Introduction and Background

Ton 4.7. Legan A MANUAL oF MODERN SURGERY: AN EXPOSITION OF THE ACCEPTED DOCTRINES AND APPROVED OPERATIVE PROCEDURES OF THE PRESENT TIME. FOR THE. UsH CF STUDENTS AND PRACTITIONERS. BY JOHN B. ROBERTS, A.M., M.D., PROFESSOR OF ANATOMY AND SURGERY IX THE PHILADELPHIA PoLYCLINIC; MUTTER LECTURER OX SURGICAL PATHOLOGY OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA. ILLUSTRATED WITH 473 ENGRAVINGS AND 8 PLATES IN COLOR AND MONOTONE. LEA BROTHERS & CO. PHILADELPHIA AND NEW YORK 1899. Entered according to Act of Congress, in the year 1899, by LEA BROTHERS & CO., in the Office of the Librarian of Congress at Washington. All rights reserved. M3) _ POAe (833 TO THE MEMORY oF MY FATHER CALEB C. ROBERTS; CALEB CRESSON ROBERTS, MY SON. PREFACE TO THE SECOND EDITION. Tue purpose of the author, as stated in the Preface to the first edition, was to give to the profession in a condensed form the accepted doctrines and approved procedures of Modern Surgery. The criticisms of the author’s efforts have seemed to indicate that he succeeded ; and in the belief that a volume from a single pen may be more equable in its teachings than a composite book from many minds, he presents a new edition to his surgical colleagues. Much space has been given to modern pathology and asepsis, with- out a knowledge of which no surgeon is equipped for work. Frac- tures and dislocations have been discussed in a specially practical and comprehensive manner, because of their daily importance to the prac- titioner of medicine and surgery. The articles on Appendicitis, Dis- eases and Injuries of the Joints, Diseases and Injuries of the Genito- Urinary Organs, Dislocations, Excisions, and Amputations have been entirely rewritten, and the text throughout has been carefully revised. The volume has been indexed very thoroughly in order that it may be used with satisfaction as a book of reference. The author is greatly indebted to his friend Dr. William S. Wray for valuable assistance in proofreading. JOHN B. ROBERTS. 1627 Wauwur Street, PHILADELPHIA. October, 1899. FROM THE PREFACE TO THE FIRST EDITION. Tuis treatise is the result of an effort to give the profession, in a condensed form, the accepted doctrines and approved procedures of Modern Surgery. I have endeavored to write a practical work, giving the surgical principles and operative methods generally accepted and practiced by the leading surgeons of the world at the present time. The opinions of the best authorities, the methods of the most practical surgeons, and the well established facts of surgical science are discussed ; but the consideration of theories, historical questions, traditional views and operations, and innovations of undecided value has been rigidly avoided, The value of an author’s discretionary power in such rejection or acceptance of material depends upon the carefulness of his analysis and the impartiality and soundness of his judgment. It has been my aim to bring these essentials to the work; hence, the statements of the volume represent my appreciation of the questions that have pre- sented themselves. In order to depict the present state of modern surgery I have con- Sulted standard text-books and current surgical literature. The best and newest thought is usually found in the latest editions of mono- gtaphs ; therefore much use has been made of such works. CONTENTS. PART I. GENERAL SURGICAL PATHOLOGY OR PRINCIPLES OF SURGERY. CHAPTER I. INFLAMMATION . g 3 3 % #8 CHAPTER II. DESTRUCTIVE INFLAMMATORY PROCESSES . . CHAPTER II. TRAUMATIC FEVERS AND COMPLICATIONS OF WOUNDS CHAPTER IV. TUBERCULUSI8, ACTINOMYCOSIS, ANTHRAX, EQUINIA CHAPTER V. SYPHILIS CHAPTER VI. RICKETS «we wee CHAPTER VII. TUMORS. CHAPTER VIII. SHOCK, FAT EMBOLISM AND WOUNDS . PagR. 17-39 57-70 71-75 76-86 87-88 89-117 118-133 10 CONTENTS. CHAPTER IX. ANSTHESIA . : . . . . * . . » 184-138 CHAPTER X. OPERATIVE SURGERY . . . . . . . . + 139-156 CHAPTER XI. PLASTIC OR REPARATIVE SURGERY =. . . : . . 157-164 PART II. SPECIAL SURGICAL PATHOLOGY OR PRACTICE OF SURGERY. CHAPTER XII. DISEASES AND INJURIES OF THE 8KIN AND ITX APPENDAGES AND OF THE SUBCUTANEOUS TISSUE. . . « * : + 165-183 CHAPTER XIII. DISEASES AND INJURIES OF MUSCLES, TENDONS AND BURSHE . 184-197 CHAPTER XIV. DISEASES AND INJURIES OF THE NERVOUS CENTERS AND NERVES 198-235 CHAPTER XV. DISEASES AND INJURIES OF THE HEART AND BLOOD VESSELS . 236-322 CHAPTER XVI. DISEASES AND INJURIES OF BONES. . . » 823-345 CONTENTS. CHAPTER XVII. FRACTURES . er * CHAPTER XVIIL SURGICAL DISEASES OF THE JOINTS, CARTILAGES AND LIGAMENTS CHAPTER XIX. INJURIES OF JOINTS, CARTILAGES AND LIGAMENTS CHAPTER XX. SURGICAL DISEASES OF THE RESPIRATORY ORGANS CHAPTER XXI. DISEASES OF THE MOUTH . . * “8 CHAPTER XXII. DISEASES OF THE ABDOMEN AND PELYI8 . 7 F ; F CHAPTER XXIII. HERNIA. ‘ . es oe CHAPTER XXIV. DISEASES OF THE RECTUM . F ow CHAPTER XXV. SURGICAL DISEASES AND INJURIES OF THE URINARY ORGANS CHAPTER XXVI. SURGICAL DISEASES AND INJURIES OF THE REPRODUCTIVE ORGANS. ‘ CHAPTER XXVIII. DEFORMITIES OR ORTHOPEDIC SURGERY . i i 346-483 484-515 516-560 561-590 591-613 614-664 665-686 687-712 713-759 5 760- 777-789 12 CONTENTS. CHAPTER XXVIII. 