Diagnosis and Rontgen Ray

CHAPTER I. DIAGNOSIS AND RONTGEN RAY. Diagnosis is the process whereby the nature of a disease is determined; the term is applied also to the result of this process, i.e., the name of the disease. In many instances the condition, a crushed foot for instance, is self- evident and a direct diagnosis may be made; in others the symptoms suggest two or more affections, which must be distinguished by differential diagnosis; and occasionally a diagnosis by exclusion must be made; thus in a case of retroperitoneal sarcoma, it may be necessary to consider all the other forms of abdominal tumor, and to rule them out one by one, because of the absence of special symptoms, until finally the real cause of the growth is determined. In order to be complete a diagnosis should include the organ or part affected (anatomical diagnosis), the nature of the affection (pathological diagnosis), the constitutional change resulting from or causing the local lesion, the presence or absence of independent or associated maladies, and the indi- viduality of the patient. A diagnosis is made by interrogating the patient (subjective symptoms) and by physical examination (objective symptoms or signs). The chief factors in diagnosis are to obtain correct facts, to interpret them properly, to know what to look for, and above all to look. ‘‘More mistakes are made by want of looking than by want of knowing.” In practice the analytical method is usu- ally employed; the attention is first directed to the offending part, and by examination, coupled with questioning the patient, one considers the condi- tions most likely to be the cause of the symptoms, and then by further examin- ation the diagnosis is finally reached. The synthetical or historical method is more scientific, more accurate, and better adapted for the keeping of written records. It consists of (a) the history (anamnesis), which, with the name of the patient and the date of examination, includes (1) the age, (2) address and nationality, (3) sex, (4) social condition, (5) family history, (6) previous his- tory, and (7) the history of the present illness; and (b) the physical examination (status presens), which comprises (8) an examination of the affected part, (9) an examination of regions clinically related to the affected part, and (10) a general examination of the whole body. 1. The apparent as well as the real age should be noted. In childhood irritability of the nervous system is marked, and high fever and convulsions may be caused by trivial affections which would cause no such disturbances in the adult. A malignant neoplasm in a child would probably be a sarcoma, in later life a carcinoma. Ulcers in children may be due to tuberculosis or congenital syphilis; in adults syphilitic and traumatic ulcers are frequent; later in life the varicose ulcers and epitheliomata predominate. In the 1 2 MANUAL OF SURGERY child an injury to an extremity may result in a greenstick fracture or epi- physeal separation, the same in an adult might cause a complete fracture or a dislocation. In intestinal obstruction one would suspect imperforate anus in the new born, intussusception in infancy, and impacted feces or cancer in old age. In children difficulty in urination would probably be due to phimo- sis or calculus, in adults to stricture, in old age to enlarged prostate. In childhood infantile paralysis, congenital syphilis, rickets, adenoids, prolapse of the anus, rectal polypi, malformations, nevi, noma, foreign bodies in the air passages, tuberculous lymph glands, acute infectious osteomyelitis, postpharyngeal abscess, hemophilia, renal sarcoma, hydrocephalus, cretinism, and intussusception are common; in adolescence appendicitis, gastric ulcer, osteoma, chondroma, tuberculosis of bones and joints, and sexual disorders are frequent; in middle age aneurysm, carcinoma, floating kidney, mollities ossium, and gall-stones are most apt to occur; in old age hypertrophy of the prostate and degeneration of the circulatory apparatus, leading to gangrene and other disorders, are prone to develop. Hernia is most frequent at the extremes of life. Infancy and old age do not stand operations well, but infants who escape the immediate dangers of operation often convalesce more rapidly than adults. 2. Not only the present, but previous addresses should be ascertained, as well as the place of birth. Goiter is prevalent in Switzerland, Tyrol, South- eastern France, Northern Italy, parts of England, and in the Himalayas and Andes; leprosy in Norway and the tropics; bilharzia hematobia, tetanus, filariasis, and hepatic abscess in the tropics; rachitis in densely populated centers; vesical calculus in India and parts of England; hydatid disease in Iceland and Australia. The Negro is more susceptible to tuberculosis, aneurysm, elephantiasis, tetanus, and benign neoplasms, especially the fibro- mata; less liable to malignant disease, stone in the bladder, varicose veins, appendicitis, congenital deformity, enlarged prostate, and gall-stones; and less resistant to operative procedures. The Hebrew suffers frequently from intestinal and rectal disorders, and is more prone to develop diabetes with its surgical complications; his symptoms should be analyzed with due con- sideration to his highly sensitive nervous system. 