 267, 271, 273 Paranephritis, 442 Paraphimosis, 474, 475 Paraplegia dolorosa in compression of Cauda, 499 — , spastic, occurrence of, 509 — — • — -in spinal caries, 519 Paresis of shoulder muscles, diagnosis of, 549 Paronychia syphilitica, 603 Parotid, abscess of, 62 — , cancer of, 169 — , chondroma of, 169 — , mixed tumours of, 168 — , sarcoma of, 169 — , tubercle of, 167, 168 Parotitis, 62, 132 — , epidemic, 62 Patella, dislocation of, 676 — , fracture of, 672, 674 — , laceration of ligamentum patellae, 674 — , riding of, in articular effusion, 667 — , sarcoma of, 687 Patellar reflexes in vertebral injuries, 493 Pelvic cellular tissue, tumours of, 481 • — , dermoids of, 481 — cellulitis, 271, 273, 275 — viscera, surgical diseases of, 235, 273, 274, 275, 276 Pelvis, abscesses of, 517 — , burrowing abscesses in, 479 — , crushing of acetabulum of, 637 — , exudation in, 407, 431 — , fibroma of, 480 — , fractures of, 628 — — ■ pelvic fossa, 630, 631 ■ — ring, 629, 631 — , inflammatory process in, true, 275, 276 — , injuries of urethra in fractures, 474, 630 INDEX 769 Pelvis, sarcoma of bones of, 480 — — muscles, 480 — , sinuses of, 424 — , true, cysts of, 407 — , tumours of, 480, 481 — • — , examination of, 479, 480 in true, symptoms caused by compression and displacement, 407, 431, 478 Penis, constriction of, 474 — , deformities of, 475 — , injuries of, 474 — , osseous nodules in, 475 — , subcutaneous tumours of, 475 — , surgical diseases of, 474 — , ulcers of, 476 , cancerous, 476, 477 , tubercular, 476 Perichondritis, laryngeal, 114, 132 Pericolitis, 344, 345 Perimetritis, intestinal obstruction in, 354 — • with peritonitis, 271 Perinephritis, 442 — , diagnosis from pleurisy, 442 — — , tubercular hip, 652 — , ileus in, 354 — , in renal tuberculosis, 461 — , origin of, 443 Periorchitis, 420 — , secondary, 421 — , serous and proliferating, 421 Periostitis of bones of skull, 51 — ■ humerus, 575 — ■ hyoid, 132 — , see also Osteomyelitis — jaw, 59, 60, 78, 79, 83, 85, 86, 131 - — metacarpals, 605, 609 — tibia, 703, 704 Periproctitis, 275, 431 Perisalpingitis, 271 Peritoneum, congenital pouches of, strangulation of bowel in, 366 ■ — , inflammation of, 254-265 , spreading from one area over whole abdomen (types), 255 — , tuberculosis of, 264, 281 Peritonitis, 254-261 — , adhesive, 284, 285 — , commencing, 255 • — , determination of leucocyte blood count in, 261 ^—, physical condition in, 257-261 Peritonitis, diagnosis from dysmenor- rhoea, 263 — — gall-bladder pain, 262 ■ hysteria, 262 ileus, 286 intestinal obstruction, 255, 263 — ■ — mucous colic, 262 — • — pneumonia and pleurisy, 263 • renal colic, 262 • spinal caries, 263 — ■ — - tabes, 262 — — ■ of cases of abdominal pain with- out evident changes from stranga- lated hernia, 263 --, diffuse, 254, 255 , without localization, 263, 264 — , examination in, 282 — , exudative, 283 — in a hernial sac, 401 — , indications for exploratory punc- ture in, 286 — • in intestinal injuries, 246 — , localized, 265 , in epigastrium, 265 — ■ — , hypochondrium, 265 — ■ — , hypogastric region, 266 — ■ — , lumbar region, 266 — — , true pelvis, 275 — , nodular, 284 — , origin of tubercular, 285 — , perforative, 254, 258 — , peripheral (Lennander's), 259, 297 — , prognosis of, 261 — , residual abscesses after, 256, 270, 334 — , sero-purulent, 255 — , serous, 255, 268 , in appendicitis, 270, 334 — , significance of age and sex in diagnosis of, 256 history in diagnosis