General surgical pathology and therapeutics, in fifty-one lectures ...

Front matter

v* y

GENERAL SURGICAL

PATHOLOGY AND THERAPEUTICS

Preface To The Eighth German Edition

This edition also lias been carefully revised, and some additions have been made to it. It is the hope of the author that the book will continue to be acceptable and beneficial to students of surgery.

In addition to previous translations, there has been a new English one made under the auspices of the New Sydenham Society, as well as one into Japanese by Dr. Susum Sato.

TH. BILLEOTH.

Author's Preface To The Sixth Edition

The steady advance of science, and the progress that we onr selves make as long as we have the inclination and strength to swim with the stream, become most apparent when we are from time to time obliged to go over our old work. On a similar occasion I have already expressed this thought, but do not hesitate to repeat it here ; for this perception of progress is a great support to us in the many dark hours when, with the greatest zeal to serve our fellow-men, we feel oppressed by the impotence of our knowledge and ability.

I have again done my best to raise this book to the present level of our knowledge, and have untiringly striven to improve its form and contents ; the section on Deformities has been entirely rewritten, old woodcuts have been replaced by better ones, and some new ones have been added ; prescriptions have been given in grammes.

May this enlarged edition also be well received, and arouse in the student a love of surgery !

TH. BILLROTH.

Vienna, November, 1872.

Preface To The Fourth Edition

Almost every time that it has become my pleasant task to go over this book in preparing a new edition, I have thought, this time at least, there will not be mnch to alter ; nevertheless, I always found much, very much to improve, to cut out or to add. In so doing, I have always had the satisfaction of knowing that even in short periods the progress of science had been quite perceptible. We do not notice this much while swimming with the stream, but it becomes very evident when we have before us a book that is to a certain extent a photogram of the state of affairs two years since. The success that this edition meets with will show whether I have again succeeded in presenting my book in a shape to meet the requirements of physicians and students.

The section on traumatic inflammation has been revised in accordance with recent advances. In the chapter on tumors, the part treating of carcinoma has been simplified, the term " connective-tissue cancer " being omitted, to prevent confusion.

De. TH. BILLROTH.

A^ienna, November, 1869.

Contents

LECTUEE L

Introduction

Relation of Surgery to Internal Medicine. — Necessity of the Practising Physician being acquainted with both. — Historical Bemarks. — Nature of the Study of Surgery in the German High-school, page 1

Chapter I. Simple Incised Wounds Of The Soft Parts

LECTUEE II.

Mode of Origin and Appearance of theae "Wounds. — Various Forms of Incised "Wounds. — Appearance during and immediately after their Occurrence. — Pain, Bleeding. — Varieties of Haemorrhage ; Arterial, Venous. — Entrance of Air through "Wounded Veins. — Parenchymatous Haemorrhage. — Haemorrhagic Diathesis. — Haemorrhage from the Pharynx and Eectum. — Constitutional Effects of Severe Haemorrhage, p. 17

LECTUEE III.

Treatment of Haemorrhage. — 1. Ligature and Mediate Ligature of Arteries. — 2. Compression by the Finger ; Choice of the Point for Compression of the Larger Arteries. — Tourniquet. — Acupressure. — Bandaging. — Tampon. — 3. Styptics. — General Treatment of Sudden Anaemia. — Transfusion, . .... p. 26

LECTUEE IV.

Gaping of the "Wound. — Union by Plaster. — Suture ; Interrupted Suture ; Twisted Suture. — External Changes perceptible in the United "Wound. — Healing by First Intention, p. 41

LECTUEE V.

The more Minute Changes in Healing by the First Intention.— Dilatation of Vessels in the Vicinity of the "Wound. — Fluxion. — Different Views regarding the Causes of Fluxion, p. 49

LECTUEE VI.

Changes in the Tissue during Healing by the First Intention. — Plastic Infiltration. — Inflammatory New Formation. — Eetrogression to the Cicatrix. — Anatomical Evix CONTENTS.

dences of Inflammation. — Conditions under which Healing by First Intention does not occur.— Union of Parts that have been completely separated, . . page 58

LECTUEE VII.

Changes perceptible to the Naked Eye in Wounds with Loss of Substance.— Finer Processes in Healing with Granulation and Suppuration. — Pus. — Cicatrization. — Observations on "Inflammation." — Demonstration of Preparations illustrative of the Healing of Wounds, p. 70

LECTUEE VIII.

