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Epithelioma of Lip.



Lumiere colored photograph of a patient in the author's service at the
Roosevelt Hospital.



A



TEXT-BOOK OF SURGERY



FOR STUDENTS AND PRACTITIONERS



BY

GEORGE EMERSON BREWER, A.M., M.D.

PROFESSOR OF SURGERY AT THE COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK;

SURGICAL DIRECTOR OF THE PRESBYTERIAN HOSPITAL; CONSULTING SURGEON TO THE ROOSEVELT

HOSPITAL, THE CITY HOSPITAL, THE MUHLENBERG HOSPITAL OF PLAINFIELD, N. J., AND THE

PERTH AMBOY CITY HOSPITAL; FELLOW OF THE AMERICAN SURGICAL ASSOCIATION, OF

THE AMERICAN ASSOCIATION OF GENITO-URINARY SURGEONS, OF THE NEW YORK

ACADEMY OF MEDICINE, AND OF THE NEW YORK SURGICAL SOCIETY; MEMBRE

DE LA SOCIETE INTERNATIONAL DE CHIRURGJE; MEMBRE DE LA SOCIETE

INTERNATIONAL DE UROLOGIE: MEMBRE CORRESPONDENT DE

L'ASSOCIATION FRANC AISE d' UROLOGIE

ASSISTED BY

ADRIAN V. S. LAMBERT, M.D.

ASSOCIATE PROFESSOR OF SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY;
ATTENDING SURGEON TO THE PRESBYTERIAN HOSPITAL

AND BY

MEMBERS OF THE SURGICAL TEACHING STAFF OF
COLUMBIA UNIVERSITY



THIRD AND ENLARGED EDITION, THOROUGHLY REVISED AND

REWRITTEN

ILLUSTRATED WITH 500 ENGRAVINGS IN THE TEXT AND 23 PLATES
IN COLORS AND MONOCHROME




LEA & FEBIGER

PHILADELPHIA AND NEW YORK
1915




Entered according to the Act of Congress, in the year 1915, by

LEA & FEBIGER,
in the Office of the Librarian of Congress. All rights reserved.



IV s "



COLLABORATORS

HUGH AUCHINCLOSS, M.D.
SIDNEY R. BURNAP, M.D.
WILLIAM A. CLARKE, M.D.
JAMES A. CORSCADEN, M.D.
WILLIAM DARRACH, M.D.
JOHN A. McCREERY, M.D.
FRANK S. MATTHEWS, M.D.
CHARLES H. PECK, M.D.
EUGENE H. POOL, M.D.
JAMES I. RUSSELL, M.D.
FRANCIS J. SLOANE, M.D.
FORDYCE B. St. JOHN, M.D.
ALLEN 0. WHIPPLE, M.D.
ARMITAGE WHITMAN, M.D.



TO

ROBERT F. WEIR, M.D., Hon. F.R.C.S. Eng.,

PROFESSOR OF SURGERY, COLUMBIA UNIVERSITY, ETC.,

A MASTER OF SURGERY, A SCHOLARLY TEACHER, A SUCCESSFUL

PRACTITIONER, MY HONORED CHIEF AND

VALUED FRIEND,

THIS VOLUME IS AFFECTIONATELY DEDICATED

BY THE AUTHOR.



PREFACE TO THE THIRD EDITION.



The demand for a new edition has been utilized to the fullest
extent by subjecting the entire work to a thoroughgoing revision.
This has resulted not only in the complete rewriting of every chapter,
with consequent enlargement, but also in the addition of many new
ones. The book, in a word, is virtually a new one, and it is confidently
hoped that it will accomplish its purpose of presenting clearly every
phase of modern surgery.

To reach this object with the maximum of certainty, the author
has availed himself of the help of a number of colleagues on the Surgical
Staff of Columbia University. The plan followed, as far as possible,
was to have the chapters upon subjects in which notable progress has
been made revised and in some instances largely rewritten by members
of the teaching staff of the Medical School who had to do directly
with the instruction in these subjects. Thus the chapters on Surgical
Pathology have been revised by Dr. Clarke ; the chapter on Anesthesia
by Dr. Whipple; that on Bone Infection by Dr. Russell; Dr. Pool
revised the subjects of shock and allied conditions, heart and peri-
cardium, and has entirely rewritten the section on goitre. The author
is indebted to Dr. Mathews for rewriting the sections dealing with
hare-lip and cleft palate; to Dr. Whitman for revising the chapter
on Deformities; to Dr. McCreery for that on the muscles, tendons,
and burs?e; to Dr. Sloane for the one on the bladder, urethra, and
male genital organs; and to Dr. Burnap for the chapter dealing with
hernia. Dr. Darrach revised the subjects of fractures and dislocations,
and added much to the modern operative treatment. Dr. Corscaden
revised the chapter on Amputations and largely rewrote the chapter
on Diseases of the Joints. Dr. Whipple and Dr. St. John have added
an important chapter on Postoperative Treatment, and Dr. Auchin-
closs, in addition to revising the chapter on the Lymphatic System,
has brought the important subject of hand infections and cellulitis
up to date. Dr. Peck revised the subjects of appendicitis, peritonitis,
and diseases of the large intestine, to make them correspond with his