of, 255, 256 — , tubercular, 264, 281, 282 , with saccular exudation, 283, 285, 290 Phantom hernia of lumbar region, 374 — • tumours of abdomen, 287 — • of neck, 139 Pharynx, abscess of, gi, 96 — , adenoids in, gi — , cancer of, 142 — , diphtheria in, iii — , examination of, in — — , in dysphagia, 125 770 INDEX Pharynx, foreign bodies in, 123, 124 — , inflamed, diffuse and unilateral, 90 — , inflammatory processes in, iii — , polypus of, 96, 97 — , pressure sore in, 103 — , sarcoma of, 95, 96 — , syphilis of, 90, 98, loi, 103 — , teratoid tumours of, 97 — , ulcers in, and their diagnosis, 98, 99, loi, 102, 103 Phlegmon in axilla, 210 — ligneux, 135, 288 — of floor of mouth, 90 — front of arm, 568 -- frontal sinus, 60 — mediastinum, 127, 133 — ■ scalp, 51 — supraclavicular region, 133 Phosphorus necrosis of jaw, 81, 100 Pituitary gland and its relation to obesity, 175 — ■ — , injuries of, 38 , tumours of, 24 Pleura, inflammation of, after peri- tonitis, 260, 263 — ■ — , purulent, 209 — , injuries of, 189 — — , with cardiac wounds, 193 Pleural exudation in subphrenic abscess, 279 Pneumococcal peritonitis, 267, 285 Pneumonia, croupous, 196 — , diagnosis from diphtheria, 113 peritonitis in children, 263 — , metastatic, 260 — , purulent, 195 — , resulting in spinal caries, 521 — , traumatic, 117, 189 Pneumothorax, traumatic, 189 Pollakiuria, 433 Polyposis of rectum, 408 Polypus at neck of bladder, 462 — ■ in nasopharynx, 96, 97, 98, 123 — of ear, 26 Polyuria, 433 Pons, injuries of, focal symptoms, 44 — , tumours of, diagnostic signs, 24 Porencephaly, traumatic, 35, 54 Pott's deformity, 511 Pouches, ileo-appendicular and right retrocaecal hernia in, 366 Precentral sulcus, determination of, on skull, 47 Pressure diverticulum of oesophagus, 128 Processus vaginalis of peritoneum and herniae, 387 Proctitis, gonorrhoeal and syphilitic, 408 Prolapse of anus and rectum, 411 Prostate, abscess of, 431, 471 -- — , diagnosis, 276, 439 — , carcinoma of, 470 — ■, cysts of, 481 — , examination of, .438, 439 — •, gonorrhoea of, 471 — -, hsemorrhage from, 470 — , hypertrophy of, 430, 431, 438, 439 — - — , symptoms and course, 469, 470 — , sarcoma of, 470 — , tuberculosis of, 471 Prostatitis, 411 — , diagnosis of, 439 Pseudo-hermaphroditism, 383 Pseudo-leukaemia, glandular enlarge- ment in, 157, 158, 203 — , pharyngeal swelling in, 95 — , splenic enlargement in, 331 Psoas abscess, 443, 517 Pupils in cerebral pressure, 13 — , reaction of in vertebral injuries, 502 in visual disturbances in, 39, 40 Pyelitis, 451, 452 — , anatomical diagnosis of, 452 — , gonorrhoeal, 451 — ■ in prostatic hypertrophy, 450 — of pregnancy, 451 Pyelonephritis, 452 Pyloric cancer, 311 — ■ — , signs of retention in, 311 — • — 5 skiagrams of, 302, 303, 312 — spasm, 301 — ■ stenosis, cancerous, 303, 311, 312 , innocent, 304 — • — -of infants, 305 Pyonephrosis, 449, 450 Pyorrhoea alveolaris, 100 Pyosalpinx, 271 Quadriceps tendon, laceration of, 671 INDEX 771 Rachischisis, posterior, 482, 483 Radial paralysis, posture of hand in, 593 Radio-carpal joint, dislocation of, 585 Radius, absence of, 595 — fracture, 577, 578, 580, 581, 582 , combined, 579 — — • — , caused by wrench, 579 — , with fork-like posture, 577 ■ — , into joint, 577 — , head of, chisel fracture, 565, 566 — , individual dislocation of, 563, 576 — , separation of epiphysis, 577, 579, s8o Ranula, 92 — , differential diagnosis, 92, 93, 94 Raynaud's disease, 603, 606, 607 Reclvlinghausen's