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THE INTERNATIONAL

TEXT-BOOK OF SURGERY

AMERICAN AND BRITISH AUTHORS

EDITED KY

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

Professor of Surgerj' in Harvard Medical School ; Surgeon to the Massa-
chusetts General Hospital

AND

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

Surgeon to Middlesex Hospital; Lecturer on Surgery, iNIiddlesex Hospital Medical School;

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

Royal College of Surgeons, England



Secon^ EMtion, Xlborouoblv 1Revi!3e^



IN TWO VOLUMES

CONTAINING 977 ILLUSTRATIONS, LNCLUDING
FULL-PAGE PLATES IN COLORS



Volume II

REGIONAL SURGERY

With 507 Illustrations



PHILADELPHIA AND LONDON

W. B. SAUNDERS & COMPANY
1902



Copyrighted January, 1900.
Reprinted July, 1900, and December, 1901.



Copyright, .go-', by W. B. SAUNDERS it COMPANY
Registered at Stationers' Hall, London, England.



ELECTROTYPED BY
WESTCOTT & THOMSON. PHILADA.



PRESS OF
W. B. SAUNDERS 81 CO., PHILADA



CONTRIBUTORS TO VOLUME U.



ROBERT ABBE
WILLIAM T. BULL
JAMES CANTLIE
WILLIAM BRUCE CLARKE
WILLIAM B. COLEY
E. TREACHER COLLINS
H. HOLBROOK CURTIS
N. P. DANDRIDGE
JOHN B. DEAVER
JOHN W. ELLIOT
CHRISTIAN FENGER
W. H. FORWOOD
A. PEARCE GOULD
J. ORNE GREEN
M. L. HARRIS

J. COLLINS



FERNAND HENROTIN
RUDOLPH MATAS
CHARLES McBURNEY
ANDREW J. McCOSH
LEWIS S. McMURTRY
J. EWING MEARS
JOHN MURRAY
ROBERT W. PARKER
GEORGE A. PETERS
JAMES J. PUTNAM
A. W. MAYO ROBSOxN
WILLIAM L. RODMAN
CHARLES A. SIEGFRIED
H. TUHOLSKE
WELLER VAN HOOK
WARREN



385379



Digitized by the Internet Archive

in 2010 with funding from
Columbia University Libraries



http://www.archive.org/details/internationaltex1902warr



CONTENTS OF VOLUME II.



CHAPTER I.



Surgery of the Mouth and Tongue 17

By N. P. Daxdridge, M. D., Cincinnati, Professor of the Prac-
tice of Surgery and Clinical Surgery, Miami Medical College ;
Surgeon to the Cincinnati Hospital and Children's Hospital.

CHAPTER n.

Diseases of the Jaws and Gums, Pharynx, and Tonsils ... 49

By J. EwiNG Mears, M. D., Philadelphia.

CHAPTER HI.

Surgery of the Nose 85

By H. HoLBROOK Curtis, M. D., New York, Consulting Surgeon
to the New York Nose and Throat and the Minturn Diphtheria
and Scarlet Fever Hospitals.

CHAPTER IV.

Surgery of the Neck 107

By A. Pearce Gould, M. S., F. R. C. S., London, Surgeon to
the Middlesex Hospital ; Lecturer on Surgery, Middlesex Hospi-
tal Medical School ; Member of the Council and of the Court of
Examiners of the Royal College of Surgeons, England.

CHAPTER V.

Surgery of the Esophagus 176

By John B. Deaver, M. D., Philadelphia, Surgeon-in-Chief to
the German Hospital ; Consulting Surgeon to the Germantown
Hospital.

CHAPTER VL

Surgery of the Thorax 199

By JoHX Murray, M. B., B. A., F. R. C. S., London, Assistant
Surgeon, Middlesex Hospital.

9



10 CONTENTS.

CHAPTER VII.

PAGE

Surgery of the Breast 240

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

CHAPTER VIII.

The Technic of Abdominal Surgery 293

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

CHAPTER IX.