5 AMPUTATIONS. . . . . . . . . + 790-805 CHAPTER XXIX. SURGICAL DISEASES OF THE BREAST . . . . . + 806-814 PART I. GENERAL SURGICAL PATHOLOGY OR PRINCIPLES OF SURGERY. CHAPTER I. INFLAMMATION. DEFINITION, CAUSES, VARIETIES, EXTENSION OF INFLAMMATION. Definition.—The term “inflammation” refers to the changes observed in living animal structure following an injurious influence insufficient to cause immediate loss of vitality. This initial factor may originate from without, extrinsically, as from a blow; or from within, intrinsically, as in inflammations due to deleterious elements circulating in the blood current. Tnflammation may be provisionally described as a peculiar molecular change in the walls of the small blood vessels, dependent upon an ex- trinsic or an intrinsic irritation, which increases the adhesion of the blood to the vessel walls and allows abnormal permeation of the blood elements through them. It must not be supposed, however, that an alteration can occur in the vessel walls without the tissues also being affected, for the lesion of the vessel wall is evidently not the essential feature of the process. Until the blood elements are allowed to escape by the abnormal permeability of the vascular coats, inflammation may be said not to exist. Inflammation is a nutritive disturbance arising from damage to the tissues, and the object of the various phenomena produced is to over- come or lessen the effects of the injury. It is Nature’s reparative effort to overcome the perturbations caused by an injurious influence on the living animal organism. The microscopic changes in inflammation and in repair of wounds, for example, are nearly or quite identical ; but repair need not show the clinical symptoms which are usually found in inflammation. This is well exhibited in the healing or repair of aseptic wounds. The symptoms observed clinically in surgical lesions, and to which the term 2 7 18 INFLAMMATION. inflammation is applied, are the result of bacterial infection of the lesion, either from within the vessels and tissues or from without the animal. There are three terms, to which authors have given somewhat dif- ferent applications, that, on account of their relationship to the pro- cess of inflammation, require explanation at this time. Hyperemia is an unusual amount of blood in the vessels, due to any cause what- ever. A hyperemia due to physiological causation, as in glands dur- ing active secretion, in the skin in blushing, and in erectile structures, is called a determination of blood. Hyperemia resulting from im- perfect venous return, due to mechanical pressure on veins, gravity, or diminished cardiac power, is called congestion, which term should be employed only in this restricted sense. Hyperemia produced by an increased amount of blood thrown into a part is often denominated “active congestion,” but this tends to produce confusion. For prac- tical purposes this form of hyperemia is an early phenomenon in in- flammation, and though often no sensible effusion occurs, it might, with considerable propriety, be styled inflammatory hyperemia. The hyperemia probably occurs because the damaged structures need re- construction. It is possibly due to an alteration in the attraction be- tween the blood and the tissues. Hyperemia and inflammation have a close relationship, since hy- peremia, whether physiological, mechanical, or active, if continued, leads to effusion and exudation, and inflammation at once exists. When inflammation subsides, hyperemia is left as the last step toward restoration of the part to health. To indicate inflammation of a structure the termination “itis” is added to the name indicating the structure affected, as peritonitis, pleuritis. Causes.—The causes of inflammation are: the exciting or deter- mining, which give rise to the actual outbreak of inflammation, and the predisposing, which have previously created a tendency that re- quires merely an exciting cause to initiate the inflammatory process. Exciting causes may be local, as in injuries, and constitutional, as in syphilis. Predisposing causes, in like manner, may be local, as in the weakness of an organ resulting from previous inflammations, and constitutional, as in inherited or acquired impairment of bodily vigor. A given cause may be at one time an exciting, at another a predispos- ing, cause. For example, hypermmia due to increased functional activ- ity of an organ may be the exciting cause of inflammation ; again, the same hyperemia of the same organ may be the predisposing cause to which an irritation, acting as an exciting cause, must be added to in- duce the outbreak of inflammation. Inflammation due to external injury is called traumatic, that without definite assignable cause cryptogenetic or idiopathic. The latter term must not be understood as implying that inflammation can arise with- out a cause. Inflammation cannot spread unless its cause has ex- tended its area of influence, nor can it persist without a similar persis- tence of its causation. CAUSES. 