vin PREFACE TO THE THIRD EDITION

lectures and clinical teaching. To Dr. Lambert the author is indebted
not only for a careful revision of the chapters on Surgical Technic,
Injuries and Diseases of the Nerves, Head, Brain, and Spinal Cord,
but also for assuming in large part the duties of Editor.

The author's personal revisions have been limited to the chapters
dealing with the surgery of the face, neck, mouth, pharynx, larynx,
pleura, lung, mammary gland, stomach and duodenum, liver and
biliary passages, pancreas, spleen, kidney and ureter.

Many of the subjects were completely rewritten, and considerable
extra space had to be allotted to include the advanced ideas of
pathology and treatment which have been developed since the pub-
lication of the second edition. Particularly was this the case in
dealing with hand infections and cellulitis, with goitre, and with
joint diseases.

Many new illustrations have been introduced from photographs

from the Record Room and Surgical Laboratory of the Presbyterian

Hospital, also an increased number of full-page colored plates have

been reproduced from a series of Lumiere photographs of clinical

conditions.

G. E. B.
New Yobk, 1915.



CONTENTS.



CHAPTER I.
Infection Considered in its Surgical Relations 17

CHAPTER II.
Inflammation 31

CHAPTER III.
Acute Infectious Surgical Diseases 38

CHAPTER IV.
Chronic Infectious Surgical Diseases 58

CHAPTER V.
Tumors 74

CHAPTER VI.
Shock and Allied Conditions 101

CHAPTER VII.

Surgical Technic 128

CHAPTER VIII.
Anesthesia 153

CHAPTER IX.

Treatment of Postoperative Conditions 174

CHAPTER X.
Injuries and Diseases of the Skin and Subcutaneous Tissues . 189

CHAPTER XI.

The Surgery of the Pericardium and Heart 241



x CONTENTS

CHAPTER XII.
Injuries and Diseases of the Lymphatic System 278

CHAPTER XIII.
Injuries and Diseases of the Muscles, Tendons, Fascle and Bunas . 294

CHAPTER XIV.
Injuries and Diseases ok the Xerves 303

CHAPTER XV.
Injuries and Diseases ok Head and Brain 324

CHAPTER XVI.
Injuries and Diseases of the Spine 374

CHAPTER XVII.

Injuries and Diseases of the Face and Neck, Oral, Nasal, and

Pharyngeal Cavities 387

CHAPTER XVIII.
Injuries and Diseases of the Thorax, Pleura, and Lung .... 459

CHAPTER XIX.
Malformations and Diseases of the Mammary Gland 483

CHAPTER XX.

Injuries of the Abdomen 500

CHAPTER XXI.
Diseases of the Abdomen 507

CHAPTER XXII.

Diseases and Injuries of the Kidneys and Ureters 600

CHAPTER XXIII.
Injuries and Diseases of the Bladder and Urethra G46

CHAPTER XXIV.
Injuries and Diseases of the Penis and Scrotum 688



CO NT R NTS xi

CHAPTER XXV.
Injuries and Diseases of the Testicle, Seminal Vesicle, and Prostate 699

CHAPTER XXVI.

Injuries and Diseases of the Rectum and Anus 723

CHAPTER XXVII.
Diseases of Bone 741

CHAPTER XXVIIT.
Injuries and Diseases of Joints 766

CHAPTER XXIX.
Fractures ' 806

CHAPTER XXX.
Dislocations 873

CHAPTER XXXI.
Hernia 909

CHAPTER XXXII.
Amputations 944

CHAPTER XXXIII.
Deformities and Their Correction 964



SURGERY.



CHAPTER I.
INFECTION CONSIDERED IN ITS SURGICAL RELATIONS.

INTRODUCTION.

Surgery is that branch of the healing art directed toward the
remedying of injuries, deformities, and many other morbid conditions
by mechanical operations.

Such a conception of surgery differentiates it from the art of
medicine. So intimately related, however, are the two that it is
almost impossible to draw a sharp dividing line between them.
Therefore, in the broader sense, surgery may be said to include the
subjects of infection, inflammation, injuries, new growths, foreign
bodies, malformations, deformities, and the relief of pain, with the
various methods of operative and therapeutic procedure which their
betterment entails.

