Introduction and Background

Ulcerating Sarcoma of Breast. TENT-BOOK OF SURGERY, FOR STUDENTS AND PRACTITIONERS. BY GEORGE EMERSON BREWER, A.M., M.D., LECTURER ON CLINICAL SURGERY AT THE COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA YORK; ATTENDING SURGEON TO THE CITY HOSPITAL; JUNIOR SURGEON TO THE ROOSEVELT HOSPITAL; CONSULTING SURGEON To THE PERTH AMBOY HOSPITAL; FELLOW OF THE AMERICAN SURGICAL ASSOCIATION, OF THE AMERICAN ASSOCIA- TION OF GENITO-URINARY SURGEONS, AND OF THE SOCIETY OF AMERICAN ANATOMISTS; MEMBER OP THE NEW YORK ACADEMY OP MEDICINE AND OF THE NEW YORK SURGICAL SOCIETY ; MEMBRE CORRE- SPONDENT DE L'ASSOCIATION FRANCAIME D'UROLOGIE, ILLUSTRATED WITH 280 ENGRAVINGS IN THE TEXT AND 7 PLATES IN COLORS AND MONOCHROME. LEA BROTHERS & CO., NEW YORK AND PHILADELPHIA. Entered according to Act of Congress, in the year 1903, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. HLLIAM J. OORMAN, TO ROBERT F. WEIR, M.D., Hoy. F.R.C.8. Ena., PROFESSOR OF SURGERY, COLUMBIA UNIVERSITY, BTC, A MASTER OF SURGERY, A SCHOLARLY TEACHER, A SUCCESSFUL PRACTITIONER, MY HONORED CHIEF AND VALUED FRIEND. THIS VOLUME I8 AFFECTIONATELY DEDICATED BY THE AUTHOR. PREFACE. Tue need of a comprehensive yet abridged text-book on Surgery, suitable for the use of students and practitioners, and presenting clearly the accepted modern views of surgical pathology and treatment, has been felt by the author of this work during his experience in teaching at the College of Physicians and Surgeons. That such a need has existed in the past is evidenced by the fact that a number of excellent manuals have appeared from time to time; that it is not adequately filled at present is perhaps due to the fact that the best of these have, by their success, passed into new editions in each of which the tendency to enlarge has not been sufficiently resisted. As a result such manuals have grown into creditable treatises, but thereby have outgrown the demand which originally called them into being. Following these ideas the author has endeavored in the present work to give the essential facts in practical surgery as briefly as is compatible with clearness. No attempt has been made to review the historical aspects of the subjects, to describe rare conditions, or to enter into theoretical discussions regarding the nature of obscure pathologic processes. The same reason has excluded the description of more than one or two methods of treating a given surgical affection. It is often a difficult task to select from the many procedures which have been proposed that which is most applicable and successful, but such selection is a great aid to the reader. Space has also been gained by the avoidance of quota- tion of authorities except where advanced ideas are mentioned which have not yet received general recognition. 92052 6 PREFACE. The first five chapters on surgical pathology were written by Dr. August Jerome Lartigau, Instructor in Pathology at the College of Physicians and Surgeons, and Assistant Pathologist to the Roosevelt Hospital. The writer is indebted to Dr. Pearce Bailey for suggestions regarding the treatment of neurologic subjects; to Dr. Robert W. Lovett for assistance in the preparation of the chapters dealing with orthopedic surgery; to Dr. F. Tilden Brown for reviewing the chapters on genito-urinary diseases ; to Drs. Carle- ton P, Flint and Evan Evans for valuable suggestions and assist- ance; and to Mr. Martin Petersen for painstaking work in the preparation of original drawings. G. E. B. New York, 1903. CONTENTS. CHAPTER I. PAGE INFECTION CONSIDERED IN ITS SURGICAL RELATIONS .... = 17-31 CHAPTER II. INFLAMMATION ......- See ee wee - 32-41 CHAPTER III, ACUTE INFECTIOUS SURGICAL DISEASES .... 42-55 CHAPTER IV. CHRONIC INFECTIOUS SURGICAL DISEASES........... 56-68 CHAPTER V. TUMORS. ¢ ce. ee ee ae seeRE eS ie PESOS BF 69-86 CHAPTER VI. SHOCK AND ALLIED CONDITIONS ..........-25+0% 87-103 CHAPTER VII. SURGICAL TECHNIC... ....-- 200 eee Se eens 104-127 CHAPTER VIII. ANESTHESIA, 6 ee ee ee eee rec ee ea 128-139 CHAPTER IX. INJURIES AND DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUES ice ecm hoy oncene OY KON A MERRION BRD 140-153 CHAPTER X. INJURIES AND DISEASES OF THE HEART, PERICARDIUM, AND BLOODVESSELS. ©... ee 154-182 8 CONTENTS. CHAPTER XI. PAGE INJURIES AND DISEASES OF THE LYMPHATIC SYSTEM . . . . 183-190 CHAPTER XII. INJURIES AND DISEASES OF THE MUSCLES, TENDONS, AND BURSB eioves % 8 XH EE Role a ERE seen ee 191-198 CHAPTER XIII. INJURIES AND DISEASES OF THE NERVES ........... 200 212 CHAPTER XIV. INJURIES AND DISEASES OF THE BRAIN AND SPINAL CORD . 213-235 CHAPTER XV. INJURIES AND DISEASES OF THE HEAD, FACE, AND NECK; ORAL, NASAL, AND PHARYNGEAL CAVITIES ...... . 