CHAPTER XLVIII (Part 5)

the ground in standing, the deformity is known as talipes equinus. This de- formity varies much in degree, and the patient may walk on the ball of the toes or on the dorsum of the foot. The position of corns and callosities is a useful indication of the part of the foot upon which the patient walks. When the ankle is flexed, and the patient rests solely on the heel with the toes raised from the ground, it is talipes calcaneus. When the foot is rotated in at the transverse tarsal joint so that its inner border is raised and shortened, and is marked by a deep groove under the head of the astragalus, while the outer border is depressed and a corn or callosity is developed over the cuboid bone, it is talipes varus. If the foot is rotated out so that its outer border is raised from the ground and the peroneal tendons are tense while the inner border is depressed, it is talipes valgus. If the arch of the foot IS abnormally deep, the patient resting merely upon the heel and the ball of the toes, it is talipes cavus • while when the arch of the foot is lost, so that in standing the whole length of the inner border of the foot rests upon the gromid, the head of the astrafralus and the tubercle of the scaphoid being unduly^ro- mment.Jt is talipes planus, " flat-foot," or " spurious valgus. ' Two or more forms of talipes may be com- X* 713 714 SURGICAL DIAGNOSIS [chap. bined ; thus, talipes equinus and varus are frequently associated, and talipes cavus may be superadded ; talipes valgus and calcaneus are often found together, and in extreme cases of talipes planus some amount of valgus may be found. Talipes is either congenital or acquired. The con- genital cases are recognizable by their history, and in some cases by associated deformities such as spina bifida, and, where not due to paralysis, by the well-nourished condition of the limb and the great resistance to correction of the deformity. Cases of acquired talipes must be carefully in- vestigated with a view to tracing the deforrnity to the contraction of cicatrices or injuries dividing nerves {traumatic) ; to retention of the foot for a long period in one position {static) ; to paralysis of muscles {paralytic) ; or to spasm of muscles (sp«s^ic) : in the last case some source of reflex irritation or evidence of neuromimesis , such as intermission of the deformity, must be sought. When the leg is cold, perhaps even livid, and the muscles are wasted, and the patient is unable to move the foot and toes m the usual directions, the talipes is certainly faralytic. Occurring as it usually does in children, the disease interferes with the growth of the limb, which is more or less shortened, and the skin may be dry and rough. The surgeon must notice how far, and with how much force, he can correct the deformity, and what tendons or bands of fascia are then made tense. The great toe is often found pushed out of the straight line under or over the outer toes {hallux valgus), and then a bursa is apt to develop over the head of the metatarsal bone— this is known as a huninn ; the bursa may become inflamed and sup- purate. Loss of free flexion in the first metatarso- phalangeal joint produces what is known as Mkix DISEASES OF FOOT 715 rujidus ; this is often associated with ialifes flanus. If a toe is bent back at the metatarso-phalangeal joint, and flexed at the two terminal joints, the de- formity is known as hammer-toe ; this afiects especi- ally the second toe and is often complicated with a corn over the dorsum of