19 In considering the causes of inflammation it must be remembered that there are two factors in its etiology—the cause which exerts an exciting influence, and the tissue upon which such influence is exerted. In some cases the exciting cause acts without any predisposition of the tissue being present, while, at other times, the same exciting cause cannot produce inflammation unless the normal resisting power of the tissue is lowered. This impaired resistance of the tissue may result from either an acquired or an inherited predisposition. It is seen, therefore, that the predisposing cause of inflammation may be anything which has a tendency to lower the normal resistance of the body or any part of the body to irritating influences. The exciting causes of nearly all inflammations may be classed under one of three heads: 1. Mechanical, as in injuries. 2. Thermal, as in. burning and freezing. 3. Chemical, as in toxic inflammations, such as arsenical neuritis, and in inflammations due to the chemical prod- ucts, or tuxines, of micro-organisms. Among causes which may in- duce inflammation there are some which are perfectly obvious and easily detected. These produce what are often called simple traumatic inflammations. Under this head may be included mechanical and chemical injuries ; injuries due to the application of heat or cold ; those due to electricity, which causes electrolysis of the fluids, or to pro- longed anemia, or bloodlessness, of the part. Excessive functional activity and nervous influences are said to produce inflammation. Such inflammations do not tend to spread beyond the site originally sub- jected to injurious influences, nor to increase in severity after the appli- cation of the exciting cause has ceased. In fact, the height of the inflammation is reached soon after the receipt of the injury, and the in- flammation rapidly subsides. The irritation and consequent inflammation produced by a chemical agent does not, however, always show itself at the point at which the chemical agent gains admission to the body. Examples of this are seen in instances of inflammation of the internal organs, such as the kidneys and liver, produced by the absorption of drugs through the skin or stomach. Alcohol, for instance, produces chemical inflamma- tion of the liver. Certain drugs, on the other hand, act injuriously on the kidneys, by which organ they are eliminated from the blood. These are instances of inflammation due to chemical causes, but widely different, of course, from the inflammation of the skin produced by powerful caustics, where the inflammation is produced at the point of application of the agent. Rheumatic and gouty inflammations are perhaps due to a similar action of chemical agents in the blood. The inflammations due to what is ordinarily called exposure to cold or wet are probably associ- ated with an irritation of the vessels, due to driving the blood from the surface of the body to the internal organs. Many inflammations whose causation was formerly obscure, and which were, therefore, called idiopathic, are now known to be due to the presence of vegetable organisms. These fungi, which are vari- 20 * INFLAMMATION. ously called bacteria, microbes and micro-organisms, multiply in the fluids of the human body, and therefore furnish continuously acting causes. Inflammations resulting from these fungi, or microscopic plants are probably due to the chemical rather than the mechanical ac- tion exerted by them. There is a very great variation in the severity or type of inflammation or disease due to these organisms; some of them are very virulent, causing at once gangrene, others cause a suppurative inflammation, and still others a chronic inflammation. The variety of inflammation may be fibrinous, suppurative, or productive. Some of them produce conditions which are not inflammatory. Tuberculosis, tetanus, anthrax, actinomycosis, glanders, abscesses and many other surgical conditions are caused by these fungi. Some fungi have a specific action and pro- duce one disease which cannot be produced by any other organism. Other organisms produce different pathological consequences under varying circumstances. Some conditions, as virulent inflammation, may be produced by several varieties of bacteria. Again. there are many organisms which, by entering the fluids of the body, do not, so far as known, produce any form of inflammation or disease. These are called non-pathogenic organisms in contra-distinc- tion to those referred to above, which are called pathogenic organisms. In studying the microbic, or mycotic, origin of inflammation it must be remembered that the inflammation is not due to the mere presence of the microbes within the body, because, under ordinary circum- stances, the