3. The sex is occasionally of some importance in making a diagnosis. Ex- cluding diseases of the reproductive organs, females are more liable to goiter, floating kidney, enteroptosis, gall-stones, mollities ossium, Raynaud’s disease, myxedema, stricture of the rectum, tuberculous peritonitis, arthritis defor- mans, hysteria, and functional nervous troubles, but they stand operations better than men. Afales are more apt to develop aneurysm, actinomycosis, appendicitis, cerebral abscess, cystic kidney, cirrhosis of the liver, Dupuy- tren’s contraction, hematoma auris, hemophilia, intussusception, lymphade- noma, pancreatitis, stricture of the urethra, stone in the bladder, cancer of the lip, stomach and rectum, and conditions produced by exposure, hard work, and injurious habits. 4. Under the social condition note whether the patient is single or mar- ried, widow or widower. Ifa woman, elicit the menstrual history, the amount and character of leukorrhea, the number of children and miscarriages, the date of the last confinement, and the presence or absence of puerperal com- plications. Ascertain the nature of previous occupationsas well as the present one. Active occupations predispose to hernia, aneurysm, and various forms of injury; sedentary occupations to gall-stones, hemorrhoids, ulcer of the stomach, and functional neuroses; standing occupations to varicose veins and DIAGNOSIS AND RONTGEN RAY 3 flat-foot. Certain occupations, by forcing the individual to assumea particular attitude or to use a certain set of muscles, produce alterations in the form of the body, thus the shoemaker, tailor, and rag-picker become round shouldered, and one who carries a load on the same shoulder day after day, or who uses one arm or leg constantly, may develop scoliosis. Constant pressure on a part, necessitated by many occupations, may produce deformity, callosities, burs, and even neoplasms. Skin handlers and wool-sorters are predisposed to anthrax; hostlers to glanders and tetanus; butchers, doctors, and veterinar- ians to anatomical tubercle and other infections; painters, potters, plumbers, lead-makers, tailors, and seamstresses to lead poisoning; match-makers to phosphorous necrosis of the lower jaw; morocco workers and those who use acids to ulcers of the hands and forearms; and those who handle grain to actinomycosis. 5. The family history includes an investigation into the diseases which have occurred, or the cause of death, in the parents, grandparents, uncles and aunts, brothers and sisters, husband or wife, and children. Especially to be inquired for are calculus, malformations, hemophilia, syphilis, tuberculosis, rheumatism, alcoholism, malignant tumors, and nervous affections. 6. In the previous history note the habits of the individual, especially regarding alcohol, which predisposes to aneurysm, delirium tremens, tuber- culosis, neuritis, etc.; tobacco, which predisposes to carcinoma of the mouth and nervousness; tea and coffee, with reference to neuroses and gastric disorders; and the sexual life, particularly as to excesses and masturbation. Inquiry should be made also for previous injuries, diseases, and operations. Injuries may be followed by sarcoma, tuberculosis, epilepsy, abscesses, and many other disorders. Among the diseases which may have occurred the most important are syphilis and tuberculosis. Certain diseases predispose to subsequent attacks of the same malady; among such are appendicitis, sal- Pingitis, gall-stones, kidney-stones, erysipelas, delirium tremens, neuralgia, theumatism. Others render a patient more vulnerable to dissimilar affec- tions; appendicitis, gall-stones, and osteomyelitis often follow typhoid fever; stricture of any of the canals of the body, ulceration involving those canals; vesical calculus, renal colic; arthritis, gonorrhea. Operations are responsible for a host of evils, e.g., laparotomy may be followed by hernia, adhesions, or intestinal obstruction, ovariectomy by amenorrhea, gastroenterostomy by ulcer of the jejunum, thoracotomy by scoliosis, trephining by epilepsy, thyroid- ectomy by tetany, myxedema, or aphonia. The history of removal of a tumor may explain obscure brain symptoms due to metastases. We recently saw acase in which a hernia cerebri was incised for an abscess, a mistake that could not have occurred had the physician known that a decompressive operation had been performed. 