236-279 CHAPTER XVI. INJURIES AND DISEASES OF THE THORAX, PLEURA, AND LUNG. 280-287 CHAPTER XVII. DISEASES OF THE MAMMARY GLAND .... . . see ee 288-300 CHAPTER XVIIL INJURIES OF THE ABDOMEN... . . - 4h eb eveneweceng we + 301-307 CHAPTER XIX. ES OF THE ABDOMEN . CHAPTER INJURIES AND DISEASES OF THE KIDNEY AND URETERS . . 375-403 CHAPTER XXI. ES OF THE BLADDER AND URETHRA . 404-435 INJURIES AND DIS! CHAPTER XXII. INJURIES AND DISEASES OF THE PENIS AND SCROTUM. . . . 436-442 CHAPTER XXIII. EASES OF THE TESTICLE, SEMINAL VESICLE, AND PROSTATE, 443-462 CONTENTS. 9 CHAPTER XXIV. Page DISEASES OF THE RECTUM... 0 1. ee ete eee eee 463-479 CHAPTER XXV. DISEASES OF BONE .....-----.-. +0005 ies FP EE 480-491 CHAPTER XXVI. INJURIES AND DISEASES OF THE JOINTS... .......4- 492-518 CHAPTER XXVII. FRACTURES .........-.-5- trees eee» 519-580 CHAPTER XXVIII. DISLOCATIONS «0. 6. ee es 581-618 CHAPTER XXIX. HERNIA. ce ceo eee now ee ++ + 619-641 CHAPTER XXX. AMPUTATIONS «26 0. eee ++ + 642-662 CHAPTER XXXI. DEFORMITIES AND THEIR CORRECTIONS ... . or . + 663-681 SURGERY. CHAPTER I. INFECTION CONSIDERED IN ITS SURGICAL RELATIONS. INTRODUCTION. Pernaps one of the most universally known facts respecting bacteria is that they are related to the development of certain patholugic processes ; but it also should be held in mind that many micro-organisms play a very beneficent part in nature. Micro-organisms are distributed widely in air, soil, and water, bat 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 harm- less species ; but pathogenic forms may occasionally be found, lv 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 suitable nidus there. So far as we know, then, with few exceptions micro-organisms whose natural habitat is in the oil, air, or water, are not under normal conditions harmful to man, for they are present in greater or le~= 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 intro- duced into a world of bacteria that fall upon the skin, and gain entrance to the rexpiratory passiges and alimentary canal * through air and food. In a xhort time they may be found in various parts of the body, =o 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 2 av 18 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS. 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 condi- tions, 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, cesophagus, and vagina, While the cylindric epithelium cover- ing 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, as 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 they are injured, even if ever so slightly. Having overcome the external defensive barriers, they usually are arrested or destroyed in the adjoining lymph-nodes. In a most suggestive article, Manfredi brings forward sufficient evidence to show that protection by lymphoid tissue occurs in three ways: by filtra- tion of the bacteria; by an attenuation of the virulence of the micro-organisms that reach them ; and by the whole body obtain- ing a greater or less immunity while the two first processes are in operation. If bacteria do reach the blood, they again have to contend with the body-fluids and leucocytes. 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 “On Latent Infection and Subinfection,” Jour. Am, Med. Assoc., 1899, p. 1572, PORTALS OF ENTRY. 19 is unable to offer adequate resistance ; obviously, however, it is usually when the vital resistance of the body-cells has been lowered that bacteria overcome the natural safeguards to infection. PORTALS OF ENTRY. Bacteria may gain entrance to the body-tissues through 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. Most of the surgi- cally 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 im- probable 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. Animal experiments show that the portal of entry and the chan- nel of infection bear a more or less direct relation to the severity of the infection which follows their entrance. For instance, sub- cutaneous inoculations into animals are usually much less severe in their results than those made directly into the peritoneal cavity or general vascular system. External Sources.—The bacteria derived from without the body are those chiefly concerned in the infection of wounds and many other primary surgical infections. If pathogenic bacteria can be kept out of an external wound, no suppuration of the wound ordinarily occurs. They usually gain access to wounds through contact with infected objects. Air infection is relatively animportant, and here the bacteria usually occur as clumps attached to particles of dust, so that in a perfectly quiet atmos- phere, 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 sur- faces even by strong currents of air. All the bacteria of surgical importance have been isolated from air and dust, particularly from the dust of hospitals, where they are especially