Injuries

PART III. INJURIES.

AND DIAGNOSIS OF INJURIES

THE HEAD THE NECK THE CHEST . THE ABDOMEN THE PELVIS THE SPINE

THE LIMBS .

PART I. SURGICAL DIAGNOSIS.

CHAPTER I. INTRODUCTORY.

THE art of surgical diagnosis consists in eliciting, by questions and by direct physical examination, as much information as possible about the case that is the object of diagnosis ; in examining the information thus obtained ; in reasoning upon it; and in deducing a correct conclusion therefrom.

In order that the conclusion or diagnosis be correct, it is desirable that the information obtained should be as full and complete as possible, and that the reasoning be correct.

It is obvious that the correctness of the diagnosis will depend :

i. Upon the fulness and the accuracy of the infor-

mation obtained.

ii. Upon the experience and knowledge of surgery possessed by the surgeon, which enable him to reason correctly upon the information he has obtained.

Accurate information about the various points of the

A

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case will not suffice for a correct and reliable diagnosis unless a knowledge of surgery, and especially of surgical pathology, as well as a certain amount of practical experience, be possessed by the diagnostician. On the other hand, it is essential that the premisses upon which the conclusion is based should be correct, if a correct interpretation is to be placed upon them.

Incorrect diagnosis may arise either from incomplete or inaccurate premisses, or from incorrect deduction therefrom.

Surgical diagnosis ought not to consist, as some students seem to imagine that it does, in the mere fitting of a name to a diseased condition. It should be much more than this. It should aim at ascertaining as exactly as possible in what respect, and to what extent, the patient’s condition deviates from that of perfect health. In other words, it should comprise, not only the nomenclature of the disease, but also the degree and extent of that disease.

The diagnostician has two main sources of informa- tion upon which to found his diagnosis.

He ascertains from the patient, or from others, the history of the various ailments or symptoms which have been noticed. He ascertains, by direct physical examination, to what extent the condition of the body before him differs from the normal condition of a body of the same age and sex.

By putting together all the pieces of information obtained from these two sources, by reasoning about them and by exercising his judgment, he endeavours to arrive, if possible, at a diagnosis of the diseased condition,

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Sometimes the one and sometimes the other of these two main sources of information is the more important. Asa rule neither should be completely ignored.

Thus, in the case of an otherwise healthy person who has a large, soft, lobulated tumour in the subcutaneous tissue over the shoulder, the physical characters alone are usually sufficient for a diagnosis of fatty tumour. The history is comparatively unimportant, and would probably merely refer to the duration of the tumour and to any other ailments of which the patient may also be the subject.

Conversely, a history of repeated severe attacks of excruciating pain in the area of distribution of some portion of the fifth nerve may be sufficient for the diagnosis of epileptiform neuralgia, even though the patient may present no physical sign of disease.

Much caution should, however, be exercised before making a diagnosis upon history alone. Physical signs‘of disease which the surgeon can himself observe are as a rule much more important to him than mere history, for which he has to depend upon what is told him by others.

If history and physical examination appear to be contradictory, more stress should, as a rule, be laid upon the latter than upon the former.

Importance of Care and Thoroughness in Conducting the Examination.

The examination, both oral and physical, should be conducted carefully, and should be as thorough as circumstances allow.

It is all very well for a surgeon of considerable age

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and vast experience to glance at a patient, just lay his hands on the affected part, perhaps ask one or two questions, and then deliver himself of a diagnosis. For such surgeons this book is not intended, although even such as they will sometimes make mistakes if they practise too frequently such rapid and cursory examinations. For the less experienced practitioner it cannot too earnestly be laid down that care and thoroughness in examination are allimportant. “ Snap- shot” diagnoses, although sometimes impressive to the onlooker, carry with them the risk of serious error, and are not to be recommended. More mistakes in surgical diagnosis have arisen from carelessness and over confidence than from actual want of knowledge on the part of the surgeon.

In conducting his examination of the patient the surgeon should not confine his attention exclusively to that particular part of the body of which the patient complains. Although this is the part which first and chiefly engages his attention, he should not omit to examine other parts as well. If the affection is a unilateral one, he should carefully examine the corres- ponding part on the opposite side of the body, com- paring it with the affected region.