7. The history of the present illness includes not only the symptoms, but the supposed cause, the duration, the manner of onset, and the previous treatment. As to the supposed cause, there may be a history of exposure to one of the infective diseases, such as erysipelas or syphilis; in this connection it is important to ascertain the time elapsing between the exposure to infection and the beginning of the symptoms, i.e., the period of incubation. The dura- ion sometimes has considerable bearing on the diagnosis, e.g.,a tumor which has lasted a number of years is probably benign, one which has lasted but a few months and is growing rapidly is probably malignant. The onset is sudden in appendicitis, perforative peritonitis, various colics, and acute in- fections; aneurysm, tumors, ascites, and strictures of various kinds come on 4 MANUAL OF SURGERY slowly. ‘The previous treatment may be of assistance in diagnosis; it may have failed, e.g.,a tumor or ulcer unmodified by mercury and potassium iodid is probably not syphilitic, chills uninfluenced by quinin are not malarial; it may have succeeded, e.g., a scrotal tumor disappearing temporarily after withdrawal of a serous fluid is a hydrocele, after taxis a hernia; it may have intensified the symptoms, e.g., intestinal obstruction is made worse by purga- tives, internal hemorrhage by stimulants; or it may have created additional mischief, e.g., drug eruptions, mercurial stomatitis, catheter cystitis, carbolic acid gangrene, iodoform delirium, splint sores, crutch palsy, ligature sinus, paraffin tumor, X-ray burn, cystoscopic ulcer. It may also obscure the diagnosis, e.g., chancre and epithelioma may be disfigured by caustics, the symptoms of peritonitis may be clouded by opium, and an unconscious man who has been given whiskey may be wrongly treated as an alcoholic. 8. The local examination needed will usually be indicated by the patient. By inspection the size, shape, situation, and color of the lesion may be determined, as well as abnormal motion, and the lesion may be studied with reference to the influence of posture, active or passive motions, etc. Whenever possible the size of a lesion should be expressed in exact terms, thus a tumor may be measured with calipers or tape measure, instead of being compared in size with an orange or other object. The length of a limb com- pared with that of its fellow is of the greatest value in the diagnosis of fractures and dislocations, as are also the length of the urethra in enlarged prostate, the width of the intercostal spaces in empyema, and the size of the head in hy- drocephalus and microcephalus. The shape may be accurately determined by a plaster cast, soft lead strips, photographs, or autoprints, e.g., in flat-foot. It is frequently of assistance in recognizing surgical conditions, especially fractures and dislocations. As other examples may be mentioned the notched teeth of hereditary syphilis, the pear-shaped swelling of a hydrocele, and the fusiform enlargement of a tuberculous joint. The situation of a lesion may indicate not only the anatomical but also the pathological diagnosis (see diagnosis of ulcers and tumors). The color should always be observed. Localized yellowish discoloration may be caused by xanthoma, an old bruise, or a nitric acid or iodin stain; bronze patches by syphilis, tuberculosis, scurvy, abdominal tumors, oil of cade, blistering agents, exposure to electric light or the X-ray, and the pressure of garters, belts, or collar buttons; white patches by ergotism, scars, frost bite, carbolic acid, leukoplakia, Raynaud's disease, neuritis, and leprosy; redness by acute inflammation or hyperemia (disappears on pressure but returns immediately on removal of the pressure), or by dyes, etc. (does not disappear on pressure and may ‘be washed off) ; b/ueness, or lividity, by venous obstruc- tion, nevus (returns quickly after pressure is removed), beginning gangrene (returns slowly after the relief of pressure), and ecchymosis (unaffected by pressure); blackness by moles, warts, gangrene, and melanotic sarcoma; &reenish discoloration by chloroma; change of color by nevi; and linear dis- coloration by lymphangitis, rarely phlebitis and neuritis. The mingling of purple and red is often observed-over malignant growths. Pelechia and ecchymosis are unaffected by pressure; they occur in many diseases, but it will suffice here to mention only those which interest the surgeon, viz. scurvy, hemophilia, iodism, jaundice, pyemia, septicemia, snake poisoning, and lightning stroke. Occurring several days after an injury, ecchymosis indi- cates rupture of some deep structure, such as muscle or bone. DIAGNOSIS AND RONTGEN RAY § Absence of motion is noticed in most inflammatory troubles, e. g., the chest in pleurisy, the abdomen in peritonitis; it is caused by a tonic contraction of the muscles, which gives another important sign, rigidity. Pulsation may be expansile (the swelling enlarges in all its diameters with each cardiac systole), e.g., in aneurysm, tumors communicating with the cranial cavity, and very vascular growths, such as goiter, some sarcomata, and certain angiomata; or transmitted (the movement is in one direction only), e.g., in tumors situated over an artery and in