The phenomena of infection and inflammation, occurring, as they
do, more commonly than all others in surgery, being of fundamental
importance and far reaching in their relations to other surgical
aspects, it is essential that any exposition of the subject of surgery
must be preceded by a thorough comprehension of these phenomena.

Although the occurrence of inflammation is often aided by the
existence of predisposing agencies, the direct or exciting causes are
usually to be found under the heads, direct violence and physical
irritation, chemical irritants, and microorganisms.

Microorganisms are distributed widely in air, soil, and water,
but it is among the habitations of man, where the conditions for
their growth and development are especially suitable, that they are
most numerous. For the most part, they are harmless species;
but pathogenic forms may occasionally be found, especially in
localities where the discharges of diseased animals have been allowed
to collect. Thus, while the conditions here are unfavorable for
the growth of most harmful species, it has been shown that certain
pathogenic bacteria have their primary habitat in soil; while others
are capable, at any' rate during part of their existence, of finding a
nidus there.



IS INFECTION CONSIDERED IN ITS SURGICAL RELATIONS

So far as we know, then, with few exceptions, micro-organisms
whose natural habitat is in the soil or water, are not under normal
conditions harmful to man, for they are present in greater or less
numbers upon the exposed cutaneous or mucous surfaces of the
body, sometimes serving useful functions, as do those in the
intestines.

Experiments by Nuttall and Schottelius show that the healthy
animal is born germ-free. At birth, however, it is at once introduced
into a world of bacteria that fall upon the skin and gain entrance
to the respiratory passages and alimentary canal through air and
food. In a short time they may be found in various parts of the
body, so that each part ultimately becomes a regular habitat for a
number of species.

Notwithstanding, however, the occurrence of bacteria in these
situations in great numbers, they do not often gain entrance into
the body tissues, so that under normal conditions the blood and
viscera have been considered germ-free. It has, however, been
urged by Adami and Ford that bacteria reach not alone the deeper
structures of the intestine under what appear to be normal conditions,
but commonly also invade the blood of the portal circulation and
the liver and kidneys during life.

Whenever bacteria do find their way into the body, the condi-
tions are usually so unsuitable for their existence that they are soon
destroyed. Against such incursions the body is guarded in various
ways. Of the defensive arrangements which normally exist at the
various portals of entry, some are partly mechanical by reason of the
anatomic structure of the part. Thus the thick cutaneous covering
is impenetrable to most bacteria; the same is equally true for the
stratified squamous layer of the mouth, esophagus, and vagina.
While the cylindric epithelium covering other mucous surfaces is
doubtless less efficient, it should be remembered that they are so
situated as to be less exposed to injury.

There are certain situations, such as the tonsils and lymphatic
apparatus of the gut, which are especially liable to bacterial invasion
on account of their delicate covering; but there is abundant reason
to suppose, as will be seen shortly, that they are endowed with
vital protective properties.

In addition to these mechanical defences are the antibacterial
qualities of the secretions on mucous surfaces. Some of the prop-
erties depend on the chemical action of the gastric juice; some
partly on the antagonism offered to invaders by the normal flora
of the part; while still others depend largely upon the germicidal
qualities of the secretion.

But notwithstanding these protective factors, bacteria do some-
times penetrate the normal body coverings, and this may especially
occur whenever these coverings are injured, even if ever so slightly.
Having gained entrance to the tissues they may be engulfed by



PORTALS OF ENTRY 19

leukocytes or destroyed by tissue fluids. Escaping, they may be
arrested in the regional lymph nodes.

If bacteria do reach the blood, they again have to contend with
the body fluids and leukocytes. It is evident that in health the
body is protected abundantly against ordinary bacterial invasion,
but there are conditions in which the strongest and healthiest
body is unable to offer adequate resistance; obviously, therefore,
it is usually when the vital resistance of the body cells has been
lowered that virulent bacteria overcome the natural safeguards to
infection.

PORTALS OF ENTRY.

Bacteria may gain entrance to the body tissues in several different
ways. According to the portal of entry, differences not only in
the susceptibility of the host but also in the lesions and symptoms
of the disease will be noted. Many surgically important bacteria
may gain entrance through any portal and induce infection in any
part of the body, but some are restricted to certain modes of entrance,
as in the case of the tetanus bacillus. For the most part, micro-
organisms reach the interior of the body from the skin and mucous
surfaces. It is very improbable that bacteria present upon the skin
can penetrate this tissue when uninjured. It is true, however,
that often they appear to reach the interior of the body from what
seems to be an uninjured skin surface, but in these cases it is probable
that the skin injury has been overlooked by reason of its smallness.
It is only very rarely that bacteria directly gain entrance into the
general blood current. They ordinarily reach it through the atria,
which have been mentioned.