General Eeaction after Injury. — Surgical Fever. — Theories of the Fever. — Prognosis. — Treatment of Simple Wounds and of Wounded Persons. — Burrowing Wounds. — Open Treatment of Wounds.— Lister's Method.— Coccobacteria Septica, . p. 88

LECTUEE IX.

Combination of Healing by First and Second Intention. — Union of Granulation Surfaces. Healing under a Scab. — Granulation Diseases. — The Cicatrix in Various Tissues ; in Muscle; in Nerve; its Knobby Proliferation; in Vessels. — Organization of the Thrombus. — Arterial Collateral Circulation, . . . . . . . p. 99

Chapter II. Some Peculiarities Of Punctured Wounds

LECTUEE X.

As a Eule, Punctured Wounds heal quickly by First Intention. — Needle Punctures ; Needles remaining in the Body, their Extraction. — Punctured Wounds of the Nerves. — Punctured Wounds of the Arteries : Aneurysma Traumaticum, Varicosum, Varix Aneurysmaticus. — Punctured Wounds of the Veins, Venesection, . .p. 130

Chapter III. Contusions Of The Soft Parts Without Wounds

LECTUEE XI.

Causes of Contusions. — Nervous Concussion. — Subcutaneous Eupture of Vessels. — Bup ture of Arteries.— Suggillations. — Ecchymoses. — Eeabsorption. — Termination in Fibrous Tumors, in Cysts, in Suppuration, and Putrefaction. — Treatment, p. 141

Chapter IV. Contused And Lacerated Wounds Of The Soft Parts

LECTUEE XII.

Mode of Occurrence of these Wounds ; their Appearance. — Slight Haemorrhage in Contused Wounds. — Early Secondary Haemorrhages. — Gangrene of the Edges of the Wound. — Influences that effect the Slower or more Eapid Detachment of the Dead Tissue. — Indications for Primary Amputation. — Local Complications in Contused Wounds ; Decomposition, Putrefaction, Septic Inflammations.— Contusion of Arteries ; Late Secondary Haemorrhages, p. 152

CONTEXTS. xi

LECTUKE XIII.

Progressive Suppuration starting from Contused Wounds. — Secondary Inflammations of the "Wound: their Causes; Local Infection. — Febrile Eeaction in Contused Wounds : Secondary Fever ; Suppurative Fever ; Chill ; their Causes. — Treatment of Contused "Wounds : Immersion, Ice-bladders, Irrigation ; Criticism of these Methods. — Incisions. — Counter-openings. — Drainage. — Cataplasms. — Open Treatment of "Wounds. — Prophylaxis against Secondary Inflammations. — Internal Treatment of those severely "Wounded. — Quinine. — Opium. — Lacerated "Wounds : Subcutaneous Eupture of Muscles and Tendons ; Tearing out of Muscles and Tendons ; Tearing out of Pieces of a Limb, page 164

CHAPTER Y.

SIMPLE FRACTURES OF BOXES

LECTUKE XIV.

Causes, Different Varieties of Fractures. — Symptoms, Diagnosis.— Course and External Symptoms. — Anatomy of Healing, Formation of Callus.— Source of the Inflammatory Osseous New Formation. — Histology, p. 185

LECTUEE XV.

Treatment of Simple Fractures.— Eeduction. — Time for applying the Dressing, its Choice. — Plaster of Paris and Starch Dressings, Splints, Permanent Extension. — Eetaining the Limb in Position. — Indications for removing the Dressings, p. 201

Chapter VI. Open Fractures And Suppuration Of Bone

Difference between Subcutaneous and Open Fractures in regard to Prognosis. — Varieties of Cases. — Indications for Primary Amputation. — Secondary Amputation. — Course of the Cure. — Suppuration of Bone. — Necrosis of the Ends of Fragments, p. 210

LECTUEE XVI.

Development of Osseous Granulations. — Histology. — Detachment of the Sequestrum. — Histology. — Osseous New Formation around the Detached Sequestrum. — Callus in Suppurating Fractures. — Suppurative Periostitis and Osteomyelitis. — General Condition. — Fever. — Treatment ; Fenestrated, Closed, Split Dressings. — Antiphlogistic Eemedies. — Immersion. — Lister's Method. — Eules about Bone-splinters. — After-Treatment, . p. 216

Appendix To Chapters V. And VI

LECTUEE XVII.