The Diagnosis of Abdominal Diseases 307

By A. W\ Mayo Robson, F. R. C. S., Leeds, Senior Surgeon to
the General Infirmary, Leeds ; Emeritus Professor of Surgery,
Yorkshire College of the Victoria University ; Member of the
Council of the P.oyal College of Surgeons, England.

CHAPTER X.
Peritonitis 334

By Robert Abbe, M. D., New York, Clinical Lecturer on Surgery,
Columbia University, New York ; Attending Surgeon to St.
Luke's Hospital, New York.

CHAPTER XL

Acute Intestinal Obstruction 346

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

CHAPTER XII.

Surgery of the Stomach and Intestines 376

By Andrew J. McCosh, M. D., Visiting Surgeon to the Presby-
terian Hospital ; Clinical Lecturer on Surgery, College of Phy-
sicians and Surgeons, New York.

CHAPTER XIII.

Surgery of the Vermiform Appendix 414

By Charles McBurney, M. D., New York, Professor of Clinical
Surgery, College of Physicians and Surgeons ; Consulting Sur-
geon to the New York Hospital, St. Luke's Hospital, and the
Presbyterian Hospital, New York City.



CONTENTS. I I

CHAITKR XIV.



445



Surgery of the Liver, Qall-Bladder, Biliary Passages, and

Pancreas

By John W. Elliot, M. 1)., Boston, Surgeon to the Massachusetts
General Hospital ; Lecturer on Surgery, Harvard Medical
School, Boston.

CHAPTER XV.
Hernia 471

By WiLLL\.M T. Bull, M. D., New York, Professor of Surgery, Col-
lege of Physicians and Surgeons (Columbia UniversityJ ; Sur-
geon to the New York Hospital and to the Hernia Department
of the Hospital for Ruptured and Crippled, New York ; and
William B. Coley, M. D., New York, Clinical Lecturer on
Surgery, College of Physicians and Surgeons (Columbia Uni-
versity) ; Surgeon to the Cieneral Memorial Hospital ; Assistant
Surgeon to the Hospital for Ruptured and Crippled.

CHAPTER XVL

Diseases of tiie Rectum and Anus 526

By George A. Peters, M. B., F. R. C. S., Toronto, Associate
Professor of Surgery and of Clinical Surgery, University of
Tdronto.

CHAPTER XVIL

Surgery of the Penis, Urethra, Prostate, and Bladder .... 552
By William Bruce Clarke, M. A., ^l. B., F. R. C. S., London,
Assistant Surgeon, St. Bartholomew's Hospital ; formerly Sur-
geon to the West London Hospital and St. Peter's Hospital for
Diseases of the Urinary Organs ; Examiner in Surgery at the
University of Oxford.

CHAPTER XVIIL

Surgery of the Ureters 589

By Weller Van Hook, M. D., Chicago, Professor of Surgery in
the Northwestern University Medical School and in the Chicago
Policlinic ; Surgeon to the Cook County and Wesley Hospitals.

CHAPTER XIX.

Surgery of the Kidney , 600

By the late Christian Fencer, M. D., Chicago, Professor of Clin-
ical Surgery in Rush Medical College and the Chicago Policlinic ;
Surgeon to the Presbyterian Hospital.



1 2 CONTEXTS.

CHAPTER XX.

PAGE

Surgery of the Scrotum and Testicle 640

By H. TuHOLSKE, M. D., St. Louis, Professor of Clinical Surger}-
and Surgical Pathology, St. Louis Post-Graduate School of Medi-
cine ; Surgeon-in-Chief to the Polyclinic Hospital ; Surgeon-in-
Chief to the St. Louis Jewish Hospital, etc.

CHAPTER XXL

Gynecology 656

By F. Henrotin, M. D., Chicago, Professor of Gynecolog}-, Chi-
cago Policlinic ; Surgeon to the Alexian Brothers' Hospital ;
Gynecologist to St. Joseph's Hospital and the German Hospital,
Chicago; and M. L. Harris, M. D., Chicago, Professor of
Surger}-, Chicago Policlinic ; Attending Surgeon to St. Luke's,
Alexian Brothers', Passavant, and Children's Memorial Hospi-
tals, Chicago.

