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THE INTERNATIONAL

TEXT-BOOK OF SURGERY

BY

AMERICAN AND BRITISH AUTHORS

EDITED BY

J. Collins Warren, M.D., LL.D., Hon. F. R.C.S. Eng.

Professor of Surgery in Harvard .Medical School ; Surgeon to the Massa-
chusetts (Icneral Hospital

\M>

A. Pearce Gould, M. S., F. R. C. S.

Surgeon to Middlesex Hospital; Lecturer cm Surgery, Middlesex Hospital Medical School;

Member of the Council and of the Court of Examiners of the

Royal College of Surgeons, England



Second EMtion, TTborougfolY? IRevteefc



IN TWO VOLUMES

CONTAINING 977 ILLUSTRATIONS, INCLUDING
FULL-PAGE PLATES IN COLORS



Volume I
general and operative surgery

With 470 Illustrations



PHILADELPHIA AND LONDON

W. B. SAUNDERS & COMPANY

I Q02



Copyrighted August, 1899. Recopyrighted January, 1900
Reprinted February, 1900, and June, 1900.



Copyright, 1902, by W. B. SAUNDERS & COMPANY



Registered at Stationers' Hall, London, England.



ELECTROTYPEO BY PRESS OF

WESTCOTT & THOMSON, PHILADA, W. B. SAUNDERS & COMPANY.



PREFACE TO THE SECOND EDITION.



Since the publication of the first edition, about two years ago,
surgery has progressed in almost every direction, and several of the
chapters have needed extensive alterations and additions to bring them
up to date. The entire book has been carefully revised, not only by
the individual authors, but by the editors, and special effort has been
made to bring the work down to the present day. Since the publica-
tion of the first edition the knowledge in regard to military and naval
surgery, the effect upon the human body of various kinds of bullets,
and the results of surgery in the field have been largely added to
through the Spanish-American War and the war in South Africa.
The chapters on Military and Naval Surgery have therefore been
very extensively revised and rewritten. The chapter on Diseases of
the Lymphatic System has been completely rewritten and brought
up to date. Of special importance in this chapter is the Surgery of
the Spleen. The chapter on Surgery of the Kidney has been exten-
sively revised. Furthermore, the addition of a large number of new
cuts serves to make the text more lucid.

The editors regret to record the death of two of the original con-
tributors, Dr. Christian Fenger and Dr. Charles A. Siegfried, U. S. X.

The editors desire to acknowledge their indebtedness to Dr. Farrar
Cobb, for valuable aid in preparing this edition for the press.

J. COLLINS WARREN,
A. PEARCE GOULD.



385378



PREFACE.



In presenting a new work on surgery to the medical profession the
editors feel that they need offer no apology for making an addition to
the list of excellent works already in existence. Modern surgery is
still in the transition stage of its development. The art and science of
surgery are advancing rapidly, and the number of workers is now so
great and so widely spread through the whole of the civilized world
that there is certainly room for another work of reference which shall
be untrammelled by many of the traditions of the past, and shall at
the same time present with due discrimination the results of modern
progress.

Their aim has been to produce a reliable text-book of surgery
embodying a clear but succinct statement of our present knowledge
of surgical pathology, symptomatology, and diagnosis, and such a
detailed account of treatment as to form a reliable guide to modern
practice. While not aiming at the merely novel, they have carefully
omitted antiquated methods, and they hope that the reader will find in
these pages only what is practically useful to-day.

The ever-widening field of surgery has been developed largely
by special work, and this method of progress has made it practically
impossible for one man to write authoritatively on the vast range of
subjects embraced in a modern text-book of surgery. In order, there-
fore, to accomplish their object, the editors have sought the aid of
men of wide experience and established reputation in the various de-
partments of surgery, and they most gratefully acknowledge the very
able assistance received from them. The editors have endeavored, by
means of careful scrutiny of the manuscripts, to secure uniformity of
standard and teaching.