1. Eetarded Formation of Callus and Development of Pseudarthrosis.— Causes often unknown. — Local Causes. — Constitutional Causes. — Anatomical Conditions. — Treatment: internal, operative; Criticism of Methods. 2. Obliquely-united Fractures; Eebreaking, Bloody Operations. — Abnormal Development of Callus, p. 226 xii CONTENTS.

Chapter VII. Injuries Of The Joints

Contusion.— Distortion.— Massage. — Opening of the Joint, and Acute Traumatic Articular Inflammation. — Variety of Course, and Kesults. — Treatment. — Anatomical Changes, page 234

LECTUEE XVI11.

Simple Dislocations; Traumatic, Congenital, Pathological Luxations, Subluxations. — Etiology. — Difficulties in Eeduction, Treatment; Eeduction, After-Treatment. — Habitual Luxations. — Old Luxations, Treatment. — Complicated Luxations. — Congenital Luxations, p. 242

Chapter VIII. G Unshot- Wounds

LECTUEE XIX.

Historical Eemarks. — Injuries from Large Missiles. — Various Forms of Bullet-Wounds. — Transportation and Care of the "Wounded in the Field. — Treatment. — Complicated Gunshot-Fractures, p. 254

Chapter IX. Burns And Frost-bites

LECTUEE XX. 1. Burns: Grade, Extent, Treatment.— Sunstroke.— Stroke of Lightning.— 2. Frost-bites : Grade. — General Freezing, Treatment. — Chilblains, . . .p. 266

Chapter X

ACUTE NON-TRAUMATIC INFLAMMATION OF THE SOFT PARTS. LECTUEE XXI.

General Etiology of Acute Inflammations.— Acute Inflammation : 1. Of the Cutis. a, Erysipelatous Inflammation ; J, Furuncle ; c, Carbuncle (Anthrax), Pustula Maligna. 2. Of the Mucous Membranes. 3. Of the Cellular Tissue, Acute Abscesses. 4. Of the Muscles. 5. Of the Serous Membranes, Sheaths of the Tendons, and Subcutaneous Mucous Bursa?, p. 277

Chapter XI

ACUTE INFLAMMATIONS OF THE BONES, PERIOSTEUM, AND JOINTS. LECTUEE XXII.

Anatomy.— Acute Periostitis and Osteomyelitis of the Long Bones : Symptoms, Terminations in Eesolution, Suppuration, Necrosis, Prognosis, Treatment.— Acute Ostitis in Spongy Bones.— Multiple Acute Osteomyelitis.— Acute Inflammations of the Joints.— Hydrops Acutus ; Symptoms, Treatment.— Acute Suppurative Inflammations of Joints : Symptoms, Course, Treatment, Anatomy.— Acute Articular Eheumatism.— Arthritis.— Metastatic Inflammations of Joints (Gonorrhoeal, Pyemic, Puerperal), p. 300

Appendix To Chapters I.-xi

Eevicw.— General Eemarks about Acute Inflammation, p. 317

CONTENTS. xiii

Chapter XII. Gangrene

LECTURE XXII I.

Dry, Moist Gangrene. — Immediate Causes. — Process of Detachment. — Varieties of Gangrene according to the Remote Causes.— 1. Loss of Vitality of the Tissue from Mechanical or Chemical Causes. — 2. Complete Arrest of the Afflux and Efflux of Blood. — Incarceration. — Continued Pressure. — Decubitus. — Great Tension of the Tissue. — 3. Complete Arrest of the Supply of Arterial Blood. — Gangrena Spontanea. — Gangrena Senilis. — Ergotism. — 4. Noma. — Gangrene in Various Blood- Diseases. — Treatment, page 326

Chapter XIII. Accidental Traumatic And Inflammatory Diseases, And Poisoned

WOUNDS.

LECTURE XXIV.

I. Local Diseases which may accompany "Wounds and Other Points of Inflammation : 1. Progressive Purulent and Purulent Putrid Diffuse Inflammation of Cellular Tissue. — 2. Hospital Gangrene. — 3. Traumatic Erysipelas. — 4. Lymphangitis, p. 338

LECTURE XXV.

5. Phlebitis ; Thrombosis ; Embolism. — Causes of Venous Thrombosis ; Various Metamorphoses of the Thrombus. — Embolism. — Red Infarction, Embolic Metastatic Abscesses.— Treatment, p. 353

LECTURE XXVI.

II. — General Accidental Diseases which may accompany "Wounds and Local Inflammations. 1. Traumatic and Inflammatory Eever ; 2. Septic Fever and Septicemia ; 3. Suppurative Fever and Pyemia, p. 362

LECTURE XXVII.