disease, 55, 170 Reclus's disease, 223 Rectal fistulae, 410, 424, 425 , acquired, inflamed, 424 — — , complete and incomplete, 426 — — , congenital, 424 , ischio-rectal and pelvi-rectal, 426 Rectum, carcinoma of, 408, 409, 411 — • — , causing perirectal suppuration, 275 — ■ stenosis, 352 — , condition of, in spinal injuries, 492 ■— , fissure of, 409 — , fistulae of, 410 — , foreign bodies in, 412 — • — ■ — , introduced into, 413 — , gonorrhoeal stricture of, 407 ■ — , injuries of, 412, 413 — , polyposis of, 408 — , prolapse of, 411 — , sarcoma of, 409, 411 — , syphilis of, 341, 353, 407, 408 — , tenesmus of, 407 — , tuberculosis of, 341, 407 Recurrent nerve paralysis, 200 — ■ — ■ — , symptoms of, 118 Reflex epilepsy, 35 — symptoms after wounds of hea't, IQ2 of chronic purulent otitis, 29 Retention swellings of kidney, 457 Retrobulbar fatty tissue, venous thrombosis of, 50, 6i. Retroflexion of gravid uterus causing constipation, 407 — — ■ — causing ileus, 353 Retropharyngeal abscess, 91, 114 , important diagnostic signs of, 123, 124 Retroperitoneal inflammation, 266 Retrotonsillar abscess, 91 Rhagades on tongue, nature of, 107 Rheumatism of ankle, 725, 726 — elbow, 571 — hip, 639, 651, 654 — - knee, 679, 681 , ankylosing, 686 — shoulder, 550, 552 — ■ wrist, 589 — — , chronic, 589, 590 Rhinoscleroma, 103 Ribs, chondritis of, after typhoid, 213 — , fractures of, 187 — , gumma of, 213 — , ostitis of, 213 — , protuberance of, 528, 529, 531, 532 — , tuberculosis of, 213, 222 Rickets, bone changes in, 591, 636 — , protuberance on ribs, due to, 532 Rider's bone, 658 Risus sardonicus in tetanus, 75 Rodent ulcer of face, 68, 6q, 70 Rontgen dermatitis of hand, 601 Roser-Nelaton's line, determination o/, 612 — in congenital dislocation of hip, 632 Rotation dislocation of cervical verte- bra, 182, 183 ■ — fracture of thigh, 623, 624, 625 Sacral tuberculosis, 517 Sacro-lumbar tumours, congenital, 486 Salivary glands, swelling of, 89 , diagnosis from tumours of neck, 140 — stones in Steno's duct, causing acute swelling of parotid, 62 Wharton's duct, causing in- flammatory swelling of sub- maxillary, 132 Salpingitis, 273 — , diagnosis from appendicitis, 276 Sarcoma of abdominal wall, 376 50 //■ INDEX Sarcoma of arm, 572, 574 ^- back of neck, 175 — bladder, 467 — cervical glands, 170 — clavicle, 212 — diploe, 57 — femur, 657, 661, 665 — gluteal region, 680 — gum, 94 — hand, 600 — kidneys, 457 — ■ knee-joint, 684, 687 — ■ lower jaw, 87, 88 — ■ lung, 207, 208 — ■ mamma, 232, 233 — • mediastinum, 207 — ■ neck, 170 — — , pulsating, 163 — nose, 07 — OS calcis, 726, 73g — parotid gland, 169 — patella, 687 — pelvis. 480 — penis, 475 — pharynx, 96 — ■ prostate, 470 — • rectum, 409, 411 — sacral region, 486 — ■ scapula, 214 — . scrotum, 415 — shoulder, 553 — skull, 57 — ■ spermatic cord, 416 — ■ spinal cord, 509 — spleen, 331 — ■ submaxillary gland, 170 — testicle, 422 — thigh, 637, 658, 659 — thorax, 217, 218 — thyroid, 1 54 — tibia, 699, 700, 705 — - tongue, io5 — tonsillar region, 95 — trachea, 121 — • umbilicus, 374 — upper jaw, 83, 84 — vascular sheaths of neck, 171 — • vertebral column, 509 Scalp, fibroma of, 55 — , gumma of, 56, 58 — , sebaceous cysts of, 55, 56, 57, 58 Scaphoid of foot, fracture of, 721 — ^ hand, fracture of, 584, 587 Scapula, fracture of, 545, 546 — , osteo-myelitis of, 210 — , sarcoma of, 214 — , tuberculosis of, 214 Scarlatinal arthritis of hip, 644 shoulder, 550 School scoliosis, 532 