CHAPTER XXIL

Gynecology (Continued 1 696

By F. Henrotix, M. D., Chicago, Professor of Gynecology, Chi-
cago Policlinic ; Surgeon to the Alexian Brothers' Hospital ;
Gynecologist to St. Joseph's Hospital and the German Hospital,
Chicago; and M. L. Harris, M. D., Chicago, Professor of
Surgery, Chicago Policlinic : Attending Surgeon to St. Luke's,
Alexian Brothers', Passavant, and Children's Memorial Hospi-
tals, Chicago.

CHAPTER XXIIL

Surgery of the Uterus 745

By Lewis S. McMurtry, A. ^L, M. I)., Louisville, Professor of
Gynecology and Abdominal Surgery in the Hospital College of
Medicine ; Gynecologist to Sts. ^lary and Elizabeth Hospital,
etc.

CHAPTER XXIV.

Influence of Age and Race in Surgical Affections 766

By W. L. Rodman, jSL D., Philadelphia, Professor of the Princi-
ples of Surgen^ and of Clinical Surger}-, Medico-Chirurgical Col-
.lege of Philadelphia ; Professor of Surgery and Clinical Surger}-,
Woman's Medical Collesre of Pennsylvania.



CONTENTS. 1 3

CHAPTER XXV.

PAGB

Gonorrhea 782

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

CHAPTER XXVI.

Syphilis 791

By Robert W. Parker, M. R. C. S., London, Senior Surgeon to
the East London Children's Hospital ; Consulting Surgeon to
the German Hospital in London.

CHArTi:R XXVIL

Surgery of the Eye 823

By E. Treacher Collins, F. R. C. S., London, Surgeon to the
Royal London Ophthalmic Hospital ; Ophthalmic Surgeon to the
Charing Cross Hospital, and Lecturer on Ophthalmology at the
Medical School.

CHAPTER XXVIIL

Surgery of the Ear 876

By J. Orne Green, M. D., Boston, Clinical Professor of Otology,
Harvard Medical School ; Aural Surgeon to Massachusetts Char-
itable Eye and p]ar Infirmary ; Formerly Aural Surgeon to Bos-
ton City Hospital and Massachusetts General Hospital.

CHAPTER XXIX.

Surgery of the Skin 919

By Rudolph Matas, M. D. , New Orleans, Professor of General
and Clinical Surgery, Tulane University.

CHAPTER XXX.

Military Surgery 955

By W. H. Forwood, M. D., LL. D., Washington, Surgeon-Gen-
eral, U. S. Army.

CHAPTER XXXI.

Naval Surgery looi

By the late Charles A. Siegfried, M. D., Medical Inspector,
U. S. Navy. Revised and partly rewritten by Henry G. Beyer,
M. R. C. S., M. D., Ph. D., Lecturer on Naval Hygiene, Naval
War College, Newport, R. I.



14 CONTENTS.

CHAPTER XXXII.

PACK

Traumatic Neuroses 1031

By James J. Putnam, M. D., Boston, Professor of Diseases of the
Nervous System, Harvard Medical School ; Physician to Patients
with Diseases of the Nervous System, Massachusetts General
Hospital.

CHAPTER XXXIII.

Tropical Surgery 1067

By James Cantlie, M. A., M. B., F. R. C. S., Eng., Surgeon
to the Seamen's Hospital, Albert Dock, London ; Lecturer on
Applied Anatomy, Charing Cross Hospital Medical School,
London ; Lecturer on Surgery, London School of Tropical
Medicine.

Index iioi



REGIONAL Surgery.



CHAPTER I.
SURGERY OF THE MOUTH AND TONGUE.

CONGENITAL DEFORMITY OF THE LIPS AND MOUTH.

A PROPER understanding of the congenital deformities of the mouth
and lips requires a knowledge of the various phases of development
which these parts go through in early fetal life. The common buccal
and nasal cavity is formed by the growth of the mandibular arches
from either side, from which are developed the lower jaw, and the tis-
sues which enter into the lower lip and the floor of the mouth. The
common cavity is then divided into buccal and nasal cavities by the
development of the hard palate from the horizontal outgrowth of plates
from the maxillary process (Fig. i).




