Alexis Thomson and Alexander Miles - Manual of Surgery

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OXFORD MEDICAL PUBLICATIONS

MANUAL OF SURGERY

BY

ALEXIS THOMSON, F.R.C.S.Ed.
_PROFESSOR OF SURGERY, UNIVERSITY OF EDINBURGH_
SURGEON EDINBURGH ROYAL INFIRMARY

AND

ALEXANDER MILES, F.R.C.S.Ed.
SURGEON EDINBURGH ROYAL INFIRMARY

VOLUME FIRST
GENERAL SURGERY

_SIXTH EDITION REVISED_
_WITH 169 ILLUSTRATIONS_

LONDON
HENRY FROWDE and HODDER & STOUGHTON
THE _LANCET_ BUILDING
1 & 2 BEDFORD STREET, STRAND, W.C.2

First Edition 1904
Second Edition 1907
Third Edition 1909
Fourth Edition 1911
" " Second Impression 1913
Fifth Edition 1915
" " Second Impression 1919
Sixth Edition 1921

PRINTED IN GREAT BRITAIN BY
MORRISON AND GIBB LTD., EDINBURGH

PREFACE TO SIXTH EDITION

Much has happened since this Manual was last revised, and many surgical
lessons have been learned in the hard school of war. Some may yet have
to be unlearned, and others have but little bearing on the problems
presented to the civilian surgeon. Save in its broadest principles, the
surgery of warfare is a thing apart from the general surgery of civil
life, and the exhaustive literature now available on every aspect of it
makes it unnecessary that it should receive detailed consideration in a
manual for students. In preparing this new edition, therefore, we have
endeavoured to incorporate only such additions to our knowledge and
resources as our experience leads us to believe will prove of permanent
value in civil practice.

For the rest, the text has been revised, condensed, and in places
rearranged; a number of old illustrations have been discarded, and a
greater number of new ones added. Descriptions of operative procedures
have been omitted from the _Manual_, as they are to be found in the
companion volume on _Operative Surgery_, the third edition of which
appeared some months ago.

We have retained the Basle anatomical nomenclature, as extended
experience has confirmed our preference for it. For the convenience of
readers who still employ the old terms, these are given in brackets
after the new.

This edition of the _Manual_ appears in three volumes; the first being
devoted to General Surgery, the other two to Regional Surgery. This
arrangement has enabled us to deal in a more consecutive manner than
hitherto with the surgery of the Extremities, including Fractures and
Dislocations.

We have once more to express our thanks to colleagues in the Edinburgh
School and to other friends for aiding us in providing new
illustrations, and for other valuable help, as well as to our publishers
for their generosity in the matter of illustrations.

EDINBURGH,
_March_ 1921.