Sciatica, 689-693 --, diagnosis from hip disease, 652, 654 — , scoliotic, 522, 524, 691 Scirrhus of breast, 225, 226 Sclerosis, multiple, paraplegia in, 509 Scoliosis, 523, 524, 525, 527, 528, 529, 530, 531 — , causes of, 532 — , complete, 531 — , fixed, 531 — ischiodica, 522, 524, 691 — , mobile, 531 — ■ of dorsal vertebree, primary, 532 Scrofula, tubercular lymphoma, 156 Scrotum, acute inflammation of, 414 — , carcinoma of, 415 — , contents, 415 — , dermoid of, 415 — , elephantiasis of, 415 — , fibroma of, 415 — , Ij^mphangioma of, 415 — , sarcoma of, 415 — , sebaceous cyst of, 415 — , swellings of, 414 — , tumours of, 414 — , urinary infiltration of, 414 Scurvy, gangrene in, 91 — , haemorrhage from gums in, 100 Sebaceous cyst of face, 63, 64 • hand, 599 — • — neck, 165, 174 • penis, 475 — • — ■ root of nose, 64 ■ scalp, 55, 56, 57 , malignant degeneration of. 58 — ■ — scrotum, 415 skin of back, 216 skull, 55 • — with sinus formation, 55 — ■ — umbilicus, 378 Segmental diagnosis of spinal cord, 405, 496, 400, 510 Semilunar bone^ dislocation of, 579, 583 INDEX Semilunar bone, fracture of, 585, 586 — cartilage, incarceration of, 670, 678 , laceration and displacement of. 670 Seminal vesicles, abscess of, 431 Sensation in vertebral injuries, 490 , partial, 493, 494 Sesamoid in knee-joint, 669 — of tarsal bones, fracture of, 723, 724 Shoulder, rigidity of, 549 Shoulder-joint, contusion of, 546 — , dislocation of, 538, 539, 540 — , elevated level of, congenital, 523, 525 ~, fractures of, 537, 538, 539, 540 — , gonorrhoea of, 551 — , injuries of (examination for), 537, 538, 539 — , inflammatory processes, 547 , diagnosis from diseases of bursa and of joint, 547, 548 — , primary disease of bones of, 553 — , sprain of, 546 — , testing movements of, 548, 549 — , tubercle of, 551, 552 Sigmoid, cancer of, 352 — , stenosis of, 356 — , volvulus of, 365 Sigmoiditis, 275 — , ulcerating, 342 Sinus at umbilicus, 378 — , cavernous, thrombosis of, 61 — ■ from biliary tract, 378 — ■ intestine, 378 — • rectum, 424, 425 — stomach, 378 — thyroid gland, 139 — urachus, 2)11 — • vitelline duct, 2>T] — frontal phlegmon, arising there- from, 60 — in perinseum, 424, 425 — , longitudinal, angioma of, 54 ^, maxillary, chronic inflammation of, 82 — of abdomen, 2>~~i 3/8 — branchial cleft, 138 — inguinal region, 379 — urinary tract, 378, 426 — on neck, 136 J actinomycotic, 136 Sinus on neck (complete and incom- plete), 139 , congenital, 137, 138 — ■ — , gummatous, 136 — • — , traumatic, 136 — - — , tubercular, 136 — , pericranial, blood cyst of, 53 — , secretions of, 378 — thrombosis, after aural suppura- tion, 29, 32, 33 Sinusitis, acute, 60 — , chronic, 60 — , frontal, 60 Situs inversus of unpaired abdominal viscera, 236 — • — , partial inferior, 236 Skin appendages in front of ear and on face, 64 — cancer of, on foot, 740 , on face, 69, 70, 71 , on hand, 601 , on umbilical region, 374 — • reflexes in spinal injuries, 493 — -, seborrhoea of, 58 , on forehead and temples, 71 Skull, acute inflammatory processes on, 51 — , base of, fibroma of, 96, 97 — ■ — , fractures of, 3, 6 — — , nerves at, 46 — - — , sarcoma of, 96 — , chronic inflammatory swellings of, 56 — — , ulcerating growths of, 58 — , demarcation of cortical centres on the surface of, 47, 48, 49 — , dermoid of, 53, 54 — , erysipelas of, 51 — , exploration of, 16 — , fissures of, 6 — , fractures of, i , direct symptoms, 2 , indirect symptoms, 4 — — , position and