4. Tetanus; 5. Delirium Potatorum Traumaticum ; 6. Delirium Nervosum and Mania. — Appendix to Chapter XIII. — Poisoned "Wounds ; Insect-bites, Snake-bites ; Infection from Dissecting Wounds. — Glanders. — Carbuncle. — Diseases from Mouths and Claws of Animals.— Hydrophobia, p. 386

Chapter XIV

CHRONIC INFLAMMATION ESPECIALLY OF THE SOFT PARTS. LECTURE XXVIII.

Anatomy: 1. Thickening, Hypertrophy ; 2. Hypersecretion; 3. Suppuration, Cold Abscesses, Congestive Abscesses, Fistulas, Ulceration. — Results of Chronic Inflammation. — General Symptomatology. — Course. p. 403

LECTURE XXIX.

General Etiology of Chronic Inflammation. — External Continued Irritation. — Causes in the Body. — Empirical Idea of Diatheses and Dyscrasiae.— General Symptomatology and Treatment of Morbid Diatheses and Dyscrasiae. 1. The Lymphatic Diathesis (Scrofula); 2. Tuberculous Dyscrasia (Tuberculosis); 3. The Arthritic Diathesis ; 4. The Scorbutic Dyscrasia ; 5. Syphilitic Dyscrasia, . . . .p. 410

XIV CONTENTS.

LECTURE XXX.

Local Treatment of Chronic Inflammation : Eest, Compression, Moist Warmth, Hydropathic Wraps, Eesorbents, Antiphlogistics, Derivatives, Eontanels, Setons, Moxas, the Hot Iron, page 429

Chapter XV. Ulcers

LECTURE XXXI.

Anatomy. — External Peculiarities of Ulcers ; Form and Extent, Base and Secretion, Edges, Parts around. — Local Treatment according to the Local Condition of the Ulcer ; Fungous, Callous, Putrid, Phagedenic, Sinuous Ulcers, Etiology, Continued Irritation, Venous Congestion, Dyscrasial Causes, . . . .p. 434

Chapter XVI. Chronic Inflammation Of The Periosteum, Of The Bone, And

NECROSIS.

LECTUEE XXXII.

Chronic Periostitis and Caries Superficialis. — Symptoms. — Osteophytes. — Osteoplastic, Suppurative Forms. — Anatomy of Caries. — Etiology.— Diagnosis.— Combination of Various Forms, p. 448

LECTUEE XXXIII.

Primary Central, Chronic Ostitis, or Caries. — Symptoms. — Ostitis Interna Osteoplasts, Suppurativa, Fungosa. — Abscess of Bone. — Combinations. — Ostitis with Caseous Metamorphosis. — Tubercles of Bone. — Diagnosis of Caries. — Dislocation of the Bones after their Partial Destruction. — Congestion Abscesses. — Etiology, p. 458

LECTUEE XXXIV.

Process of Cure in Caries and Congestion Abscesses. — Prognosis.— General Health in Chronic Inflammations of the Bone. — Secondary Lymphatic Enlargements. — Treatment of Caries and Congestion Abscesses. — Eesections in the Continuity, p. 468

LECTUEE XXXV.

Necrosis. — Etiology. — Anatomical Conditions in Total and Partial Necrosis. — Symptoms and Diagnosis. — Treatment. — Sequestrotomy, p. 479

LECTUEE XXXVI.

Rachitis. — Anatomy. — Symptoms. — Etiology. — Treatment. — Osteomalacia. — Hypertrophy and Atrophy of Bone, p. 495

Chapter XVII. Chronic Inflammation Of The Joints

LECTUEE XXXVII.

General Remarks on the Distinguishing Characteristics of the Chief Forms. — A. Fungous and Suppurative Articular Inflammations (Tumor Albus), Symptoms, Anatomy, Caries Sicca, Suppuration, Atonic Forms. — Etiology.— Course and Prognosis, p. 508

CONTENTS. xv

LECTURE XXXVIII.

Treatment of Tumor Albus.— Operations.— Resection of the Joints.— Criticisms on the Operations on the Different Joints, page 514

LECTURE XXXIX.

B. — Chronic Serous Synovitis. — Hydrops Articulorum Chronicus; Anatomy, Symptoms, Treatment. — Typical recurring Dropsies of the Knee. — Appendix : Chronic Dropsies of the Sheaths of the Tendons, Synovial Hernias of the Joints and Subcutaneous Mucous Bursae, p. 524

LECTURE XL.