CONTENTS

PAGE
CHAPTER I
REPAIR 1

CHAPTER II
CONDITIONS WHICH INTERFERE WITH REPAIR 17

CHAPTER III
INFLAMMATION 31

CHAPTER IV
SUPPURATION 45

CHAPTER V
ULCERATION AND ULCERS 68

CHAPTER VI
GANGRENE 86

CHAPTER VII
BACTERIAL AND OTHER WOUND INFECTIONS 107

CHAPTER VIII
TUBERCULOSIS 133

CHAPTER IX
SYPHILIS 146

CHAPTER X
TUMOURS 181

CHAPTER XI
INJURIES 218

CHAPTER XII
METHODS OF WOUND TREATMENT 241

CHAPTER XIII
CONSTITUTIONAL EFFECTS OF INJURIES 249

CHAPTER XIV
THE BLOOD VESSELS 258

CHAPTER XV
THE LYMPH VESSELS AND GLANDS 321

CHAPTER XVI
THE NERVES 342

CHAPTER XVII
SKIN AND SUBCUTANEOUS TISSUES 376

CHAPTER XVIII
THE MUSCLES, TENDONS, AND TENDON SHEATHS 405

CHAPTER XIX
THE BURSAE 426

CHAPTER XX
DISEASES OF BONE 434

CHAPTER XXI
DISEASES OF JOINTS 501

INDEX 547

LIST OF ILLUSTRATIONS

FIG. PAGE

1. Ulcer of Back of Hand grafted from Abdominal Wall 15

2. Staphylococcus aureus in Pus from case of Osteomyelitis 25

3. Streptococci in Pus from case of Diffuse Cellulitis 26

4. Bacillus coli communis in Pus from Abdominal Abscess 27

5. Fraenkel's Pneumococci in Pus from Empyema following 28
Pneumonia

6. Passive Hyperaemia of Hand and Forearm induced by Bier's 37
Bandage

7. Passive Hyperaemia of Finger induced by Klapp's Suction 38
Bell

8. Passive Hyperaemia induced by Klapp's Suction Bell for 39
Inflammation of Inguinal Gland

9. Diagram of various forms of Whitlow 56

10. Charts of Acute Sapraemia 61

11. Chart of Hectic Fever 62

12. Chart of Septicaemia followed by Pyaemia 63

13. Chart of Pyaemia following on Acute Osteomyelitis 65

14. Leg Ulcers associated with Varicose Veins 71

15. Perforating Ulcers of Sole of Foot 74

16. Bazin's Disease in a girl aet. 16 75

17. Syphilitic Ulcers in region of Knee 76

18. Callous Ulcer showing thickened edges 78

19. Tibia and Fibula, showing changes due to Chronic Ulcer of 80
Leg

20. Senile Gangrene of the Foot 89

21. Embolic Gangrene of Hand and Arm 92

22. Gangrene of Terminal Phalanx of Index-Finger 100

23. Cancrum Oris 103

24. Acute Bed Sores over right Buttock 104

25. Chart of Erysipelas occurring in a wound 108

26. Bacillus of Tetanus 113

27. Bacillus of Anthrax 120

28. Malignant Pustule third day after infection 122

29. Malignant Pustule fourteen days after infection 122

30. Colony of Actinomyces 126

31. Actinomycosis of Maxilla 128

32. Mycetoma, or Madura Foot 130

33. Tubercle bacilli 134

34. Tuberculous Abscess in Lumbar Region 141

35. Tuberculous Sinus injected through its opening in the 144
Forearm with Bismuth Paste

36. Spirochaete pallida 147

37. Spirochaeta refrigerans from scraping of Vagina 148

38. Primary Lesion on Thumb, with Secondary Eruption on 154
Forearm

39. Syphilitic Rupia 159

40. Ulcerating Gumma of Lips 169

41. Ulceration in inherited Syphilis 170

42. Tertiary Syphilitic Ulceration in region of Knee and on 171
both Thumbs

43. Facies of Inherited Syphilis 174

44. Facies of Inherited Syphilis 175

45. Subcutaneous Lipoma 185

46. Pedunculated Lipoma of Buttock 186

47. Diffuse Lipomatosis of Neck 187

48. Zanthoma of Hands 188

49. Zanthoma of Buttock 189

50. Chondroma growing from Infra-Spinous Fossa of Scapula 190

51. Chondroma of Metacarpal Bone of Thumb 190

52. Cancellous Osteoma of Lower End of Femur 192

53. Myeloma of Shaft of Humerus 195

54. Fibro-myoma of Uterus 196

55. Recurrent Sarcoma of Sciatic Nerve 198

56. Sarcoma of Arm fungating 199

57. Carcinoma of Breast 206

58. Epithelioma of Lip 209

59. Dermoid Cyst of Ovary 213

60. Carpal Ganglion in a woman aet. 25 215

61. Ganglion on lateral aspect of Knee 216

62. Radiogram showing pellets embedded in Arm 228

63. Cicatricial Contraction following Severe Burn 236

64. Genealogical Tree of Haemophilic Family 278

65. Radiogram showing calcareous degeneration of Arteries 284

66. Varicose Vein with Thrombosis 289

67. Extensive Varix of Internal Saphena System on Left Leg 291

68. Mixed Naevus of Nose 296

69. Cirsoid Aneurysm of Forehead 299

70. Cirsoid Aneurysm of Orbit and Face 300

71. Radiogram of Aneurysm of Aorta 303

72. Sacculated Aneurysm of Abdominal Aorta 304

73. Radiogram of Innominate Aneurysm after Treatment by 309
Moore-Corradi method

74. Thoracic Aneurysm threatening to rupture 313

75. Innominate Aneurysm in a woman 315

76. Congenital Cystic Tumour or Hygroma of Axilla 328

77. Tuberculous Cervical Gland with Abscess formation 331

78. Mass of Tuberculous Glands removed from Axilla 333

79. Tuberculous Axillary Glands 335

80. Chronic Hodgkin's Disease in boy aet. 11 337

81. Lymphadenoma in a woman aet. 44 338

82. Lympho Sarcoma removed from Groin 339

83. Cancerous Glands in Neck, secondary to Epithelioma of Lip 341