course of, 5, 6 — , gummata of, 56, 58 — , injuries of, causing epilepsy, 34, 35 — , new growths of internal layer, 22 — , osteoma of, 55 — , osteomyelitis of, 51 — , periostitis of, 51 — , phlegmon of glands of, 51 ^-, sarcoma of, 56, 57 774 IXDE^t Skull, sarcoma of, periosteal, 57 — , sebaceous cyst of, 55 — , secondary growths of, 57 — , tubercle of, 56 Small intestine, gall stones in, 275 , intussusception of, confusion with, appendicitis, 275 , palpation of, 23Q — — , stenosis of, 349, 355, 359 — through fibro-sarcoma, 348 , torsion of, 364 , tumours of, 28g Solitary kidney, displacement of, 235 Spermatic cord, hydrocele of, 385, 415 , diagnosis from inguinal hernia, 388 , tumours of, 415 Spermatocele, 419, 420 Sphincter of bladder, ulceration of, as a cause of incontinence, 432 Spina bifida, 218, 481 — • — , forms of, 482 occulta, 485 — ■ , club foot in, 735 , pes cavus in, 735 Spinal caries, 50Q, 511 — ■ — , ankylosing, 521 causing bending of spine, 522 — • — , cervical, 515, 51G, 517 — • , commencing, 513, 514 commencing, 512, 313 — ■ — , diagnosis from peritonitis — ■ spinal cord tumour, 509 sarcoma of vertebra, 510 , non-tubercular, 520 , ankylosing, 521 , secondary after pneumonia and typhoid, 521 of dorsal vertebrae, 513, 516, 517 lumbar vertebrae, 516, 517 , osteo-myelitic, 521 -J posture of head in, 180, 514 , syphilitic, 521 , traumatic, 520 , tubercular, 181, 215, 511, 515 , in adults, 513 , in children, 511 — - — with burrowing abscess, 515 ■ cord symptoms, 519 — • — - without protuberance and with- out burrowing abscess, 511 — cord, Brown-Sequard's syndrome, 494, 508 Spinal cord, compression of, 494, 526 — - — , congenital clefts in, 485 , contusion of, 494 — • — , gumma of, 510 , haemorrhage in, 495 , injuries of, 489 — — — , complete, 493 — , partial, 494 , non-traumatic diseases of, 507 — — , sarcoma of, 510 — — , segmental diagnosis, 495, 496, 499 , solitarj- tubercle of, 510 , tumours of, 508, 509 — meninges, innocent growths of, 510 Spine of tibia, detachment of, 671 — ■ — ■ — , normal picture of, 671 Spleen, abscess of, 266, 330 — , amyloid disease of, 331 — , congenital syphilis of, 331 — , displacement of, 236, 238 — , hypertrophy of, 331, 332 — , injuries of, 247 — , swelling of, in diphtheria, 113 — , tumours of, 331 Sporotrichosis of elbow region, 571 Staphylomycosis of breast, 221 :2 — medulla of femur, 662, 665 — ■ tibia, 703 Sterno-clavicular joint, injuries of, 53.1 Sterno-mastoid, gumma of, 140 263 — . — J myositis of, 133 — • — , tuberculosis of, 140 Sternum, abscess of, 211 — , fracture of, 188 , transverse, in upper portion, 505 — , gumma of, 213 — , malignant growth of, 213 — , osteo-myelitis of, 133 — , tubercle of, 212, 213 Stomach, abnormalities in position of, 236, 242, 293 --, cancer of, 302, 303, 305 — — at cardia, 306 • fundus, 310 pylorus, 311 — — , chemistry in, 309 , varieties of, 310, 311 — , cicatricial stenosis of, 299, 300, 301, 303 — , contusion of, 245, 247 — , dilatation of, 302, 303 I liS'DEX 775 Stomach, foreign bodies in, 292, 293 — , gunshot wounds of, 252, 253 - -, haemorrhage from, 296, 308 — hour-glass, 302, 303, 304 — , perforation of, 296 , differential diagnosis, 299 , local symptoms, 298 — . shape and position of, abnormal, 292, 302, 303 ■ — , normal, 240 — , sinuses from, 378 — , skiagram of, 302, 303 in retention of contents, 301 , technique and diagnostic signi- ficance, 292 — , surgical diseases of, 291 , with peritoneal