the first iiiterphalangeal joint and another over the tip of the toe. The skin of the sole is often the seat of corns or callosities over the points of greatest pressure. Syphilis may give rise to thickening of the skin of the sole, with marked Assuring ; this condition must be distinguished from psoriasis. Irregular fissures and ulcers may be found between the toes in syphilitic patients, called rhagades digitorum. An ulcer may be found at either side of the nail of the great toe — most commonly the outer side — into which the edge of the nail presses ; this is a cause of great pain, and is attended with discharge and the growth of a fleshy mass over the nail ; it is known as ingroiving toe-nail. Ulcers are sometimes met with in the sole of the foot in the centre of corns ; they are painless, very chronic in their course, and a probe is found to pass in deeply between the metatarsal bones, or to strike bare bone ; they are known as perforating ulcers. The surgeon should examine the sensibility of the surrounding skin and the con- dition of the tendon reflexes, the gait, the pupil, and the spine, and should inquire for lightning-like pains in the legs ; these ulcers are often found in connexion with local_ anaesthesia, or tabes dorsalis, or spina bifida occulta. Sinuses are also met with in connexion with diseases of the bones and joints. Tumours. — Circumscribed ganglion may occur on the dorsum of the foot as on the hand. A firm tumour rising up under and displacing the nail of the great toe is a subungual exostosis. 716 SURGICAL DIAGNOSIS [chap. The bones and joints of the foot can easily be individually examined, and any swelling or tender- ness to pressure or movement can be readily deter- mined, while the probe passed into sinuses may detect either necrosed or carious bone. By pressing each toe separately back towards the heel, evidence of inflammation of the bases of the metatarsal and anterior tarsal bone 5 can be obtained. A good skiagram is of great value in the diagnosis by show- inff the integrity or otherwise of individual bones. ° Tuberculous disease of a tarsal bone is very prone to spread to one of its joint surfaces, and, from the large size and complexity of the synovial mem- branes, to extend quickly thence to several bones. This is especially true of the astragalus and scaph- oid bones. The position of swelling and tender- ness, and the movements which cause pain, as well as tiic position of sinuses, are the signs, in addition to the evidence afforded by the skiagram, by which the locality of tuberculous disease of the bones of the foot is determined. Extensive tuberculous disease may occur m the os calcis without involvement of either of the other bones. Gout attacks the metatarso-phalangeal joint of the great toe with much frequency. If the , great toe is chronically displaced outwards, and the usual prominence of the head of the metatarsal bone is much swollen, very painful, tender, reddened, and fluctuating, there is a suppurating bumon. ihe abscess may burst and leave a sinus, or may spread into the joint ; this will be shown by the occur- rence of grating and of great pain on moving the phalanx on the metatarsus. The acute inflammation of the bunion will be distinguished from gout by tlie history of the case and by the absence of the pre- monitory signs of gout. DISEASES OF FOOT 717 When a patient complains of great pain on stand- ing or walking, felt in the sole under the head of the third or fourth metatarsal bone and shooting down along the