C. — Chronic Rheumatic Inflammation of the Joints. — Arthritis Deformans. — Malum Coxae Senile. — Anatomy, Different Forms, Symptoms, Diagnosis, Prognosis, Treatment. — Appendix I. : Foreign Bodies in the Joints : 1. Fibrinous Bodies ; 2. Cartilaginous and Bony Bodies ; Symptomatology, Operations. — Appendix II. : Neuroses of the Joints, p. 534

LECTURE XLI.

Anchyloses : Varieties, Anatomy, Diagnosis, Treatment ; Gradual Forced Extension ; Operations with the Knife, p. 546

Chapter XVIII

CONGENITAL DEFORMITIES OF THE JOINTS DUE TO MUSCULAR AND NER- VOUS AFFECTIONS AND CICATRICIAL CONTRACTIONS.- LOX ARTHROSES.

LECTURE XLII.

I. Deformities of Intra-uterine Origin due to Disturbances of Development of the Joint. — II. Deformities occurring only in Children and Young Persons, caused by Impaired Growth of the Joint. — III. Deformities from Contractions, or Paralysis of Single Muscles or Groups of Muscles. — IV. Limitation of Movements in the Joints from Contraction of Fasciae and Ligaments. — V. Cicatricial Contractions. — Treatment. — Extension by Apparatus, Straightening under Anaesthesia. — Compression.— Tenotomy and Myotomy. — Division of the Fasciae and Articular Ligaments. — Gymnastics and Electricity. — Artificial Muscles. — Supporting Apparatus, p. 558

Chapter XIX. Varices And Aneurisms

LECTURE XLIII.

Varices: Various Forms, Causes, Various Localities where they occur, — Diagnosis. — Vein-stones. — Varix Fistulae. — Treatment. — Varicose Lymphatics, Lymphorrhoea. — Aneurisms : Inflammation of Arteries. — Aneurysma Cirsoideum. — Atheroma. — Various Forms of Aneurism. — Their Subsequent Changes, — Symptoms, Results, Etiology, Diagnosis. — Treatment: Compression, Ligation, Injection of Liquor Ferri, Extirpation, p. 576

Chapter XX. Tumors

LECTURE XLIV.

Definition of the Term Tumor. — General Anatomical Remarks; Polymorphism of

Tissues. — Points of Origin of Tumors. — Limitation of the Development of Cells to

Certain Types of Tissue. — Relation to the Generative Layers. — Mode of Growth. —

Anatomical Metamorphosis of Tumors; their External Appearances, . . p. 595 xvi CONTENTS.

LECTUEE XLV.

Etiology of Tumors ; Miasmatic Influence. — Specific Infection.— Specific Eeaction of the Irritated Tissues ; its Cause is always constitutional.— Internal Irritations ; Hypotheses as to the Character and Mode of the Irritant Action. — Course and Prognosis : Solitary, Multiple, Infectious Tumors. — Dyscrasia. — Treatment. — Principles of the Classification of Tumors, ....... page 605

LECTUEE XLVI.

1. Fibromata: a, Soft; b, Hard Fibroma. — Mode of Occurrence ; Operations; Ligature; Ecrasement ; Galvano-caustic. — 2. Zipomata : Anatomy ; Occurrence ; Course. 3. Chondromata: Occurrence; Operation. — 4. Osteomata: Forms; Operation, p. 618

LECTUEE XLVII. 5. Myoma. — 6. Neuroma. — 7. Angioma: a, Plexiform; J, Cavernous. — Operations, p. 637

LECTUEE XLVIH.

9. Sarcomata.— Anatomy : a, Granulation Sarcoma ; 5, Spindle-celled Sarcoma ; c, Giant-

celled Sarcoma ; d, Stellate Sarcoma ; e, Alveolar Sarcoma ; y, Pigmented Sarcoma. — Clinical Appearance. — Diagnosis. — Course. — Prognosis. — Mode of Infection. — Topography. — Central Osteosarcoma. — Periosteal Sarcoma. — Sarcoma of the Mamma, of the Salivary Glands. — 9. LympTiomata. — Anatomy.— Eelations to Leucaemia. — Treatment, p. 645

LECTUEE XLIX.

10. Papillomata. — 11. Adenomata. — 12. Cysts and Cystomata.— Follicular Cysts of the

Skin and Mucous Membranes. — Neoplastic Cysts. — Cysts of the Thyroid Gland. — Ovarian Cysts. — Blood-Cysts, p. 666

LECTUEE L.