If the case be an obscure one, a very thorough and minute examination of many parts may become necessary.

It should not be forgotten that a patient may be suffering simultaneously from two or more diseases. The one which is most obvious and most easily dis- covered is by no means necessarily the most important.

Thus a patient may present himself with the symptom of piles, but have also a carcinomatous

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stricture of the rectum. A woman with a femoral hernia may be suffering from internal strangulation of some other portion of the bowel.

A patient with an adenoma of the breast may have enlarged axillary glands due to old tuberculous or jother disease, and so on.

“Have you, or have you ever had, any- thing else the matter with you?”’ is a useful question, the answer to which may perhaps, by reveal- ing some obscure or unnoticed feature in the condition of the patient or in the history of the case, throw an entirely new light upon the problem of diagnosis, and may be of the utmost importance.

This question is often useful when the investigator begins to feel that he is being puzzled by the case, or is uncertain as to its exact nature.

A patient was admitted into hospital on account of a chronic ulcer of the leg. The dresser made excellent notes about the ulcer, but found himself wholly unable to give any diagnosis as to its nature, since the diagnostic features of the ulcer were not in themselves sufliciently characteristic. A more complete examination revealed, on the patient’s back, a circular, deeply excavated ulcer; there were also, in various other parts of the body, round depressed scars of healed ulcers. Also careful examination of the pupils showed considerable irregularity in one of them, and be- tokened a former attack of iritis.

It was then clear that the patient was suffering from tertiary syphilis, and much light was thrown upon the nature of the ulcer of the leg.

A boy was admitted on account of a swelling of one knee-joint, which had supervened, apparently sponta- neously, a few days previously. It was obvious that the joint was full of fluid, but the nature of the fluid was not

6 SURGICAL DIAGNOSIS.

apparent until cross-examination elicited the information that on several previous occasions he had bled severely after the extraction of teeth, that he had also suffered from hemorrhage from the rectum and that other members of his family had also shown a marked tendency to hemorrhage. The swelling of the knee-joint was thus suspected to be due to hemophilia, and closer examination of the joint showed a very slight discoloration, which confirmed the diagnosis.

Excessive Examination.

In the case of patients who are acutely ill, prolonged and thorough examinations are often inadvisable. How- ever desirable from the point of view of exact diagnosis, they may cause much distress and even harm to the patient, from exposure, pain, or fatigue.

It may be better to remain in ignorance about certain points necessary for a complete diagnosis, rather than run the risk of doing harm to the patient by thorough investigation of these points.

Unless some important point of treatment depends upon the exactness of the diagnosis, it is often better, at any rate for the time, to defer making that thorough examination without which complete diagnosis may be impossible.

Probability as an Element in Diagnosis.

Students often show a tendency to diagnose rarities of which they have read in books, but which they have never actually seen. The experienced practitioner will hesitate to do so until he has fully considered the possibility of the existence of some commoner affection.

This is frequently shown, for example, in the diag-

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nosis between chronic inflammatory affections of bone, which are common, and malignant tumours of the same part, which are distinctly less common.

The diagnosis of a rare disease should not be made unless its features are characteristic and unmistakable, or until the possibility of its being some more common disease has been carefully considered and excluded.

If an example of some rare disease has recently been under his observation, the surgeon, when he meets with a second case of apparently similar nature, should be on his guard against jumping hurriedly to the conclu- sion that this also is an example of the same disease. It is probable that it will not be the same disease, and he should examine most carefully before pronouncing it to be of the same rare nature as the first.

The age and sex of the patient are important elements in this question of probability.

A disease that is common in the male subject may be rare in the female, and vice versa. Thus the symptoms of perforative peritonitis at the upper part of the abdomen in the case of an anzemic young woman are very suggestive of a perforated gastric ulcer. Similar symptoms in a young man would be more likely to indicate a perforated duodenal ulcer.

A disease that is frequently seen in the young may be uncommon or unknown in an older person, and vice versa. Thus, a history of frequent slight haemor- rhage from the rectum in the case of a young child would suggest a polypus; the same symptom in an adult would be more likely to indicate piles, or some form of ulceration of the rectum.