toes, and on examining the part no acute or grave change is found, but pressure on one particular spot causes the same severe pain, the affection is Morton's disease, and the pain is caused by pressure of the bone upon a digital nerve. Less severe pain, not shooting down to the toes, and not associated with such acute local tenderness, is caused by undue thinness oi the soft tissues of the sole. INDEX (IVIiere two or more references are (/iveii, and one is of superior importance, it appears in licavier tt/pc) Abdominal contusions, 151 sequelfe of, 159 diseases, action of bowels in, 537 a-cute, 525 • blood-count in, 538 collapse in 529 nervous pheno- mena in, 539 Ijain in, 525 pelvic examina- tion in, 534 percussion in, 533 previous history in, 534 pulse and tem- perature in, 530 rigidity of pari- eties in, 530 stethoscopy in, 538 swelling in, 531 • urine in, 538 vomiting in, 523 X-rays in, 539 distension, postoperative, 586 fistula, 169 hernia, 591 injuries, 150 operations, sequcke of, 583 tumoiire, 495 ■ coiisistenee of, 498 • — examination of blood in, 500 Hatiilent distension and, 502 • mobility of, 496 obesity and, 501 ontlin<' of. 498 wall, diseases of, 491 Abdominal wall, rigidity of, 164, 530 suppuration in, 159 tumours of, 492 Abscess, abdominal, 163, 5 24 alveolar, 3 8 4, 388 anal, 604 appendicular, 541 ■ beneath temporal fascia, 367 cerebellar, 379 cerebral, 98 , 3 7 8 chronic, 273 • extradural, 98, 378 hepatic, ruptured, 545 iliac, 666, 668 intra-abdominal, 587 ■ intraperitoneal, 512 ischio-rectal, 604 labial, acute, 628 • liver, 515 rupture of, 545 mammary, 480 chronic, 485 mediastinal, 148 of abdominal wall, 493 of Bartholin's gland, 628 of bone, 323 of groin, 667 of lung, 147 of nasal septum, 428 of scalp, 76 of scrotum, 633 of spermatic cord, 660 of tongue, 455 over aneurysm, 284 over artery, 285 parotid, 418 pelvic, 172, 587, 669 periappendicular, 541 perineal, 687 pcripleuritic, 145 peritoneal, 165 periuretliral, 689 psoas, 354 , 666 6 6 8 719 720 INDEX Abscess, retropharyngeal, 439, 459 spinal, 402 • subdural, 98 ■ submammary, 480 subpectoral, 145 • subphrenic, 587 • ■ supramammary. 481 • tuberculous, 458 iu muscle, 268 of spine, 402 Acetabulum, fracture of, 172 fissure across, 172 Acromegaly, 371 Actinomycosis, 2 61, 296, 462 Adenoids, 429, 438 Adenoma, mucous, of lips, 419 of breast. 484 of prostate, 690 of thyroid, 470 of umbilicus, 491 Adhesions, visceral, 582 Air-passages, foreign bodies in, 125 Air-sinuses, diseases of, 422 Albuminoid liver, 513 Albuminuriix, 681 Alcoholism as a complication of diagno.sis, 24 Alimentary canal, tumours of, 512 Alveolar abscess, 384, 3 88 Anaemia, splenic, 517 Anaesthesia, " stocking," 52 Anal abscess, 504 fistula, 605 tabs, 608 Aneurysm, 439 aortic. 94 arterio-venous, 282 carotid, 463 circumscribed traumatic, 36 ■ cirsoid, 281 of scalp, 366 diffused, 238 fusiform, 280 innominate, 463 ruptured, 238, 2 82 sacculated, 280 subclavian, 463 varicose, 282 Aneurysmal varix, 282 Aim-ina, Ijudwig's, 457 Angialar curvature, 402 Ankle, injuries about, 211 Ankle-.joinl. diseases of, 358 Ankylosis. 360 of ankle. 363 Ankylosis of digits, 362 of elbow, 362 of hip, 362 of knee, 365 of lower jaw, 361, 391 of shoulder, 361 ■ of tarsus, 363 of tempore - mandibular joint, 391 of vertebral bodies, 399 of wrist, 362 Aunulus migrans. 