The work is so arranged that Volume I. is devoted chiefly to



(j PREFACE.

General Surgery, and Volume II. to the various branches of Special

Surgery — a plan well adapted to the present needs of both the student

and the practitioner.

It is with deep regret that the editors are obliged to record the

death of one of their contributors, Dr. John B. Hamilton of Chicago.
The editors take this opportunity to express their obligations to

Dr. F. B. Lund of Boston for his able assistance in the work of editing

these volumes.

J. COLLINS WARREN,
A. PEARCE GOULD.



CONTRIBUTORS TO VOLUME L



C. H. GOLDING BIRD
EDWARD H. BRADFORD
J. G. A. BURNS
HERBERT L. BURRELL
RICHARD C. CABOT
I. H. CAMERON
W. WATSON CHEYNE
J. CHALMERS DaCOSTA

harold c. ernst
george ryerson fowler
george w. gay
robert b. greenough
george h. makins

Deforest



CHARLES McBURNEY
GEORGE H. MONKS
RUSHTON PARKER
LEWIS S. PILCHER
FRANZ PFAFF
MAURICE H. RICHARDSON
GUY BELLINGHAM SMITH
WALTER GEORGE SPENCER
J. BLAND SUTTON
L. McLANE TIFFANY
WELLER VAN HOOK
JAMES P. WARBASSE
J. COLLINS WARREN
WILLARD



IO CONTENTS.

CHAPTER VII.

PAGE

Erysipelas; Hospital Gangrene; Tetanus 173

By J. Collins Warren, M. D., LL. D., Hon. F. k. ('. s., Eng.,

Professor of Surgery, Harvard Medical School; Surgeon to the
Massachusetts General Hospital.

CHAPTER VIII.

Hydrophobia; Anthrax; Glanders; Actinomycosis; Madura=

Foot; 5nake=Bite ; Insect=Bite 190

By Weller Van Hour, M. I)., Professor of Surgery in the North-
western University Medical School and in the Chicago Poli-
clinic ; Surgeon to the Cook County and Wesley Hospitals.

CHAPTER IX.

Gangrene 213

By Walter George Spencer, M. S., F. R. C. S., Surgeon to the
Westminster Hospital, London.

CHAPTER X.

Surgical Tuberculosis 240

By I. H. Cameron, M. B., Hon. F. R. C. S., Eng., Professor of
Surgery and of Clinical Surgery in the University of Toronto ;
Surgeon to the Toronto General Hospital, St. Michael's Hospi-
tal, the Victoria Hospital for Sick Children, St. John's Hospital
for Women.

CHAPTER XI.

The Technic of Aseptic Surgery 269

By Charles McBurney, M. D., Professor of Clinical Surgery,
College of Physicians and Surgeons ; Consulting Surgeon to the
New York Hospital, St. Luke's Hospital, and the Presbyterian
Hospital, New York City ; assisted by Howard D. Collins,
M. D., Assistant Visiting Surgeon to the New York City Hos-
pital ; Assistant Demonstrator of Anatomy, Columbia Univer-
sity ; and Frank Oastler, M. D., Physician in Chief, Good
Samaritan Dispensary, New York City.

CHAPTER XII.

Operative and Plastic Surgery 312

By J. Collins Warren, M. D., LL. D., Hon. F. R. C. S., Eng.,
Professor of Surgery, Harvard Medical School ; Surgeon to the
Massachusetts General Hospital.



CONTENTS. II

CHAPTER XIII.

PACK

Minor Surgery 404

By John Chalmers DaCosta, M. D., Professor of the Principles
of Surgery and of Clinical Surgery in the Jefferson Medical Col-
lege ; Surgeon to the Philadelphia Hospital.

CHAPTER XIV.

Anesthetics and Surgical Anesthesia 439

By George W. Gay, A. M., M. I)., Senior Surgeon to the Boston
City Hospital ; Franz Pfaff, M. D., Assistant Professor of
Pharmacology, Harvard Medical School ; and T. G. A. Burns,
M. R. C. S., Anesthetist to the Middlesex Hospital, London.