Frontonasal process.
Globular process.

Maxillary process.



Orbital fissure.

Internasal fissure.
Maxillary fissure.
Intermandibular fissure.



Fig. I. — Head of an embryo, showing the disposition of the facial fissures (semi-diagram-
matic) (Sutton).

The nasal cavity further is divided into two by the down-growth of
the perpendicular plate of the ethmoid and vomer from the frontonasal
processes. A failure of union between these different parts explains
the occurrence of the various kinds and degrees of deformity in hare-
lip and cleft palate. The researches of Albrecht have very fully estab-
lished the essential facts of development.

" From the buccal aspect of the maxillary process of either side
springs the palatal process which passes inward to blend with its fellow
of the opposite side to form the soft palate and the whole of the hard
palate except the intermaxillary portion." From the same source are
derived the cheek, the lateral parts of the upper lip, and the upper
maxillary bone. The frontonasal process gives origin to the external
nose, the ethmoid, the vomer, the median portion of the upper lip, and
the intermaxillary bone (Treves).

2 17



INTERNATIONAL TEXT- BOOK OF SURGERY.




Fig. 2. — Endognathion, mesognathion,
and exognathion with the sutures ; inter-
endognathic, endomesognathic, exomeso-
gnathic (Albrecht).



The intermaxillary bone is that triangular piece which is attached to
the vomer and forms so conspicuous a deformity in complete double

harelip with cleft palate, and which in
the normal jaw forms the anterior cen-
tral portion of the upper jaw, in which
the 4 incisors are inserted. It is, ac-
cording to Albrecht, composed of 4
sections, named by him gnathia, each
of which carries an incisor tooth. The
median segment is known as the endo-
gnathion, the outer the mesognathion,
while the hard palate beyond is the
exognathion. The 5 sutures formed
by the apposition of these 4 segments
with the wedge-shape gap in the hard
palate converge to the anterior palatine canal.

In the ordinar}- form of cleft palate the union of the two mesogna-
thia forms the os incisivum which carries the two central incisors, and
the cleft in the alveolar process runs between the endognathion and
mesognathion. The latter carries the lateral incisor.

It is apparent from the facts thus set forth that the central part of
the upper lip and that part of the hard palate which carries the two cen-
tral incisors are developed from different centers from those forming the
outer part of the upper lip and the rest of the hard palate, and that
union in the lip and alveolar process takes place not in the median line,

but to either side of it. It also satis-
factorily explains the clinical fact that
harelip does not occur in the median
line, and that in complete cleft palate
the intermaxillary bone is either with-
out any connection with the hard pal-
ate or is connected only on one side.
In the lower lip the mandibular
processes unite in the median line.

Varieties of Deformity. —
Harelip and cleft palate may be
divided into 6 classes, according to
Rose.

"I. The median (inter-intermaxil-
lary). This is so rarely met with that
its occurrence has been denied ; it
comes from failure of the endogna-
thion. Most frequently it involves
only the lip ; more rarely there is en-
tire absence of the intermaxillary bone
and complete cleft of the palate, hard
and soft.

" 2. Ordinary' harelip (intermaxil-
lary), either unilateral or bilateral, is
the usual form. Here there has been a failure of union between the
central and outer portions of the upper lip.




Fig. 3. — Harelip and facial cleft.



CONGENITAL DEFORMITY OF LIPS AND MOUTH.



19



" 3. Facial cleft (intermaxillary). The cleft arises from the outer
part of the upper lip, skirts around the ala of the nose, and reaches




Fig. 4. — Auricular appendage occasionally accompanying macrostoma.

It usually involves only the soft parts, and not



In this



the canthus of the eye.
the bone (Fig. 3).

" 4. Buccal cleft (maxillomandibular), or macrostoma
deformity there has been a failure
of union of that portion of the cheek
developed from the maxillary proc-
ess, and that from the mandibular
arch (Fig. 4).

"5. Mandibular cleft, or median
fissure of the lower lip, is explained
by the failure of the mandibular arch
of either side to unite. It is ver\' rare.