signs, 265, 266 — -, ulcer of, 294, 302 , diagnosis from cholecystitis, 316 • ileus, 358 — — indolent, 295 , perforating, 266, 296, 297 , uncomplicated, 294 Stomatitis, gangrenous, 76, 91 — , mercurial, 76 Stones of kidnej', infected, 455 , non-infected, 453 Stools, blood in, 245, 349, 407 — , diagnostic significance of their consistence, 407, 408 — , incontinence of, 492 — , pus in, 350 — , retention of, 349 — , shape of, 348, 349, 407 Streptococcal laryngitis, diagnosis from diphtheria, 1 1 1 Streptomycosis of breast, 221 Stricture of rectum, gonorrhoeal and syphilitic, 407 — , urethral, examination of, 439 Styloid process of radius, fracture of. 577, 578 — • — ulna, fracture of, 577, 578 Subluxation of foot, 713, 715 — radius, 563 ~, Volkmann's, 734 Submaxillary gland, inflammation, 132 , chronic, 166 , mixed tumours of, 167 — ■ — , sarcoma of, 169 , tubercle of, 167 Surgical emphysema after injuries to air passages, 116 Surgical emphysema, lung injuries, 189 Swallowing, difficulty in, 122 — — , position and nature of obstruc- tion, 127 , through aft'ections of mouth and throat, 122, 123, 124 ._.. — . — foreign bodies, 123 • — ■ laryngeal diseases. 118 — ^ — ■ oesophageal disease, 124 Sweat glands of axilla, inflammation, 211 Synovitis of ankle, tubercular, 725, 726 - knee, osteo-myelitic, 681 — — , rheumatic, 681 , syphilitic, 681 Syphilis insontium, 22, 90 — of brain, 22 — • elbow, 571 — epididymis, 419, 426 — face, 65, 71 — finger, 603, 608 — foot, 6g6, 725, 740 — hand, 605, 608 — ■ intestine, 353 — • knee, 681 — large intestine, 34: — larynx, 120, 121 — leg, 695, 696, 70c — lips, 64, 99 — mouth, 90, 99, 100 — neck, 136, 156 — • nose, 65, 66 — oesophagus, 130 — • palate, 95 — penis, 476, 478 — rectum, 341, 408 — testicle, 422 — • thoracic wall, 211 — thyroid, 153 — - tibia, 701, 704 — vertebrae, 521 Syringo-myelia, hand deformity in, 607 Tabes, diagnosis from perforation of stomach, 299 -- — peritonitis, 262 — — tumour of spinal cord, 508 Talipes, 729, 730, 731, 733, 734, 733, 737 Tar cancer, 415 Tear ducts, inflammation of, 60, 61, 167 )76 Index Tegmen tympani, suffusion of, 6 Temporal lobe, abscess of, after otorrhoea, 30 — • — , tumours of, 24 Tendon reflexes, condition of, in spinal caries, 519 — vertebral injuries, 493 Tenesmus of bladder, 432 -in stone, 462 • urinary tubercle, 458 — ■ rectum, 407 — • — with constipation, 407 Teno-synovitis of hand, 588, 603 , gonorrhoeal, 603, 608 — , tubercular, 589, sqo, 599, 607 Teratoma of pharynx, 97 — - sacral region, 486 Testicle, gumma of, 419 hsematocele of, 416, 420 hydrocele of, 387, 388, 420 infarction of, 418 inflammation of, 416, 417 — , metastatic, 417 injuries of, 416 spermatocele of, 419, 420 strangulation of, 399 syphilis of, 422 torsion of, 399, 418 tumours of, 422 Tetanus of head, with facial palsy, 75, Thigh, abscess of, 518 — , aneurism of, 658 — , blood cysts of, 660 — , dislocations of, 615-620 • — ■ — , congenital, 631 — , fractures of, 621, 631 — , muscular swelling of, 658 — , osteo-myelitis of, 656 — , tumours of, 656, 657, 659 5 in epiphysis, 661 diaphysis, 664 Thorax, angioma of, 216 — , bones of, fracture, 186, 187 — , burrowing abscess of, 517 — , empyema, breaking through, 209 ■^5 enchondroma of, 218 ■■ — , fibroma of, 216 — , inflammatory processes of, 210- 216 --, injuries of, 187-188 ^-, lipoma of, 211, 215, 217, 517 — i lymphangioma of, 217 Thorax, malignant tumours of, 2ii, 213 — muscle, gumma of, 212 — , osteoma