13 Carcinomata. — Historical Eemarks. — General Description of the Anatomical Structure. — Metamorphoses. — Forms. — Topography. — 1. Skin and Mucous Membranes with Pavement Epithelium. — 2. Milk Glands. — 3. Mucous Glands with Cylindrical Epithelium. — i. Lachrymal Glands, Salivary Glands, and Prostate Glands. — 5. Thyroid Glands and Ovaries. — Treatment. — Brief Eemarks about the Diagnosis, .p. 680

Chapter XXI

AMPUTATIONS, EXARTICULATIONS, AND RESECTIONS. LECTUEE LI.

Importance of these Operations. — Amputations and Exarticulations. — Indications. — Methods. — After-Treatment. — Prognosis. — Conical Stumps. — Artificial Limbs. — History. — Eesection of the Joints. — History. — Indications. — Methods. — After- Treatment, p. 720

Appendix: Additions from the Eighth German Edition, p. 739

Index, P- 760

LIST OF WOODCUTS.

FIG.

1. Diagram of connective tissue, with capillaries, .

2. Diagram of incision, capillaries closed by blood-clots, collateral distention,

3. Diagram representing the surface of the wound united by inflammatory new

formation, . . . .

3 a. Vessels from mesentery of frog, . 3 b. Development of vessels, .... 3 o. Vessels in vitreous body, ....

4. Diagram of a wound with loss of substance, .

5. Pus-cells from fresh pus, ....

6. Diagram of granulation of a wound,

7. Fatty degeneration of cells from granulations, . 7 a. Epithelium of the cornea of a frog,

8. Corneal incision three days old,

9. Incised wound twenty-four hours old, .

10. Cicatrix nine days after an incision,

11. Granulation-tissue, .....

12. Young cicatricial tissue, ....

13. Horizontal section through the tongue of a dog,

14. Same, ten days old, .....

15. Same, sixteen days old, .....

16. Granulation- vessels, . . .

17. Seven-days-old wound in the lip of a dog, 17 a. Micrococcus, .....

18. Cicatrix from the upper lip of a dog, .

19. Ends of divided muscular fibres, .

20. Regenerative processes in transversely-striated muscle,

21. Regeneration of nerves, ....

22. " "

22 a. Nerves after division, ....

23. Nodular nerve-terminations in an old stump,

24. Artery ligated in the continuity, .

25. Transverse section of a fresh thrombus,

26. Transverse section of thrombus six days old,

27. Ten-days-old thrombus, .....

28. Completely-organized thrombus, .

29. Longitudinal section of the ligated end of an artery,

30. Portion of a transverse section of a vein, with organized thrombus

31. Artery, injected six weeks after ligation,

32. Artery, injected thirty-five months after ligation,

33. Artery, injected three months after ligation,

34. Artery wounded on the side, with clot, ....

PAGE

51 52

59 60 66 67 73 75 77 78 78

LIST OF WOODCUTS.

35. Aneurisma traumaticum, . .

36. Varix aneurismaticus, .....

37. Aneurisina varicosum, .....

38. Granular and crystalline hsematoidin,

39. Detachment of dead connective tissue in contused wounds

40. Central end of a torn brachial artery,

41. Evulsed middle finger, .....

42. Arm torn out, with scapula and clavicle, .

43. Longitudinal section of a fracture four days old,

44. Diagram of a longitudinal section of a fracture fifteen days old,

45. Diagram of a longitudinal section of a fracture twenty -four weeks old

46. Fracture, with dislocation, after twenty-seven days,

47. Old united oblique fracture, ....

48. Longitudinal section through the cortical substance,

49. Inflammatory new formation in Haversian canals,

50. Ossification of inflammatory neoplasia on the surface of the bone and in th

Haversian canals, .....

51. Artificially-injected external callus, five days old,

52. Artificially-injected transverse section, eight days old,

53. Ossifying callus on the surface of a hollow bone,

54. Detachment of a superficial piece of a flat bone,

55. Detachment of a necrosed portion of bone,

56. Fracture of a long bone with external wound,

57. Necrosis of sawed surface of femur,

58. Bullets of various styles, . . .

59. Tiemann's bullet-forceps, ....

60. Gunshot-fractures of femur and tibia,

61. Traces of lightning, .....

62. Conjunctiva affected with catarrh, .

63. Tissue from a prepuce infiltrated from inflammation,

64. Purulent infiltration of the cutis connective tissue,

65. Purulent infiltration of the cellular membrane,

66. Vessels of the walls of an abscess, 66 a. Growth of fungus from the cornea of a rabbit,

67. Venous thrombus, .....

68. Fever curve after amputation of the arm,

69. Fever curve after resection of carious wrist,

70. Fever curve in erysipelas, ....

71. Fever curve in septicaemia, .... 71 a. Giant cells from tubercles in various stages, 71 b. Minute tubercles in the peritoneum and on a cerebral artery 71 c. Minute tubercles on a cerebral artery,