External Sources. — The bacteria derived from without the body are
those chiefly concerned in the infection of wounds and many other
primary surgical infections. They usually gain access to wounds
through contact with infected objects. Air infection is relatively
unimportant, and here the bacteria usually occur as clumps attached
to particles of dust, so that in a perfectly quiet atmosphere, as in
a closed room, these particles containing bacteria rapidly settle
upon underlying objects. It is a well-known fact that particles
including bacteria are not detached from moist surfaces even by
strong currents of air.

Among those of surgical importance which are conveyed through
external objects are Streptococcus pyogenes, Staphylococcus pyogenes
aureus, Staphylococcus pyogenes albus, Bacillus coli communis,
Bacillus pyocyaneus, Bacillus proteus, Diplococcus lanceolatus,
Bacillus anthracis, Bacillus tetani, Bacillus aerogenes capsulatus,
Bacillus tuberculosis, Micrococcus gonorrhea, and a host of others.

The relation of insects to the spread of infectious agents has
recently been emphasized by Nuttall. Considerable evidence has
been accumulated in the past few years which clearly indicates



20 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS

that insects may not only carry from place to place disease-produc-
ing micro-organisms, but they may also be concerned, directly or
indirectly, in the inoculation of pathogenic micro-organisms.

Interesting experiments made by Schimmelbusch and others
studying the rapidity of absorption of bacteria in wounds, show
that they are absorbed within a very short time by lymph and
bloodvessels from fresh bleeding wounds. Further, it has been
shown that as soon as a coagulum has been formed on the surface
of a wound the conditions are changed, and particles like bacteria
are no longer quickly transported into the blood and lymph circu-
lation. The surface of a healthy granulating wound affords great
resistance to bacterial invasion, almost as much as an intact exposed
surface of the body. Slight injuries, however, such as probing,
removing the dressing, and other manipulations which may convert
the ganulating wound into a recent wound, favor the absorption
of bacteria.

Bacteria of the Skin. — Since the skin is exposed to contamination
from the dust and other sources, it is evident that there is scarcely
any limit to the number of bacterial species which may be found
upon cutaneous surfaces. Most of the organisms ordinarily found
are such as may be found in the air or upon external objects. They
are principally cocci, but there are great variations in different
cases as to the kind and numbers. Sometimes one species far
outnumbers the rest. Further, the kind and number of bacteria
found upon exposed parts of the skin vary considerably, according
to the habits and occupation of the individual. Certain organisms
which are met with only exceptionally in most persons, are found
commonly on the hands of persons who handle or come into
proximity with infected cases.

For many of the facts relating to the bacteriology of the skin
we are indebted to Welch, who not only called attention to the
inconstant characters of the bacteria of the skin but also insisted
upon the great regularity with which Staphylococcus epidermidis
albus may be obtained in cultures taken from the skin, so that this
organism may be regarded as a normal inhabitant in this situation.
It is also regularly present in the layers of epidermis along hair-
shafts deeper than can be reached by any practical means of cutane-
ous disinfection. After complete sterilization of cutaneous surfaces,
so that scrapings are sterile, the presence of this white coccus can
still be demonstrated on sutures passed through the skin and in
excised pieces of skin.

Staphylococcus epidermidis albus is usually innocuous. It is
frequently present in aseptic wounds of the skin without inducing
suppuration or any untoward reactions. However, it may be the
cause of disturbances characterized especially by elevation of tem-
perature and moderate suppuration. It is a common excitant of
stitch abscess. Among other bacteria which may be present upon



PORTALS OF ENTRY 21

the skin are Streptococcus pyogenes, Staphylococcus pyogenes aureus
and albus, Bacillus pyocyaneus, and Bacillus coli communis.

Skin contaminated with the soil, which, as is well known, contains
in many situations abundant bacilli of tetanus and of malignant
edema, is likely to contain these bacteria. This contamination
relates especially to the hands and exposed skin.

The smegma bacillus may be considered in connection with skin
bacteria. This organism is usually present in the smegma and
may be found about the perineum. Attention is called to it par-
ticularly on account of its resemblance in morphology and tinctorial
reactions to the tubercle bacillus. It has been mistaken for Bacillus
tuberculosis in the examination of urine and of secretions and
exudates from the external genitals and the anus. Although smegma
bacilli are found to be present with pathogenic bacteria in lesions
about these parts, they do not possess pathogenic activities for man.