CHAPTER XV.

Tumors 466

By J. Bland Sutton, F. R. C. S., Senior Assistant Surgeon, Mid-
dlesex Hospital ; Surgeon to the Chelsea Hospital for Women,
London.

CHAPTER XVI.

Fractures 505

By Lewis Stephen Pilcher, M. D., LL. D., Surgeon to the Meth-
odist Episcopal and the German Hospitals in Brooklyn ; and
James P. Warbasse, M. D., Assistant Surgeon to the Methodist
Episcopal Hospital, New York City.

CHAPTER XVII.

Injuries to the Joints; Dislocations 597

By George Henry Makins, C. B., F. R. C. S., Surgeon to St.
Thomas's Hospital ; Joint Lecturer on Surgery at St. Thomas's
Hospital Medical School, London.

CHAPTER XVIII.

Dislocations of the Hip 659

By J. Collins Warren, M. D., LL. D., Hon. F. R. C. S., Eng.,
Professor of Surgery, Harvard Medical School ; Surgeon to the
Massachusetts General Hospital; assisted by F. B. Lund, M. D.,
Assistant Visiting .Surgeon, Boston City Hospital.

CHAPTER XIX.

Diseases of the Bones 675

By William Watson Cheyne, F. R. S., F. R. C. S., Professor
of Surgery, King's College ; Surgeon to King's College Hospi-
tal, London.



1 2 CONTENTS.

CHAPTER XX.

PAl .1'.

Diseases of the Joints 702

By De Forest Willard, M. D., Clinical Professor of Orthopedic
Surgery, University of Pennsylvania, Medical Department; Sur-
geon to the Presbyterian Hospital, Philadelphia.

CHAPTER XXI.

Diseases of Special Joints (Orthopedic Surgery) 723

By Rushton Parker, M. B., B. S., F. R. C. S., Professor of Sur-
gery, University College ; Surgeon to the Royal Infirmary,
Liverpool.

CHAPTER XXII.

Congenital Dislocation of the Hip; Flat=Foot; Club=Foot 751

By E. H. Bradford, M. D., Surgeon to the Children's Hospital;
Assistant Professor of Orthopedic Surgery, Harvard Medical
School, Boston; assisted by Howard A. Lothrop, A. M.,
M. D., Assistant Visiting Surgeon, Boston City Hospital and
Long Island Hospital ; Assistant in Surgery, Harvard Medical
School, Boston.

CHAPTER XXIII.

Surgery of the Muscles, Tendons, and Bursa? 763

By George H. Monks, M. D., M. R. C. S. (Eng.), Instructor in
Clinical Surgery, Harvard Medical School ; Assistant Visiting
Surgeon, Boston City Hospital.

CHAPTER XXIV.

Cranial Surgery 7 8 4

By L. McLane Tiffany, M. D., Professor of Surgery, University
of Maryland ; Surgeon to the University Hospital, Baltimore.

CHAPTER XXV.

Surgery of the Spine 823

By C. H. Golding Bird, M. B., F. R. C. S., Surgeon to Guy's
Hospital ; and Guy Bellingham Smith, M. B., B. S., F. R.
C. S., Surgical Registrar to Guy's Hospital, London.

CHAPTER XXVI.

Surgery of the Peripheral Nerves 862

By Maurice H. Richardson, M. D., Assistant Professor of Clin-
ical Surgery, Harvard Medical School ; Surgeon to the Massa-
chusetts General Hospital.



CONTENTS. 1 3

CHAPTER XXVII.

PAGE

Surgery of the Heart and Blood= Vessels 893

By Herbert L. Burrell, M. D., Assistant Professor of Surgery,
Harvard Medical School ; Surgeon to the Boston City Hospital
and the Children's Hospital.