72. Cutaneous ulcer of the leg, ....

73. Granulations of a common ulcer,

74. Caries superficial! s of the tibia,

75. Section of a piece of carious bone, 75 a. Ostitis malacissans, ....

76. Disappearance of chalky salts from periphery of bone

77. Sclerosed tibia and femur, ....

78. Point of caseous degeneration in the spinal column, .

79. Destruction of the vertebral column,

80. Total necrosis of the diaphysis of a hollow bone,

81. Total necrosis of the diaphysis of a hollow bone with detached sequestrum,

82. Total necrosis of the diaphysis of a hollow bone after removal of sequestrum

PAGE

LIST OF WOODCUTS.

XIX

S3. Total necrosis of the diaphy sis of the femur, .

84. Total necrosis of the diaphysis of the tibia,

85. Necrosis of the lower half of diaphysis of femur

86. The body extracted from Fig. 85,

87. Diagram of partial necrosis of a hollow bone, .

88. Diagram of Fig. 87 in the later stages,

89. Fig. 88, after removal of the sequestrum,

90. Scapula of a dog, resected with and without periosteum

91. Eachitic malformations of the leg,

92. "Woman with extensive osteomalacia,

93. Section of knee-joint with fungous inflammation,

94. Degeneration of cartilage in fungous inflammation

95. Subchondral caries of the astragalus,

96. Atonic ulceration of cartilage from the knee-joint,

97. Diagram of the ordinary ganglion,

98. Hernial protrusions of synovial membrane,

99. Degeneration of the cartilage in arthritis deforman

100. Osteophytes in arthritis deformans,

101. Fungous inflammation of the elbow-joint,

102. Osteophytes in arthritis deformans,

103. Multiple articular bodies,

104. Band-like adhesions in a resected elbow-joint,

105. Adhesion of articular surfaces of the elbow-joint,

106. Elbow-joint anchylosed by bony bridges, .

107. Section of the shoulder-joint,

108. Section of the shoulder-joint,

109. Contraction of the fascia lata,

110. Cicatricial contractions after burns

111. Cicatricial contractions after burns

112. Subcutaneously-divided tendon,

114. Cirsoid aneurism of the scalp,

115. Small fibroma,

116. From a myo-fibroma, .

117. Vessels from a cutis fibroma,

118. Neuroma,

119. Fibro-sarcomatous neuromata,

120. Cartilage tissue from chondromata,

121. Chondroma of the fingers,

122. Odontoma of a back tooth,

123. Section of an odontoma, .

124. Pedunculated spongy exostosis,

125. Ivory exostosis of the skull,

126. Section from an ivory osteoma,

127. Osteoma of the muscular attachments

128. Vessels from a plexiform angioma,

129. Mesh-work from a cavernous angioma

130. Tissue of granulation-sarcoma,

131. Tissue of glio-sarcoma, .

132. Tissue of a spindle-celled sarcoma,

133. Giant-cells from a sarcoma,

134. Giant-celled sarcoma with cysts,

135. Cell-globules from a sarcoma, .

136. Mucous tissue from a myxosarcoma,

PAGE

XX

LIST OF WOODCUTS.

FIG.