Many bacteria are attached to the hair, and particles containing
bacteria may readily be deposited from the hair upon wounds.
They are, for the most part, identical with those found on the skin.

Internal Sources. — The way is open for the access of bacteria
into mucous membranes; they communicate with the outer world
through the external orifices of the body. The relatively favorable
conditions here present for bacterial growth are counteracted in
large part by various mechanical and chemical influences which
prevent the survival of most bacteria which may enter. There are,
however, many bacteria which may multiply or persist for a long
time, particularly those of the alimentary canal and of the upper
respiratory tract. Among this number there are some which may be
pathogenic, but which under ordinary circumstances are not harmful.

Mouth and Pharynx. — Although the conditions in the mouth and
throat are more favorable for the prolonged existence of many
bacteria than upon other exposed mucous membranes, very few of
the large number which reach those parts persist there. Most of
them either pass into the stomach and intestines or are destroyed
in the mouth. Present in the mouth and pharynx are saprophytes,
also many streptococci, staphylococci, and pneumococci. Certain of
these organisms are frequent in dental caries.

The following pathogenic bacteria have also been found repeat-
edly in the healthy mouth: Streptococcus pyogenes, Staphylococcus
pyogenes aureus, Staphylococcus pyogenes albus, Micrococcus
tetragenus, Diplococcus lanceolatus, Bacillus pneumoniae of Fried-
lander, Bacillus coli communis, Bacillus diphtherise, Bacillus proteus,
and others. The mouth and adjacent parts are the most frequent
portals of entry of the organism of actinomycosis; it is especially
liable to lodge in or near carious teeth.

Respiratory Passages. — With inspiration, bacteria on dust reach
the upper respiratory tract. Thompson and Hewlet estimate that
from fifteen hundred to fourteen thousand bacteria are inspired



22 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS

every hour, the great majority of which are arrested in the nasal
cavities.

Among the pathogenic organisms which have been found in the
nasal cavities may be mentioned the common pyogenic cocci, Diplo-
coccus lanceolatus, Meningococcus, Bacillus diphtheria*, Bacillus
tuberculosis, Bacillus aerogenes capsnlatns, and Friedlander's
pneumobacillus. The presence of capsulated bacilli in the nose is
of considerable interest, for organisms of this class have been found
with especial frequency in cases of ozena.

Bacteria may be present in the larynx and bronchi in health,
but in small numbers. Usually the healthy lung is considered free.

Stomach and Intestines. — Under ordinary conditions of life bacteria
make their appearance shortly after birth in all parts of the digestive
tract. In many animals Bacillus coli communis, or its near allies,
seems to be, as in man, the chief obligatory form.

The relative numbers of Bacillus coli communis in different
portions of the alimentary canal have been variously estimated.
The observations of Gilbert and Dominici and those of dishing and
Livingwood indicate that there is a gradual rise in the number
from the duodenum to the ileocecal valve, at which situation the
maximum is noted. When the large bowel is reached, there is a
marked diminution in the number.

The main sources of the bacteria of the stomach and intestines are
the ingesta and from dust. From these sources great numbers and
varieties are introduced into the alimentary canal, but, as is true
of exposed mucous surfaces, only a limited number of species are
capable of prolonged existence here. The gastric juice may kill
many of those which enter the stomach, but there are many which
resist its action. Indeed, some can grow in the human stomach.
Emphasis has been laid upon the presence of the Boas-Oppler
bacillus on account of its supposed diagnostic value in carcinoma
of the stomach, but its presence has been shown to depend upon
conditions more common in other gastric diseases.

The variety of bacteria in the intestines is large; the presence of
some is only accidental or transient, while others are there with
such frequency as to merit special notice. The colon bacillus has
already been referred to. Pyogenic cocci are rarely absent from
the intestines, where they may be present in such small numbers
as to escape detection, but the great frequency with w r hich they
may be found in perforative peritonitis is significant. Bacillus
proteus, Bacillus pyocyaneus, Bacillus tetani, Diplococcus lanceo-
latus, Bacillus aerogenes capsulatus, and others have also been
found.

Under normal conditions the intestinal bacteria are found only a
short distance in the common bile-duct; but any alteration from
the normal, such as mechanical impediment to the outflow of bile,
change in the composition of the bile, or other perturbation in the



THE BACTERIAL EXCITANT AND HOST 23

physiology <>t' secretion, may be followed by an ascending infect ion
of the ducts or gall-bladder. The relation of the origin of many
cases of cholecystitis and cholelithiasis to this form of infection by
the colon and typhoid bacilli has been firmly established.