84. Stump Neuromas of Sciatic Nerve 345

85. Stump Neuromas, showing changes at ends of divided Nerves 354

86. Diffuse Enlargement of Nerves in generalised 356
Neuro-Fibromatosis

87. Plexiform Neuroma of small Sciatic Nerve 357

88. Multiple Neuro-Fibromas of Skin (Molluscum fibrosum) 358

89. Elephantiasis Neuromatosa in a woman aet. 28 359

90. Drop-Wrist following Fracture of Shaft of Humerus 365

91. To illustrate the Loss of Sensation produced by Division 367
of the Median Nerve

92. To illustrate Loss of Sensation produced by Complete 368
Division of Ulnar Nerve

93. Callosities and Corns on Sole of Foot 377

94. Ulcerated Chilblains on Fingers 378

95. Carbuncle on Back of Neck 381

96. Tuberculous Elephantiasis 383

97. Elephantiasis in a woman aet. 45 387

98. Elephantiasis of Penis and Scrotum 388

99. Multiple Sebaceous Cysts or Wens 390

100. Sebaceous Horn growing from Auricle 392

101. Paraffin Epithelioma 394

102. Rodent Cancer of Inner Canthus 395

103. Rodent Cancer with destruction of contents of Orbit 396

104. Diffuse Melanotic Cancer of Lymphatics of Skin 398

105. Melanotic Cancer of Forehead with Metastasis in Lymph 399
Glands

106. Recurrent Keloid 401

107. Subungual Exostosis 403

108. Avulsion of Tendon 410

109. Volkmann's Ischaemic Contracture 414

110. Ossification in Tendon of Ilio-psoas Muscle 417

111. Radiogram of Calcification and Ossification in Biceps and 418
Triceps

112. Ossification in Muscles of Trunk in generalised Ossifying 419
Myositis

113. Hydrops of Prepatellar Bursa 427

114. Section through Gouty Bursa 428

115. Tuberculous Disease of Sub-Deltoid Bursa 429

116. Great Enlargement of the Ischial Bursa 431

117. Gouty Disease of Bursae 432

118. Shaft of the Femur after Acute Osteomyelitis 444

119. Femur and Tibia showing results of Acute Osteomyelitis 445

120. Segment of Tibia resected for Brodie's Abscess 449

121. Radiogram of Brodie's Abscess in Lower End of Tibia 451

122. Sequestrum of Femur after Amputation 453

123. New Periosteal Bone on Surface of Femur from Amputation 454
Stump

124. Tuberculous Osteomyelitis of Os Magnum 456

125. Tuberculous Disease of Tibia 457

126. Diffuse Tuberculous Osteomyelitis of Right Tibia 458

127. Advanced Tuberculous Disease in Region of Ankle 459

128. Tuberculous Dactylitis 460

129. Shortening of Middle Finger of Adult, the result of 461
Tuberculous Dactylitis in Childhood

130. Syphilitic Disease of Skull 463

131. Syphilitic Hyperostosis and Sclerosis of Tibia 464

132. Sabre-blade Deformity of Tibia 467

133. Skeleton of Rickety Dwarf 470

134. Changes in the Skull resulting from Ostitis Deformans 474

135. Cadaver, illustrating the alterations in the Lower Limbs 475
resulting from Ostitis Deformans

136. Osteomyelitis Fibrosa affecting Femora 476

137. Radiogram of Upper End of Femur in Osteomyelitis Fibrosa 478

138. Radiogram of Right Knee showing Multiple Exostoses 482

139. Multiple Exostoses of Limbs 483

140. Multiple Cartilaginous Exostoses 484

141. Multiple Cartilaginous Exostoses 486

142. Multiple Chondromas of Phalanges and Metacarpals 488

143. Skiagram of Multiple Chondromas 489

144. Multiple Chondromas in Hand 490

145. Radiogram of Myeloma of Humerus 492

146. Periosteal Sarcoma of Femur 493

147. Periosteal Sarcoma of Humerus 493

148. Chondro-Sarcoma of Scapula 494

149. Central Sarcoma of Femur invading Knee Joint 495

150. Osseous Shell of Osteo-Sarcoma of Femur 495

151. Radiogram of Osteo-Sarcoma of Femur 496

152. Radiogram of Chondro-Sarcoma of Humerus 497

153. Epitheliomatus Ulcer of Leg invading Tibia 499

154. Osseous Ankylosis of Femur and Tibia 503

155. Osseous Ankylosis of Knee 504

156. Caseating focus in Upper End of Fibula 513

157. Arthritis Deformans of Elbow 525

158. Arthritis Deformans of Knee 526

159. Hypertrophied Fringes of Synovial Membrane of Knee 527

160. Arthritis Deformans of Hands 529

161. Arthritis Deformans of several Joints 530

162. Bones of Knee in Charcot's Disease 533

163. Charcot's Disease of Left Knee 534

164. Charcot's Disease of both Ankles: front view 535

165. Charcot's Disease of both Ankles: back view 536

166. Radiogram of Multiple Loose Bodies in Knee-joint 540

167. Loose Body from Knee-joint 541

168. Multiple partially ossified Chondromas of Synovial 542
Membrane from Shoulder-joint

169. Multiple Cartilaginous Loose Bodies from Knee-joint 543

MANUAL OF SURGERY

CHAPTER I

REPAIR

Introduction--Process of repair--Healing by primary union--Granulation
tissue--Cicatricial tissue--Modifications of process of
repair--Repair in individual tissues--Transplantation or grafting
of tissues--Conditions--Sources of grafts--Grafting of individual
tissues--Methods.