137. Mucous tissue from an adenomyxoma,

138. Alveolar sarcoma from the deltoid muscle, .

139. Alveolar sarcoma from the tibia,

140. Central osteosarcoma of the ulna,

142. Central osteosarcoma of the lower jaw,

143. Section of Fig. 142,

144. Compound cystoma of the thigh,

145. Periosteal sarcoma of the tibia, ....

146. Section of Fig. 145,

147. From an adeno-sarcoma of the female breast, .

148. From the cortical layer of a hyperplastic lymphatic gland

149. Sections of a wart, .....

150. From a mucous polypus, ....

151. Adenoma of the thyroid, . . .

152. Commencing epithelial cancer of the lip,

153. Flat epithelial cancer of the cheeks,

154. Elements of an epithelial carcinoma of the lip,

155. From an epithelial cancer of the hand, .

156. Vessels from a carcinoma of the penis,

157. Papillary formation of a villous cancer, .

158. Mammary cancer, acinous form,

159. Soft mammary cancer, .....

160. From a mammary cancer, ....

161. Connective-tissue frame-work of a cancer of breast,

162. Cancer of breast, tubular form,

163. Cancer of the mamma from an atrophied part, .

164. Vascular net-work from a very young nodule,

165. Vascular net-work around points of softening, .

166. Connective-tissue infiltration, etc., .

167. Cellular infiltration of fatty tissue, etc.,

168. Cancer of the mucous glands from nose,

169. Adenoid cancer of the rectum, . 139 a. Villous sarcoma, 139 b. Psammona, . . • 139 c. From a cerebral tumor, 139 d. Plexiform sarcoma, 139 e. From a cylindroma of the orbit, .

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693 696

SURGICAL PATHOLOGY AND THERAPEUTICS.

LECTURE I,

INTRODUCTION.

Relation of Surgery to Internal Medicine.— Necessity of the Practising Physician being acquainted with both. — Historical Eemarks. — Nature of the Study of Surgery in the German High-schools.

Gentlemen : The study of surgery, which you begin with this lecture, is now, in most countries, justly regarded as a necessity for the practising physician. We consider it a happy advance that the division of surgery from medicine no longer exists, as it did formerly. The difference between internal medicine and surgery is in fact only apparent ; the distinction is artificial, founded though it be on history, and on the large and increasing literature of general medicine. In the course of this work your attention will often be called to the frequency with which surgery must consider the general state of the body, to the analogy between the diseases of the external and internal parts, and to the fact that the whole difference depends on our seeing before us the changes of tissue that occur in surgical diseases, while we have to determine the affections of internal organs from the symptoms. The action of the local disturbances on the body at large must be understood by the surgeon, as well as by any one who pays especial attention to diseases of the internal organs. In short, the surgeon can only judge safely and correctly of the state of his patient when he is at the same time a physician. Moreover, the physician who proposes refusing to treat surgical patients, and to attend solely to the treatment of internal diseases, must have some surgical knowledge, or he will make the grossest blunders. Apart from the fact that the country physician does not always have a colleague at hand to whom he can turn over his surgical patients, the life of the patient often depends on the correct and instantaneous recognition of a surgical disease. 1

When blood spouts forcibly from a wound, or a foreign body has entered the windpipe, and the patient is threatened with suffocation, then surgical aid is required, and quickly too, or the patient dies. In other cases, also, the physician ignorant of surgery may do much harm by not recognizing the importance of a case ; he may allow a disease to become incurable, and by his deficient knowledge cause unspeakable injury, in a case which might have been relieved by early surgical treatment. Hence it is inexcusable for a physician obstinately to stick to the idea of only practising internal medicine ; still more inexcusable is it, in this idea, to neglect the study of surgery : " I will not operate, because in ordinary practice there is so little operating to be done, and I am not at all suited for an operator ! " As if surgery consisted only in operations. I hope to give you a better idea of this branch of medicine than is conveyed by the above remark, which unfortunately is too popular.

From the fact that surgery has to deal chiefly with patent diseases, it certainly has an easier position in regard to anatomical diagnosis ; but do not regard this advantage too highly. Besides the fact that surgical diseases also often lie deeply hidden, more is demanded from a surgical diagnosis and prognosis, and even in the treatment, than from the therapeutic action of internal medicine. I do not deny that in many respects internal medicine may hold a higher rank, just on account of the difficulties it has (and often so brilliantly overcomes) in localizing and recognizing disease. Very fine operation of the mind is often necessary to come to a proper conclusion, from the combination of symptoms, and the results of the examination. Physicians may point with pride to the anatomical diagnosis of diseases of the heart and lungs, where the careful student succeeds in giving as accurate a description of the changes in the diseased organ as if he had it right under his eyes. How wonderful it is to gain an accurate knowledge of the morbid state of hidden organs, such as the kidneys, liver, spleen, intestines, brain, and spinal marrow, by the examination of a patient and the combination of symptoms ! What a triumph to diagnose diseases of organs of which we do not know even the physiological function, as of the supra-renal capsules ! This is some compensation for the fact that, in internal medicine, we must more frequently acknowledge the impotence of our treatment than is the case in surgery, although, from the advances in anatomical diagnosis, we have become more certain of what we can do, and of what we cannot.