CHAPTER XXVIII.

Surgery of the Lymphatic System 922

By J. Collins Warren, M. D., LL. I)., Hon. F. R. C. S., Eng.,
Professor of Surgery, Harvard Medical School ; Surgeon to the
Massachusetts General Hospital ; and Robert B. Greenough,
M. D., Surgeon to Out-Patients, Massachusetts General Hospi-
tal ; Assistant in Surgery, Harvard Medical School, Boston.



General and Operative Surgery.



CHAPTER I.
SURGICAL BACTERIOLOGY.

A BRIEF STATEMENT OF THE ESSENTIALS IN SURGICAL
BACTERIOLOGICAL PROCESSES.

General Principles. — Before entering upon the discussion of the technic to be
employed in surgical bacteriological work, there are a few general considerations that
should be emphasized. Of these, perhaps one of the most important is the fact that bac-
teria of any kind, pathogenic and non-pathogenic, do not pass off moist surfaces. The
practical value of this observation lies in the teaching that floors, tables, and furniture in
the operating-room should be cleansed with a moist towel, mop, or other utensil, the better
to prevent the rising and dissemination of dust-particles, so often shown to be the carriers
of the bacteria.

Structure and Classification. — The structure of the bacteria is
simply cell-membrane and protoplasm, and they are not possessed
of organs of digestion or of generation. Roughly speaking, they
are classified, for medical purposes, as follows : Cells which have all
diameters the same — the spherical forms, or the micrococci ; those
in which one diameter is longer than any of the others, and at the
same time not curved — the bacilli ; and those in which one diameter
is longer than the others, and is more or less sharply curved — the
spirilla. (This grouping is, of course, of the roughest, from a botan-
ical point of view.) The development of the bacteria occurs in two
ways : by transverse subdivision in one or more planes at the same
time, and by spore-formation. The micrococci develop by transverse
subdivision in one or more directions ; if in one plane only, and if
there is an incomplete separation of the two daughter-cells, a diplo-
coccus is formed, and if this growth and incomplete separation con-
tinue in the same plane, a chain is produced — a streptococcus ; if not
in the same plane, but in irregular planes, a zooglea mass is formed,
whilst if the separation is complete, there results the grouping of the
staphylococcus. If the development is in two planes at right angles to
each other, four cells are produced from one mother-cell — a method
of development of which the M. tetragenus is an example ; and if this
growth takes place in three planes at the same time, when incomplete
separation occurs, as is usually the case, the sarcina is the result. The
development of the bacilli is similar so far as it goes ; that is to say,
it occurs by transverse subdivision. Now, this subdivision is in one
direction only, and that never in the line of the length of the rod.
Subdivision, however, is not the only method of development of the
bacilli. In certain conditions, usually those unfavorable to rapid
growth, certain highly refractive bodies make their appearance, usually
at the poles or the center of the rod, which then may disappear entirely,
leaving only these highly refractive and generally oval-shaped bodies,
which are extremely resistant to destructive agencies. These bodies

17



1 8 INTER NATIONAL TEXT-BOOK OF SURGERY.

are "spores, and form the resting and resisting stage of the develop-
ment of many bacilli.

Whether the surgeon has to do with a process set up by a spore-
bearing or a non-spore-bearing micro-organism may often be a matter
of practical importance, as influencing the adaptation of means to an
end in the measures necessary for securing sterilization of the field of
operation or the secretions and material obtained from it. Spore-pro-
duction has not been observed with certainty among the micrococci or
among the spirilla — certainly not among the varieties that are suf-
ficiently common in surgical affections to make them factors that must
be reckoned with.

Lastly, the spirilla develop, so far as is known, by transverse sub-
division only, and this division of the mother-cell occurs at the junc-
tion of two curves only, so that the young cells of the class of the
spirilla often present the appearance of short curved rods — an appear-
ance which very quickly disappears under favorable conditions of
growth.