" 6. Cleft palate. The uvula alone
may be involved, or the cleft may
extend fully or partly through the
hard palate. Union takes place
normally from before backward, so
that incomplete clefts always involve
the posterior portion of the hard pal-
ate."

Microstoma is a condition due to
undue fusion of the maxillary and
mandibular processes. The opening
of the mouth may be contracted to a
small orifice.

Deformities of the mouth and
lips may be caused by contraction
of cicatricial tissue. The mouth
may be nearly closed in this way (stenosis) (Fig. 5), or the lower lip
may be everted, producing an incontinence of saliva. The plastic oper-




FlG. 5. — Closure of mouth from congenital
syphilis.



20



IXTERKATIOXAL TEXT-BOOK OF SURGERY.




Fig. 6. — Characteristic deformitv from burn.



ation for relief of this condition consists in turning in a flap of sound
skin into the raw surface exposed by releasing the everted lip, or by




Fig. 7. — Drawn from specimen from a
child two years old who died after the
operation for harelip. Cleft palate and
harelip. The vomer is attached to the
right side of the palate and extends to
the back of the phar}-nx.



Fig. 8. — Complete cleft palate. Vomer not at-
tached to either side of hard palate (drawn from
specimenj.



CONGENITAL DEFORMITY OF LIPS AND MOUTH.



21



sliding in flaps on either side from the cheek. The operation is known
as cJicilopIastv (Fit^. 6).

Treatment of Harelip and Cleft Palate. — When in cleft pal-




FlG. 9. — Harelip and cleft palate, showing protruding intermaxillary bone attached to the

vomer.



ate the cleft is complete, the deformity involves the lip as well, and
there is a double harelip, with the os incisivum attached to the end of
the vomer and carrying the central portion of the lip. Or there may





Fig. 10. — Cleft palate and harelip. Marked
deformity from intermaxillary bone, which was
attached to the right side.



Fig. II. — Patient represented in Fig. lo,
two years after operation, showing notch
in the upper lip.



be a single harelip, usually on the left side, with the intermaxillary bone
attached to the right, and more or less projecting in front, so as to
create a very disfiguring deformity. The vomer is usually attached
to the right side of the hard palate, though it may hang entirely free,



22 INTERNATIONAL TEXT-BOOK OF SURGERY.

and may extend to the back of the pharynx, dividing that cavity into
two. In cases of harelip with cleft palate in children who have reached
five or six years of age, there is not infrequently associated adenoid
vegetations, hypertrophy of the tonsils, and great thickening of the
mucous membrane over the turbinated bones.

These conditions when present should always be corrected before
any attempt is made to operate on the palate or lip. In all cases where
the defect reaches through the entire lip, whether associated with cleft
palate or not, the nostril upon the same side is widened and flattened
so as to be very unsightly, and this is likely to be increased, as time
goes on, by the action of the orbicularis.

In harelip, either single or double, approximation of the edges of the
gap is usually opposed by reflections of mucous membrane which are
attached to the upper jaw, so as to prevent the separated portions of
the lip being brought together. In double harelip the central philtrum
of skin is usually closely bound to the underlying bone, and but partly
covers it. This is especially the case when we have an isolated os
incisivum in complete cleft palate. Children with cleft palate who
have begun to talk have a disagreeable nasal twang, and this usually
persists, though possibly improved, even after a successful operation or
the adjustment of an obturator.

Immediately after birth it may be extremely difficult for the child
to take sufficient nourishment ; the nipple cannot be grasped, and suck-
ing is impossible, and the child must be fed with a spoon. Various
shields have been suggested, but none of them are satisfactory.

Age for Operation. — It is desirable that the defect in both harelip
and cleft palate should be corrected at as early an age as possible ; the
beneficial result, so far as phonation is concerned, depends largely upon
this, and some surgeons therefore advocate operation on harelip within
a few days of birth. Such early operations are, however, attended with
so great a mortality that the majority advise waiting for the completion
of the third month. Operation at this time is indicated in all cases of
harelip, whether complicated with cleft palate or not.