INTRODUCTION

To prolong human life and to alleviate suffering are the ultimate
objects of scientific medicine. The two great branches of the healing
art--Medicine and Surgery--are so intimately related that it is
impossible to draw a hard-and-fast line between them, but for
convenience Surgery may be defined as "the art of treating lesions and
malformations of the human body by manual operations, mediate and
immediate." To apply his art intelligently and successfully, it is
essential that the surgeon should be conversant not only with the normal
anatomy and physiology of the body and with the various pathological
conditions to which it is liable, but also with the nature of the
process by which repair of injured or diseased tissues is effected.
Without this knowledge he is unable to recognise such deviations from
the normal as result from mal-development, injury, or disease, or
rationally to direct his efforts towards the correction or removal of
these.

PROCESS OF REPAIR

The process of repair in living tissue depends upon an inherent power
possessed by vital cells of reacting to the irritation caused by injury
or disease. The cells of the damaged tissues, under the influence of
this irritation, undergo certain proliferative changes, which are
designed to restore the normal structure and configuration of the part.
The process by which this restoration is effected is essentially the
same in all tissues, but the extent to which different tissues can carry
the recuperative process varies. Simple structures, such as skin,
cartilage, bone, periosteum, and tendon, for example, have a high power
of regeneration, and in them the reparative process may result in almost
perfect restitution to the normal. More complex structures, on the other
hand, such as secreting glands, muscle, and the tissues of the central
nervous system, are but imperfectly restored, simple cicatricial
connective tissue taking the place of what has been lost or destroyed.
Any given tissue can be replaced only by tissue of a similar kind, and
in a damaged part each element takes its share in the reparative process
by producing new material which approximates more or less closely to the
normal according to the recuperative capacity of the particular tissue.
The normal process of repair may be interfered with by various
extraneous agencies, the most important of which are infection by
disease-producing micro-organisms, the presence of foreign substances,
undue movement of the affected part, and improper applications and
dressings. The effect of these agencies is to delay repair or to prevent
the individual tissues carrying the process to the furthest degree of
which they are capable.

In the management of wounds and other diseased conditions the main
object of the surgeon is to promote the natural reparative process by
preventing or eliminating any factor by which it may be disturbed.

#Healing by Primary Union.#--The most favourable conditions for the
progress of the reparative process are to be found in a clean-cut wound
of the integument, which is uncomplicated by loss of tissue, by the
presence of foreign substances, or by infection with disease-producing
micro-organisms, and its edges are in contact. Such a wound in virtue of
the absence of infection is said to be _aseptic_, and under these
conditions healing takes place by what is called "primary union"--the
"healing by first intention" of the older writers.

#Granulation Tissue.#--The essential and invariable medium of repair in
all structures is an elementary form of new tissue known as _granulation
tissue_, which is produced in the damaged area in response to the
irritation caused by injury or disease. The vital reaction induced by
such irritation results in dilatation of the vessels of the part,
emigration of leucocytes, transudation of lymph, and certain
proliferative changes in the fixed tissue cells. These changes are
common to the processes of inflammation and repair; no hard-and-fast
line can be drawn between these processes, and the two may go on
together. It is, however, only when the proliferative changes have come
to predominate that the reparative process is effectively established by
the production of healthy granulation tissue.

_Formation of Granulation Tissue._--When a wound is made in the
integument under aseptic conditions, the passage of the knife through
the tissues is immediately followed by an oozing of blood, which soon
coagulates on the cut surfaces. In each of the divided vessels a clot
forms, and extends as far as the nearest collateral branch; and on the
surface of the wound there is a microscopic layer of bruised and
devitalised tissue. If the wound is closed, the narrow space between its
edges is occupied by blood-clot, which consists of red and white
corpuscles mixed with a quantity of fibrin, and this forms a temporary
uniting medium between the divided surfaces. During the first twelve
hours, the minute vessels in the vicinity of the wound dilate, and from
them lymph exudes and leucocytes migrate into the tissues. In from
twenty-four to thirty-six hours, the capillaries of the part adjacent to
the wound begin to throw out minute buds and fine processes, which
bridge the gap and form a firmer, but still temporary, connection
between the two sides. Each bud begins in the wall of the capillary as a
small accumulation of granular protoplasm, which gradually elongates
into a filament containing a nucleus. This filament either joins with a
neighbouring capillary or with a similar filament, and in time these
become hollow and are filled with blood from the vessels that gave them
origin. In this way a series of young _capillary loops_ is formed.