449 Anthrax, 416, 458 Antro-choanal polyp, 428 Antrum of Higlimore, disease of, 422, 425, 42 6 suppuratiou iu, 386 Anus, artificial, 169 diseases of, 599 eczema of, 504 ex.aminatiou of, 502 fissures of, 607 fistulas of, 605 narrowing of, congenital, 618 patulous, 607 stricture of, 607 Aorta, pulsating, 523 Aortic aneurysm, 94 Aphtha;, 420 Aphthous ulcer, 420 Apoplexy, 94 Appendicitis, acute, 540 chronic, 578 gangrenous, 540 perforative, 540 suppurative, 541 Appendicular abscess, 541 Arachnoid membrane, lacera- tion of, 91 Areola, examiuation of, 473 Arterio-venous aneurysm. 282 Arteritis, oblitcrative, 311 trauuiatic, 49 Artery, compression of, 49 dilatation of, 241 laceration of, 48 rupture of, 50, 234, 282 Arthritis, acute, 335 of infanls. 358 chondro-. syidiililica. 341 ■ deformans. 541^ gonorrhaMi, 536 gummatous. 341 secondary. 356 tuberculous. 340 Arlhropatliy, ataxic. 358 , 3 4 2 Ascites, 512 INDEX 721 Astragalus, dislocation of, 214 fracture of, 215 Ataxic arthropathy, 338 , 3 4 2 Atony of bowel, 558 Atrophic rhinitis, 427 Auditory nerve, injury of, 96 Axilla, examination of. 475 Balano-posthitis, 622 Banti's disease. 517 Barbadoes leg, 635 Barium meal and X-rays, 509, 572 Bartholin's glaiul, abscess of, 628 cyst of, 628 Beck's paste, 300 Bedsores. 106, 2 9 4 Bennett's fracture, 194 Biceps, dislocation of tendon of, 48 Bilharzia (schistosoma), hiem- orrhage due to, 683 Bismuth meal and X-rays, 560, 5 72 Bladder, calculus in, 693 examination of. 690 fistula of, 695 foreign bodies in, 177 haemorrhage from. 682 rupture of. 174 sacculus of, 691 tumours of, 506. 694 Blood-count in abdominal af- fections, 538 - — in enlarged glands, 264 Blood, extravasation of, 18 Bone, abscess of, 323 and periosteum, contu- sion of, 41 caries of, 324 crepitus of, 39 hypertrophy of, 320 in.inry of. 40 mobility of, 38 secondary carcinoma of. 327 syphilis of, 323 tumours of. 313 ulcers of, 324 — — (see also Skull. Spine) Braui, compression of. 92 concussion of, 90 contusion of. 90 laceration of. 91 — — spreading ncdi'ma of. 97 Brancliial listula, 465 " Breast, abscess of. 4 8 0 . 485 X** Breast, carcinoma of, scir- rhous, 487 diseases of, 471 enlargement of, 479 examination of, 472 hypersesthesia of, 483 hypertrophy of, 481 male, diseases of, 490 neuralgia of, 483 tumours of, 476 Broad-ligament tumours, 507, 518 Brodie's tumour, 485 Bronchocele, 469 Bronchoscope in diaenosis, 124 Bruises (see Contusions) Bruit in tumours, 277 Bryant's triangle, 199 Bubo, indolent, 672 sympathetic, 667 virulent, 663 Bunion, ruppurating, 716 Bursse of knee-.joint, 357 wounds of, 61 Bursitis, acute, 338 biceps-cmris, 358 chronic, 344 dry, 339 librous, 344 infrapatellar, 357 plastic, 344 prepatellar, 357 psoas. 354 sartorius. 358 semimembranosus. 358 subacute plastic. 339 suprapatellar, 357 tendo-Aohillis, 359 tuberculous. 344 Cachexia, tumours and, 25J Ceecal stasis, 582 Calculus, nasal, 429 ■ pancreatic, 581 preputial, 620 prostatic, 689, 690 renal, 698 salivary, 432 ureteral. 700 urethral. 689 vesical, 693 Cancer en cuirassc," 489 - (.'ce nh-n Carcinoma) Canorum oris, 415 Carbuncle, 416. 457 Carcinoma, heredity of 5 of breast. 482. '4 8 6 acute, 481 722 INDEX Carcinoma of brea.st, varie- ties of, 489 of colon, 522, 5 60 of gall-bladder, 516 of jaw. 389 of liver, 514 of pancreas, 581 of prostate, 691 of pylorus, 520 of reotum, 616 of spermatic cord. 662 of stomach, 576 scirrhous, 487 secondary, 268 in bone, 327 in spine, 407, 411 Caries, 3 0 0 , 324 of spine, 402 Carotid aneurysm, 463 body, tumours of. 462 Carpus, dislocations and frac- tures of, 191 Caruncle, urethral. 628 Causalgia. 49. 6 8 j Cellular tissue, tumours of. i 258 Cellulitis, 77 Cephalh£ematonia, 73 Cephalhydrocele. traumatic, 286 Cerebellar abscess, 379 Cerebral abscess, 98, 3 78 Cerebro-spinal fluid, escape of, in injuries of skull. 