These conditions of growth are to be considered under food-supply,
temperature, light, moisture, and gaseous surroundings.

The food-supply is obtained by the bacteria by the breaking up of
the extremely complex organic substances that form the bodies of
plants or animals dead, or which are excreted by them while still alive.
Whilst it is true that the artificial food-supply of bacteria cannot imi-
tate at all perfectly that which they find for themselves under natural
conditions, the adaptability of many varieties renders it more possible
to study them under artificial conditions than would otherwise be the
case. In general, the bacteria require certain of the albumins or car-
bohydrates for their nutrition ; and for the study of the pathogenic
varieties, the nearer their artificially prepared nutrient material ap-
proaches to that upon which they naturally thrive, the better will be
the results. For this reason preparations from fluids or tissues of the
animal body are more advantageous for the study of the bacteria than
are mixtures that must be made up more or less empirically.

Besides the necessity for a supply of certain amounts of carbon,
hydrogen, nitrogen, proteins, etc., certain general conditions must be
fulfilled to permit the development of the bacteria, pathogenic or other-
wise. They must have a certain amount of moisture ; for, whilst it is
true that simple drying, even prolonged over a term of years, does not
kill some kinds of bacteria, especially those that produce spores, it is
equally true that no development of these minute bodies will go on
under a total absence of moisture. So, also, the presence or absence
of certain gases has a marked influence upon the growth of certain
kinds of bacteria. In the case of oxygen this influence is so marked
that an attempt has been made to draw a sharp line of division
between the aerobic (needing oxygen) and the anaerobic (requiring the
absence of oxygen) bacteria. The latter division does not include
many varieties that have been studied, or, indeed, whose existence has
been revealed to us by our present means of observation, especially in
surgery. Some of them, moreover, — for example, the Bacillus tetani,
— are of great importance.

Temperature is another of the general conditions that must be



SURGICAL BACTERIOLOGY. 1 9

reckoned with to secure proper conditions for the growth of the bac-
teria. By far the larger part of them flourish well at a temperature of
between 20 and 25 ° C. ; those that produce pathogenic change in liv-
ing tissue must be able to flourish at a higher degree of heat than this,
and most of them will grow best at 37°-38° C. Above the highest
and below the lowest of these limits practically no growth occurs.
Some observations record development of certain bacteria as high as
70 C. and as low as 5 C, but no indication of development of any
••of the pathogenic species has been obtained at or near either of these
points. An important practical conclusion to be drawn from our
knowledge of the effect of temperature on the vitality of the bacteria is,
on the one hand, that cold does not destroy them, even when applied
under conditions entirely beyond those that occur in actual life. A
case in point is Koch's experiment of placing the cholera spirillum at
— 32 C. without affecting its developing powers when brought back
to normal conditions. On the other hand, a very moderate degree of
heat is sufficient to kill most bacteria, very few of them being able to
withstand so low a temperature as 57 C. if applied for a sufficient
length of time (the destruction of spores requires a much higher
degree of heat).

Light is another of the general conditions that has an influence
upon the growth of bacteria, and it has been shown that the effect of
direct sunlight is very hurtful to the vitality of many kinds of bacteria.
It is certain that the thickness of the medium in which the bacteria
are has much to do with the intensity of the effect of sunlight upon
them ; and it is still an open question whether much of the effect of
sunlight be not due to the heat of the rays and their drying effect
(depriving the bacteria of moisture). The more recent investigations
with the Rontgen rays give promise of valuable practical results.

The movements of bacteria, when they are present at all, are affected
in many ways : of course, by extremes of heat and cold, which must
more or less influence their vitality ; but of special importance is the
chemiotactic influence of certain salts and other materials, manifested
by an attracting or repellent action toward the bacterial cells. This
positive or negative chemiotaxis is of the same nature as that seen in
the case of the cells of the tissues, leukocytes and others, in response
to the irritant action of chemicals, injuries, or even of the bacteria.