of, 218 — , osteo-myelitis of, 210 — , sarcoma of, 216, 217, 218 — , sebaceous cyst of, 216 — , surgical diseases of, 186 ■ — , external, 208 — , internal, 199 ■ — , tuberculosis of, 209, 212 - — , tumours within, 199 without, 208, 216 Thrombo-phlebitis of transverse sinus in aural suppuration, 29, 32, 2>Z Thymic death, 201 Thymus, condition of, in Graves's disease, 146 — , hypertrophy of : diagnosis, 200, 201 Thyroid, cancer : secondary deposits, 57, 155 — , symptoms, 121, 155 -- fistulse, 139 — gland in obesity, 175 , inflammation of, 133, 151 , simple hyperplasia of, 141, 142 , tumours of, 154 Tibia, chronic abscess of, 703, 704 — , dislocation of, 676, 712 , posterior, 685 , at lower end, 706, 707, 711, 713 — , fractures of, 675, 676 — , laceration of crucial ligaments, 675 — , normal, 704 — , osteo-myelitis of, 699, 700, 701, 702, 703 — , periostitis of, 703 • , syphilitic, 704 — 5 syphilis of, 701, 703 — , tuberculosis of, 703, 704, 726 — , tumours of, 697, 699, 700 Tic, rotatory, 186 Toe-nail, ingrowing, 740 Toes, chondroma of, 738 — , deformities of, Tzi — , gangrene of, 728 Tongue, actinomycosis of, 105, io6j 107 — , angioma of, 105 — , cancer of, 99, 108, 109 — 3 dry (significance of), 104 INDEX 777 Tongue, fibroma of, 105 — , gumma of, 105, 106, 107 — , leucoplakia of, 104 — , lipoma of, 105 — , lymphangioma of, 105, 106 — , primary chancre of, 107 — , sarcoma of, 106 — , swelling of, go, 104 — , tuberculosis of, 105, 106, 107 Tonsil, cancer of loi, 103 , metastasis in neck, 161 — , gumma of, loi — , mixed tumours of, qs — , primary chancre of, 102 — , sarcoma of, 95 — , tuberculosis of, loi Tonsillitis, iii, 112 Torticollis, 180, 184, 185, 186 Trachea, surgical diseases of, acute, III , chronic, 118 Trismus, 75 Trochanter, fractures of, 622, 623, 624 — , level of, 612, 632 , in congenital dislocation, 632, 636 , coxa adducta, 639, 640 Tubal pregnancy, ruptured, 271, 273, 274 , diagnosis from gastric ulcer, 299 — ileus, 358 Tubercle of abdominal wall, 376, 2>n — arm, 573, 576 — bladder, 463, 465 — brain, 17, 22 — cervical vertebrae, 134, 136, 511 — elbow, 509, 570, 571, 572 — epididymis, 419, 420 — femur, 653, 658, 662 — finger, 608 — floor of mouth, 99, 100 — foot, 725, 726, 727, 728, 740 — gum, 79, 100 — hand, 607, 600 — hernial sac, 402 — hip, 645 — humerus, 551, 573, 575, 376 — inguinal glands, 375 — intestine, 351 — jaw, 60, 76, 79, 80, 81, 83, 84 ~ kidneyj 450, 451 Tubercle of knee, 680, 681, 682, 684 --- lachrymal sac, 61 — larynx, 119, 120, 121 — leg, 703 — lobule of ear, 72 — lungs, suppurative, 198, 209 — mamma, 221, 222 — neck, 134, 138, 152 — nose, 103 — OS calcis, 726, 728 — palate, 103 — parotid, 167, 168 — pelvic bones, 651 — peritoneum, 264, 281 — pre-patellar bursa, 687. — prostate, 471 — rectum, 341, 408 -- ribs, 213 — scapula, 214, 552 — shoulder, 550, 551 — - skull, 56 — sternum, 212, 213 — subdeltoid, 550 - submaxillary gland, 167 — tendon sheaths of hand, 599 — thorax, 209, 211 — thyroid, 153 — tibia, 703, 704 , at lower end, 725, 726 — tongue, 105, 107 — tonsillar region, diagnosis from gumma, loi, 102 — urinary passages, 458, 461 — vertebrae, 181, 215, 511, 515 — wrist, 589, 590, 591, 599 Typhoid fever, arthritis of hip, after, 644 vertebral joints, after, 521 , ostitis and chondritis of ribs, after, 213 Typhlitis, ulcerative, 342 u Ulcers of concha of ear, — face, 62, 64 — foot, 696, 739 — gum, 100 — intestine, 353, 358 — larynx, 115, 119, 120 • - leg, 693, 