82. 427 Chancre, hard, 294, 624 on lip. 414 on tonsil. 437 ■ Hunteriau {?ee Chancre, hard) mixed, 625 sloughing pha^edajnic, 663 soft, 296, 624 Charcot's disease. 338 . 3 4 2 Cheloid, 70 Chest, concussion of, 137 contusions of, 128 injuries of. 128 complications of, 143 - - wounds of, 137 Cholecystitis. 516, 579 i acute. 544 Cholclitliiasis. 579 Chondroma of nose. 423 Chond r-o-sarcouia. of nose. 424 [ Chondi-n - arthritis sypliililic.a of Viichow. 341 Chordop. 676 Circumscribed I r a u in a f i i' aneurysm. 36 Cirrhosis, hyperti-ophic, 513 Cirsoid aneurysm, 281 of scalp, 366 Clavicle, dislocation of, 181 fracture of, 182 Cleft, lateral facial. 413 — - palate, 433 Coccygeal cysts, 410 sinus, 407 Coccygodynia, 406 Coccyx, fracture and disloca- tion of. 109 Colic, biliary. 544 lead, 547 - renal. 545 Collapse. 21, 529 massive, of lung. 585 Collargol and X-rays, 595 Colles'e fracture, 192 Coloboma, 413 Colon, cance? of, 522. 560 stenosis of. 579 tumours of, 509 — ulceration of, into stom- ach, 529 Coma, diabetic, 95 Comminut€d fracture, 43 Compression of brain, 92 Concussion of brain, 90 of chest, 137 of spine, 103 of thorax, 137 Condensation of bone, 316 Condyloma, 256 Congestion of breast, 479 Constipation, absolute, 551 chronic. 554 Contusions, abdominal, 151 sequelae of. 159 of abdominal wall. 159 of bone and periosteum. 41 of brain. 90 of chest, 128 — of neck, 121 of uterus, 158 pelvic. 171 Corns, 715 Coryza. chronic 425 Coxa vara, 352 Cranial contents, lesions of, 85 complications of, 07 Craniotabes. 369 Crepitus. 39 Crimes. Dietl's. 700 ■ gastric. 548 Curvatur-p, angular. 402 lateral. 403 INDEX 723 C'yauosls, traumiitic, 137 €ystadenoma of breast. 485 Cybtic hygroma, 2 5 9, 670 Cysticercus celhilo:;a;, 263 Cystitis, 692 tuberculous, 692 Cystoscopy, 690. 694, 702 Cysts, 273 coccygeal, 410 (leutal, 388 (lentigerous, 388 Uermoid. 417 branchial, 433, 459 of scalp, 356 Cysbs, hydatid, of bone, 327 of liver, 514 of muscle, 268 of spleen, 517 of tongue, 455 ■ involution, of breast, 484 labial, 417 lymphatic, 460 milk, 484 mucous, of tongue. 455 multilocular, 389 of Bartholin's gland. 628 of jaw. 388 ovarian, 518 ruptured, 158 small, 542 twisted, 542 over aneurysm, 284 over artery, 285 pancreatic, 164 parotid, 417 salivary, 417 sebaceous. 3 66, 417, 459 of scrotum, 633 ulcerated. 363 serous, 326 spermatic. 643 sublingual, 432 ■ synovial, 344 thryoglossal, 459 urinary, 164 Dactylitis, 709 Deformities, na.sal, 423 of foot, 713 of hand, 705 Delirium, traumatic, 29 tremens. 29 Dental cysts. 383 Dentigcrous cysts, 388 Depressed fracture. 78 Dermoid cysts (.«c(? Cyste, der- moid) Desmoid tumours. 493 Diabetic coma, 95 ■ gangrene, 309, 310, 312 Diagnosis, detinition of, 1 principles of, 1 Diaphra.gm, rupture of, 157 Diffused aneurysm, 238 Dilatation of stomach, 510 Discliarge from prepuce, 621 nasal, 422, 425 rectal, 601 Dislocation, 44 of ankle, 212 of astragalus, 214 of carpus, 191 of clavicle, 181 of coccyx, 109 of elbow, 187 of foot, 212 of hip, 202 — congenital, 352 pathological, 352 of jaw, 117 of knee, 206 - — of medio - tarsal join t. 214 of metacarpal bones, 191 — of metatarsus, 214 - - of OS calcis, 214 of patella, 206 of radius, 193 - - of scapula, 182 — of semilunar cartilage, 207 — of shoulder, 183 - of tibia, 206 of ulna, 188 of wrist. 191 — subastragaloid, 213 Distension, abdominal, post- operative, 586 flatulent, 502 of bowel, 556 of gland, 240 of viscus, 240 Diverticulitis, chronic, 522, 560