Although disease is all that concerns us here, the bacteria are active
in many other processes. Properly looked at, disease is but another
name for a perfectly normal function, the bacteria producing the disease
doing so simply because they find in the tissues in which they grow
the nutrition necessary for that growth. This nutrition they secure by
breaking up the complex materials of which the tissues are composed
or upon which they are fed. Infectious diseases and their products are
therefore really the waste results of bacterial growth.

The methods by which the bacteria produce their effect in the
body, very briefly stated, are as follows :

It was formerly supposed that the results seen in bacterial disease
were due entirely to the direct action of the bacteria themselves. This
position, however, very quickly became untenable, for innumerable
phenomena were observed that were inexplicable upon this ground, if



20



INTERNATIONAL TEXT-BOOK OE SURGERY.



the bacteria themselves were to be looked upon as anything but accom-
paniments of the disease-process. Other explanations were therefore
sought and obtained. The influence of the bacterial cell itself in the
production of morbid phenomena is very slight. In a few cases there is
an actual mechanical action exerted by the overwhelming of special locali-
ties by masses of bacterial cells, and a resultant interference with the
function of the part, or possibly a destruction due to pressure. This,
however, is not often seen. There occurs also an absorption by the bac-
teria of nutrition meant for the tissue-cells, and in this way a destruction
of these tissue-cells that might be spoken of as starvation. Neither of




FlG. i. — Apparatus for using Chamberland filter, with glass tube inverted over filter, act-
ing by capillary attraction, so that the whole filtering surface may be in use, as suggested by
Dr. J. L. Goodale, and applied in the Bacteriological Laboratory of Harvard Medical School.

these actions, however, is sufficient to explain by far the vast majority
of the phenomena seen as the result of bacterial growth. The general
process may be made clear by the supposition that the bacteria, during
their development, take from the complex compounds in their neigh-
borhood certain chemical elements that are necessary for their own
nutrition. Thus there are left other elements in a condition of unstable
equilibrium. These elements combine in the ways necessary to satisfy
this unstable condition. As a result of this combination new com-
pounds are formed, some more simple, others more complex than the
originals. Among these new compounds there occur, in many instances



5 UR GICA L BACTERIOLOGY.



21



of bacterial growth, some that are extremely hurtful to the tissues in
which they are found. These are the toxins of which so much is now
said, and it is to these toxins and their action upon the living tissues
that are due most of the harmful results that are seen to follow bac-
terial growth.

The occurrence of variation among bacteria has been a matter of
much discussion. The general conclusion seems now to be justifiable
that only minor variations occur, and that there is a definite type of
structure and of function to which each bacterium tends to return.

Methods of Cultivation. — For a full description of these meth-
ods the student must turn to the larger text-books.




Fig. 2. — Chamberland filter in lamp-chimney for filtering small quantities of fluid (redrawn

from Muir and Ritchie).



As preliminary to the obtaining of a pure culture, the vessels containing the nutrient
media, and these media themselves, must be completely freed from any form of bacterium.
This is Sterilization, and may be secured by the use of heat in its various forms, by the
use of chemicals, and, in the case of fluids, by filtration.

Heat may be applied first by direct exposure to the naked flame ; possible with knives,
scissors, platinum wires, etc., and for burning infectious material. Second, by the use of
heated air, as in the case of the hot-air chamber, in which the temperature may be raised to
a high degree by the external application of the heat ; this method is applicable to the
sterilization of glassware, instruments, etc. Third, moist heat, either direct boiling of fluids
in suitable vessels (which is not satisfactory where spore-bearing bacteria are to be destroyed),
or by the use of steam under varying degrees of pressure. Steam-heat under pressure is
the most effective means known for the destruction of bacteria. Its action is distinctly more
rapid, penetrating, and certain than any other, and for its use many different forms of appa-



Online LibraryJohn Collins WarrenThe international text-book of surgery (Volume v.1) → online text (page 1 of 117)