normal resistance of the tissues to pathogenic processes prevents the occurrence of inflammation. In other words, bacteria moving freely in the blood current may not inflame the tissues. Cer- tain contingencies are requisite before their deleterious influence can be exerted. It is necessary that the organisms shall be arrested so as to be able to multiply and produce irritation ; because, it requires a large number of these organisms in the tissue to produce a pathogenic change. Such arrest of bacteria may be caused by the processes of embolism and thrombosis, or by injury to a blood vessel by which an ex- travasation of blood takes place into the connective tissue surrounding the capillary vessels ; or the organisms may be filtered out of the lymph current by the lymph glands. These processes which allow the micro- organisms to come to rest and settle may be the needed factor which will cause the advent of inflammation. Tt may occur that, notwithstanding the arrest of bacteria, no inflam- mation occurs, because there is no predisposition in the tissue at the point of arrest, or in the general system of the patient, to suffer from microbic invasion, Sometimes the micro-organisms remain at one point, producing local irritation, but their chemical products or toxines enter the blood current and produce effects in distant parts of the body. This is a conspicuous characteristic of the bacterium which causes diphtheria. This makes clear to us what is meant in the preceding paragraphs by “predisposing causes of inflammation.” Any circumstance which results in a depression of the vital powers, such, for example, as the CAUSES. 21 continued abuse of alcohol or prolonged anxiety and exhaustion, may induce a general or constitutional predisposition to inflammation. Bruises which cause extravasation of blood may act as a local predis- posing cause ; as, indeed, may any variety of wound. Wounds which are open to the air, by giving entrance to micro-organisms upon the surface of the body and in the air, are much more prone to inflamma~- tion than subcutaneous wounds, since the latter exclude the bacteria which are external to the patient’s body. Some bacteria will cause inflammation only when they gain access to a certain kind of soil which is favorable for their growth and develop- ment. Portions of the body, for instance, may be too cold for their development, in which event inflammation will not occur or will be arrested. If, however, these same organisms happen to become lo- cated in some part of the body which is warmer, they multiply and may at once excite inflammation. This illustrates what has been said before, that each organism has its peculiarity which must be accommo- dated in order to allow its development and pathogenic action. These microscopic plants are just as particular as to the kind of soil in which they grow and as to the circumstances surrounding their growth, as are the trees with which man comes in contact in the larger world. Certain conditions of the blood, such as diabetes and Bright’s dis- ease, are particularly favorable for the development of certain forms of bacterial life and the consequent inflammations. Again, the number of organisms which gain access to the tissues is a matter of importance. It can easily be understood that if but a small number infect the animal or human being they can be destroyed or rendered inert by the normal resistance of the tissue. The blood serum and the fluids of the tissues have a power of rendering micro- organisms inert, either by acting as an antidote to their toxines or by destroying the vitality of the germs. This protective agency is said to reside in the nucleins of the blood and tissues. It is known that the leucocytes and certain tissue cells, such as endothelial cells of ves- sels, have a tendency to surround germs and to destroy them. The force by which phagocytes are attracted towards the bacteria is called positive chemotaxis. At other times these cells appear to eat up the bacteria, and hence are called phagocytes. If, however, the dose of pathogenic organisms is very large, or relatively large compared with the resistant power of the blood serum, tissues and phagocytes, inflam- mation will be induced. The polynuclear leucocytes are apparently the most active phagocytes. It is a curious fact that the growth of several organisms together may induce pathological results, which no one of them alone is ca- pable of effecting. This is seen in the harmful effects resulting from the association of putrefuctive organisms and pus-causing organisms. In this instance it is probable that the putrefuctive bacteria destroying the granulation tissue which may be present allow the pyogenic fungi to gain access to the general circulation. It is believed, also, that some organisms act antagonistically to 22 INFLAMMATION. -other species of fungi. A patient inoculated with erysipelas becomes immune to infection with the anthrax bacillus. In a similar way the bacillus py