Chronic and severe intestinal obstruction for which no definite cause can be discovered is exceedingly likely

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to be due, in the case of an elderly person, to a carci- nomatous tumour of the large intestine. In the case of a child, such a diagnosis would be in the highest degree improbable, whereas bands of adhesion, due to some old inflammatory trouble, or some congenital affection, would be a much more likely cause.

The surgeon should always endeavour to make his diagnosis as complete as possible. Sometimes, however, a complete diagnosis may, owing to lack of sufficient evidence, be impossible. In such a case the surgeon may be able to make a partial diagnosis. He should always aim at making his diagnosis as accurate and complete as he can.

Diagnosis is usually but the first step towards prog- nosis and treatment. Sometimes these latter may be sufficiently evident even in the absence of the former in its complete form.

Thus, a patient may be suffering from acute symptoms of severe intestinal obstruction, which may obviously demand the surgical operation of abdominal section, although the precise nature of the obstruction may be problematical until the abdomen has been opened.

The diagnosis of a tumour (using the word in its widest sense of a swelling) generally involves an answer to two distinct questions.

1. Where is the lump ?—z.c., in what anatomical structure is it situated ?

2. What is the lump ?—+.c., what is its exact nature, is it inflammatory, new growth, &c. ?

Frequently the answer to one of these questions may easily and readily be given, while the answer to the other is difficult or impossible.

For instance, a small hard lump in the region of one

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lobe of the thyroid gland, and moving freely with the larynx and trachea, may without much fear of error be pronounced to be a swelling of the thyroid gland. It may, nevertheless, be a matter of considerable diffi- culty to decide whether this is a solid adenoma, a tense cyst, or a malignant tumour in an early stage.

A swelling in the scrotum may obviously be of the testis, but it may be very difficult or impossible to pronounce definitely whether it is inflammatory or malignant.

Conversely, a pulsating swelling deeply seated at the root of the neck and behind the sternum may obviously be an aneurism, and yet it may be very difficult or impossible to say whether it springs from the arch of the aorta or from the innominate artery.

A hard and somewhat nodular tumour deeply seated in the abdomen of an elderly patient who had recently lost much weight and strength without apparent cause may be clearly malignant, while the exact anatomical situation of the growth may be a matter of much doubt.

Diagnosis by Exclusion.

In a difficult case in which the history and physical signs do not point clearly to a definite diagnosis, the surgeon may find it useful to endeavour to make a diagnosis by the method of exclusion. He passes rapidly before his mind all the possible diseases, or groups of diseases, of which the case before him may be anexample. By eliminating first one then another and so on, he gradually narrows the field of diagnosis more and more until eventually he may be able to

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arrive at a conclusion as to the true nature of the affection before him.

By this method he is less likely to overlook some possible diagnosis which had perhaps not hitherto occurred to his mind.

In proceeding to make a diagnosis by exclusion, some such classification of diseases as the following may be found useful. It may be modified, extended or altered according to individual taste :

1. Congenital malformations.
2. Atrophy.
3. Hypertrophy.
4. Inflammation. (a) Acute. (b) Chronic. (c) Due to specific processes—e.., tubercle, syphilis, rheumatism. (d) Results of inflammation—ey., abscess, ulcer, scar, &c. Extravasations—e.g., of blood. Accumulations—e.g., of fluids in ducts or
5. closed cavities. Concretions—e.g., calculi, faecal concretions, &e.
6. Parasites—eg., hydatids. Cystic. Solid. ‘ Cystic. Malignant { Solid.
7. Deformities—e.g., lateral curvature of spine. g. Nervous and hysterical affections. [z0. Injuries.]

Ny

. New growths—Innocent {

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Revision of the Diagnosis.

When the whole examination of the case has been finished, and a diagnosis, more or less complete, has been made, it is often well to review once more all the facts that have been elicited, and to ask oneself the question :

“‘ Now, can this be anything else?” or, “ Supposing this were not what I believe it to be, what other diagnosis might possibly be made ?”

By exercising this wholesome mental effort, a mistake in diagnosis may sometimes, even at the last moment, be avoided. Something else may occur to the mind which, upon further consideration, may possibly lead to an alteration in the diagnosis.

A too hasty conclusion may perhaps have been drawn, and may require revision.