the abdomen of nervous individuals. Transmitted pulsation ceases if the tumor can be lifted or, by posture, made to fall away from the artery. Increased motion is exemplified in the hurried respiration of intrathoracic disease, and the active peristalsis of intestinal obstruction. In addition to the aids to the eye which have already been mentioned are the microscope, instruments for looking into cavities of the body (ophthalmo- scope, laryngoscope, bronchoscope, etc.), aspiration to determine the con- tents of a cavity or swelling, and exploratory incision. Diaphany, ortrans- lucency, is employed to detect disease of the maxillary antrum, by placing a light in the mouth; to determine the size of the stomach, by passing a light into this organ; and to ascertain the nature of some swellings, such as hydrocele and meningocele, by placing the tumor between the light and the eye, in a dark room, and looking through the barrel of a stethoscope or a tube of paper. Palpation is used to corroborate inspection, to ascertain the size, shape, position, etc., of a lesion which cannot be seen, e.g., by rectal or vaginal examination; and to determine the consistency, sensation, mobility, and local temperature. The consistency of normal tissues may be modified by the presence of solids, fluids, or gases. Solids, of which the most prominent ex- ample is tumor formation, may cause the tissues to become harder (osteoma, etc.) or softer (myxoma, etc.). Fluid infiltrates the tissues giving rise to edema, or accumulates in a cavity giving rise to fluctuation. Edema which is shown by the persistence of an indentation after digital pressure, occurs in contusions, inflammations, suppuration, obstruction to the venous or lymphatic circulation, extravasation of urine, and in diseases of the heart, lungs, liver, and blood. Hysterical edema and myxedema do not pit on pressure. Fluctuation is the wave felt by the hand on one side of a swelling when a sharp tap is given to the other side. In order to obviate the mistake due to a wave transmitted through the skin and subcutaneous tissues, the hand of an assistant may be placed on the swelling, between the hands of the examiner. This sign is often difficult to obtain when the fluid lies beneath firm fascia or thick muscle, is small in quantity, or under great tension, and it is often fallacious in semisolid tumors. Another sign, which is often called fluctuation, is the raising of the fingers of one hand when the fingers of the other hand push into the swelling; it may be obtained in normal tissues, in soft, elastic or movable tumors, and in tumors containing gas, as well as in swellings which contain fluid. Error may sometimes be avoided in eliciting this sign, e.g., in muscular tissue, by testing it longitudinally as well as trans- versely. Gas in the tissues (emphysema) causes a doughy swelling which crepitates on pressure. This crepifus, which is crackling in character, should not be confused with that of fracture or osteoarthritis, which is harsh and osseous; of epiphyseal separation, which is soft and cartilaginous; of synovial inflammation, which is creaking and leathery; or with that of blood clot or hydatid disease, which is moist and yielding. In certain bone diseases 6 MANUAL OF SURGERY (cysts, sarcomata, craniotabes, disease of the frontal and maxillary sinuses) a crackling sensation may be obtained on pressure (parchment crepitus), owing to thinning of the osseous tissue; and in synovial inflammations with rice bodies a special form of crepitation may be obtained by forcing the bodies along the sac. Related to crepitus is thrill, which may be felt over an aneu- rysm or vascular tumor, and sometimes in the case of a foreign body in the air passages. Aside from pain, disorders of sensation (hyperesthesia, hypesthesia, anesthesia, paresthesia, alteration of the heat sense or thermoesthesia, of the pressure sense, etc.) are mainly of value in diseases and injuries of the nerv- ous system. Pain is the most frequent symptom; and tenderness, which is of more value to the surgeon than pain, is pain on pressure. Its sifuation does not always indicate the seat of disease. In a lesion near the origin of a nerve pain may be felt in the periphery; in a lesion at the periphery, at the end of another branch of the same nerve. Certain diseases of the brain and spinal cord produce pain at the nerve terminations. General pain or aching of the body may be present in acute infections or intoxications. If pain corresponds exactly to the distribution of a nerve, the cause will probably be found along the trunk or at the root of that nerve; the pain of a local lesion does not confine itself to the distribution of a single nerve. Absence of tender- ness in a painful region generally but not invariably indicates that the pain is referred, but even in referred pain tenderness may be present. Pain in the top or the back of the head may be due to pelvic disease; in the supraorbital regions and the temples to d