The closure of the cleft in the palate is so much more serious that
by universal consent it is deferred until several years of life are past,
certainly not sooner than the end of the third year. The early closure
of the harelip usually exercises a beneficial effect upon the cleft, dimin-
ishing the prominence of the os incisivum and approximating the edges
of the lateral processes. Too long a delay in operating diminishes the
prospect of full improvement in articulation.

Operations for Harelip. — A variety of operations have been sug-
gested for harelip, which are generally named after their authors. A
glance at the diagram is enough to explain the general principles, with-
out going into a detailed description. Certain points must be kept in
view as essential to success (Figs. 12 and 13).

First, the lip on either side must be sufficiently freed from the cheek
to ensure easy contact of the edges of the gap without tension. This
freeing of the lip is the first step, and is best done with scissors curved
on the flat. Success in the cosmetic effect depends upon the ala of the
nose being well freed. In paring the edges of the gap in the lip care
must be taken to see that the incision is well beyond the everted mu-



CONGENITAL DEFORMITY OF LIPS AND MOUTH.



23



cous membrane. It is best made by transfixion with a narrow-bladed
knife, entered just above the vermihon border and made to cut upward.
In cutting through the vermihon border care must be taken that when
placed in apposition with the opposite side a projection will be formed,
otherwise a disfiguring notch will ultimately result. During this time





Fig. 12. — Nelaton's operation for liarelip.

of the operation the child may be upon its back, with head well ex-
tended over a pillow, bleeding being controlled by the fingers of an
assistant compressing the coronary artery. More or less blood will,
however, often be swallowed, interrupting the operation.

If, instead of being placed upon its back, the child is turned over on





Fig. 13. — Mirault's operation for harelip.

its side and the head supported by a sand-bag, swallowing of blood
will be largely prevented. Chloroform should, as a rule, be used, and
all bleeding stopped before the stitches for closure are introduced. The
edges of the gap should be brought into apposition and made to fit
accurately. The first suture should be introduced through the vermilion
border and made to come out on the opposite side. Traction on this
suture will at once show whether the two sides of the wound come
together accurately. The stitches are then introduced, commencing
above at the highest point of the defect. They should not involve the
mucous membrane. Three stitches are usually enough, and all should
be introduced before any are tied. The one through the vermilion
border should first be tied, and the others from above downward.
Harelip-pins are unnecessary. Silkworm-gut is the best material for
sutures ; silk or silver wire may, however, be used. At the end of the
suturing there should be accurate approximation thrpughout the in-
cision, and a little nipple-like projection on the vermilion border. Two
or three thicknesses of gauze extending well over the cheek may be
laid over the wound and well saturated with collodion. This is better
than adhesive straps, and prevents traction on the wound when the
child is crying. If there is any gaping, one or two fine catgut stitches



24



INTERNATIONAL TEXT-BOOK OF SURGERY.



may be placed through the mucous membrane. The stitches should
be left in until about the seventh day, and the child fed with a spoon
during this time,

IVarren's me/Aod consists in applying the sutures so that they shall cause a minimum of
deformity from stitch-scars. An "anchor suture" of silver wire is passed through the ala
nasi, high up, and the septum. It is held in place by shot. Three or 4 ordinary silk
sutures are passed from the mucous aspect of the lip through the deep tissues, coming near




Fig. 14. — Warren's operation for harelip, showing method of applying sutures.

the surface at the cut edges, but not showing outside (Fig. 14). When these sutures are
tied, any little irregularities of adjustment can be remedied by a few very fine sutures
(Fig. 15).




Fig. 15. — Warren's operation for harelip : sutures tied.



Operations for Cleft Palate. — Uranoplasty and Staphylorrhaphy. —
The operation for cleft palate and uvula is much more difficult and



CONGENITAL DEFORMITY OF LIPS AND MOUTH. 25

dangerous than that for harelip alone, and should not be undertaken
before the completion of the third year. If the cleft is complicated
with harelip, careful treatment should first be undertaken for the
removal of adenoid vegetations, enlarged tonsils, and hypertrophied
turbinated bones, provided they are present. These bodies are easily



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