694, 695, 696 — oral cavity, 98 — peni5, 4753 47^ 778 INDEX Ulcers of scalp, s8 — scrotum, 415 — stomach, 294 — tongue, 106 — tubercular, 79 Ulnar paralysis, posture of hand and fingers in, 593, 598 Umbilical cord, hernia of, 371, ■i']2> — hernia, 372 , in cirrhosis of liver, 372 , strangulation of, 403 Umbilicus, abscess of, 378 — , concretions in, 378 — , fistulse of, congenital and ac- quired, 378 — , tumours of, 374, 378 Urachus, cysts of, Z12> — , fistulae of, 377 Ureter, catheterism of, 427, 441 — , in urinary tuberculosis, 459 Ureteral stones, 453 Urethra, fistulae in, 426 — , foreign bodies in, 430 — , haemorrhage from, 435 — , injuries of, 472, 473 , in fractured pelvis, 474, 630 — , obstruction of, 430 — , stricture of, 439, 44° , of gradual onset, 431 Urethritis, differential diagnosis in, 428 Urethroscopy, 439 Urinary disturbances, 429, 440 — — , difficult and painful micturi- tion, 429, 432 , involuntary micturition, 431 — , fever, 452, 455 — , fistulas, 378, 379, 4^6, 427 — , gravel, 436, 433 — , tract, surgical diseases of, 427 , local symptoms, 445 , tuberculosis of, 434, 435) 458 Urine, albumin in, 452, 459 — , blood in, 249, 251, 435, 454, 47° — , examination of, 434, 435, 43^ — , extravasation of, 414 , in injury of kidneys, 249 J rupture of bladder, 250, 251 • , urethral injuries, 473 ^, pus in, 433, 434, 449 ■ — , retention of, 430 , results, 447, 464 — , sugar in, 329 Urticaria, in hydatid disease, 326 — , hydronephrosis, 436 Uterus, cancer of, causing intestinal obstruction, 353 — , cystoma of, 290 — , fibrous myoma of, 289 — , inflammation in and around, 266 — , pregnant, diagnosis from ab- dominal tumour, 290 V Varicocele, 388 — , with atrophy of testicle, 389 Varicose veins of leg, 693, 694, 697, 698 ■ thigh, 657 Varix, aneurismal, diagnosis from arterio-venous aneurism, 164 Vein, internal jugular, thrombo- phlebitis of, 2)2, — , saphenous, dilatations of, 392 Verruca senilis, 58 Vertebral column, arthritis deformans of, 521 , congenital deformities of, 481, 523 , curvatures of, 519, 522, 525, 526 , dislocations of, 176, 500, 502, 503 , fractures of, 176, 488, 501, 502, 503 , injuries of, 489, 493, 494, 495, 499, 501, 505, 506 , osteo-myelitis of, 180, 576 , partial injuries of, 493, 494 , rigidity of, 521 , sarcoma of, 509 , sprains of, 487, 488 — ■ — , syphilis, tertiary, of, 521 — — , tubercular abscess of, 134, 140. 215, 515, 519 — — , tumours of, 508, 510 — , diagnosis from spinal caries, 509 — , injuries, examination of, 489 • for movements, 490 • reflexes, 492, 493 — ■ sensation, 490, 491 — vasomotor state, 491 — • ■ visceral functions, 492 Vestibular nqrve, disturbances of, 43 INDEX 779 Volvulus, 364 — 5 ileo-csecal, 365 — of sigmoid flexure, 365 w Warts, soft, of face, 64 Whitlow, 602, 603, 604 Wrist, abnormal postures of, 595 — , arthritis of, 588, 5qo — , bones of, fracture of, 584, 585 — , dislocation, fracture of, 584, 585 of, 579, 583 — , gonorrhoea of, 589 — , injuries of, 577 , scheme, 587 — , normal, 583 — , rheumatism of, 589 Wrist, rheumatism of, chronic, 589 — , sprain of, 576, 577, 586 — , tuberculosis of, 589, 590, 592, 599 Wry-neck, 180, 184, 185, 186 X Xanthelasma of face, 64 Y-SHAPED fracture of femoral con- dyles, 673, 675, 676 fibula, 711 head of humerus, 545 lower end of humerus, 556, 564, 568 neck of femur, 623 I COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD35QU3131913C.1 Clinical i:,-; :a -: ^::- -,- -, '-- -• r'pnK 2002120780