frequent. Among those of surgical importance which are conveyed through 20 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS. external objects are Streptococcus pyogenes, Staphylococcus pyog- enes aureus, Staphylococcus pyogenes albus, Bacillus coli ¢« munis, Bacillus pyocyaneus, Bacillus proteus, Diplococeus lan- ceolatus, lus anthracis, Bacillus tetani, Bacillus aerogene~ capsulatus, Bacillus tuberculosis, Micrococcus gonorrhowe, 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 that insects may not only carry from place to place disease-pro- ducing micro-organisms, but that 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 blood-vessels from fresh blecding wounds. Further, it has been shown that so soon as a coagulum has been formed on the sur- face of a wound the conditions are changed, and particles like bacteria are no longer quickly transported into the blood- and lymph-circulation. The surface of a healthy granulating wound affords great resistance to bacterial invasion, almost ax much as an intact exposed surtace of the body. Slight injuries, howe such as probing, removing the dressing, and other manipulations which may convert the granulating wound into a fresh wound, favor the absorption of bacteria. Bacteria of the Skin.—Since the skin is exposed to contami- nation from the air 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 ordi- narily found are such as may be found in the air or 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. The conditions are not, however, generally favorable for considerable growth of bacteria on the healthy skin ; but under the nails and in situations where moisture collects, there may be extensive bacterial development. 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 exception- ally 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 PORTALS OF ENTRY. 21 upon the great regularity with which Staphylococcus epidermidis albus may be obtained in culture: taken from the skin, so that this organism may be regarded ax a normal habitant in this situation. It is almost regularly present in the layers of epidermis along hair-shaft< deeper than can be reached by any practical means of cutaneous disinfection. After complete sterilization of cutaneous surtaces 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. Staphylococeus epidermidis albus is usually innocuous. It is frequently present in aseptic wounds of the skin without inducing <uppuration or any untoward reactions. However, it may be the cause of disturbances characterized especially by elevation of temperature and moderate suppuration. It is a common excitant of stitch-abscess. Among other bacteria which may be present upon the skin are Streptococcus pyogenes, Staphylococcus pYegenes aureus and albus, Bacillus pyocyaneus, and Bacillus coli communis. kin contaminated with the soil, which, as is well known, con- in many situations abundant bacilli of tetanus and of mali nant cedema, i: is likely to contain these bacteria. This contamina- tion, of course, relates especially to the hands and in the case of the-~e who go barefoot or have holes in their shoes. The smeyzma 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 tinc- torial reactions to the tubercle bacillus. It has been mistaken for Bacillus tuberculosis in the examination of urine and of secretions and exudatex from the external genitals and the anus. Although smegma bacilli are found to be present with pathogenic bacteria lesions about these parts, they do not possess pathogenic activi 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 which cover parts which 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 ali- mentary canal and of the upper respiratory tract. Among this 22 INFECTION CONSIDERED IN ITS SURGICAL RELATIONS. 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 bac- teria than upon other exposed mucous membranes, very few of the large number which reach these parts persist there. Most of them either pass into the stomach and intestines or are destroyed in the mouth. Most of those present in the mouth and pharynx are saprophytes, some of which have been associated with 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 tetra- genus, Diplococcus lanceolatus, Bacillus pneumonie of Friedlander, Bacillus coli communis, Bacillus diphtherie, Bacillus proteus, and others, The mouth and adjacent parts are the most frequent por- tals of entry of the organism of actinomycosis; it is especially liable to lodge near carious teeth. Respiratory Passages.— With inspiration bacteria of air reach the upper respiratory tract. Thompson and Hewlet estimate that from fifteen hundred to fourteen thousand bacteria are inspired every hour, the great majority of which are arrested in the nasal cavities. Among the pathogenic organisms which have been found in